The Diminishing Role of Primary Care
Causes, Consequences and Cures
BY KRISTEN SCHRUM
According to a recent KFF Health News article by Elisabeth Rosenthal, “The Shrinking Number of Primary Care Physicians Is Reaching a Tipping Point,” the percentage of U.S. doctors in adult primary care has fallen to 25%. Furthermore, numbers suggest that over 100 million Americans lack access to primary care. This lack of access could be seen as the cause for patients beginning to seek holistic care from medical specialists as opposed to primary care doctors. Take, for instance, an OB-GYN who schedules various tests, such as colonoscopies and mammograms, in addition to the standard gynecological exams. However, is it realistic to expect this type of care among all specialists?
“Not really,” says Zane Lapinskes, M.D. at the Fischer Clinic in downtown Raleigh. “Some OB-GYNs now consider themselves primary care providers and are willing to schedule a range of tests unrelated to their specialty. However, not all specialists are willing to step outside their area of expertise.”
Building on this, Andrew Vaughan, M.D. at Prisma Health Family Medicine in Columbia, S.C., explains that OB-GYNs—along with pediatricians and family doctors—have long been considered a form of primary care. “I define primary care as a place where a patient can self-refer,” Vaughan says.
However, there is an increasing issue with patients either expecting specialists to address all their medical needs or resorting to urgent care when they do not have a primary care provider. In general, primary care appears to be on the decline, with fewer people regularly seeing primary care doctors and fewer doctors choosing primary care as a profession.
THE DECLINE OF PRIMARY CARE
Rosenthal’s article highlights the concerning trend of a decline in access to primary care in the United States, with the number of Americans who lack a primary care doctor nearly doubling since 2014. Additionally, the shift from primary care to specialist-driven health care is evident, with the ratio of doctor’s visits for adults aged 65 and older changing from 62% for primary care and 38% for specialists in 1980, to the exact opposite by 2013. This shift is described as “tragic” by Michael L. Barnett, a health systems researcher and primary care doctor at Harvard University, as studies show that a strong primary care foundation results in better health outcomes, greater equity in health care access, and lower per capita health costs. The decline in primary care doctors appears to correlate to the lack of primary care among Americans. But why are there less primary care physicians?
“You have doctors who are struggling to pay back student loans,” Vaughan explains, “and primary care is a less viable option for them.”
Primary care does not pay as well as other specialties, resulting in fewer doctors choosing to practice it. While this is partially due to the financial structure of the health care system, which tends to reward surgeries and procedures more than the diagnostic, prescriptive and preventive work characteristic of primary care, preventive medicine is simply not a lucrative business.
There is a “bureaucratic burden,” Lapinskes says. Corporate and governmental regulations make the cost of running a primary care practice much higher than it otherwise should be, and even changes the role of the physician. “You’re a metric data entry person,” Lapinskes laments. “A doctor is now graded on productivity (the number of patients he sees) and efficiency (how well he treats those patients) by the insurance company. You spend more time trying to do your metrics, so you can’t see patients, and you’re forced to treat the record instead of the patient.”
THE CHANGING ATTITUDE TOWARDS PRIMARY CARE
The decline in primary care doctors is not the only issue people are observing in the medical world, but there is also an ambivalence about primary care growing within the younger generations. Statistics from the American Academy of Family Physicians show that “68% of millennials have a primary care physician, compared to 91% of Gen Xers.” Retail clinics, such as One Medical, Dollar General, Walmart, Target, CVS Health and Walgreens, are preferred among the younger population. “Older people are sicker, and folks tend to need more medical care as they age. There is less need (even if it is just a lower perceived need) in a younger person,” Vaughan explains.
However, this does not mean that the desire for primary care doctors has diminished. Quite the contrary.
“Again, it goes back to the U.S. appetite for primary care,” Vaughan stresses, “The pie is so big and there is such a high demand that we shouldn’t be surprised when minute clinic companies want a slice and find a way to take it. Minute clinic and urgent care medicine serves a purpose, but without continuous or comprehensive care it would be dangerous to assume this is the same service as having a primary care physician.”
The lack of prioritizing preventive medicine is not because people do not care about their health, but because finding a primary care doctor can be so difficult. That is why there is a growing burden on minute clinics and specialists to replace primary care.
“People are just stuck,” Lapinskes says, “having to wait months and months before they can be seen by a primary care doctor, or feeling as though they are not being truly cared for by a physician who has to book and double-book their schedule to meet a CEO requirement.”
IMPROVING PRIMARY CARE ACCESS AND QUALITY
The solution to this growing issue requires a multi-faceted approach, one of which is raising awareness of the importance of preventive medicine and incentivizing people to find a primary care doctor, even if waiting to get on one’s schedule may be inconvenient.
“It’s important to find a primary care doctor before you get sick,” Vaughan says. “Normally, it is the first appointment that takes a while to schedule, but after that a primary care doctor should be able to see a returning patient on demand in cases of emergency.”
Transparency is also key. Hospital systems and clinics must work to make pricing more transparent. When people do not know how much primary services cost, “the uncertainty can be paralyzing,” Vaughan adds.
Another solution is the adoption of direct primary care (DPC) models. DPC is a health care model where patients pay a monthly or annual fee directly to their primary care provider, covering all or most primary care services. While the patient is paying out of pocket for services, payment can be flexible. “We work directly with the patient. We do not work with insurance so that we do not have to worry about metrics. We can be accessible and truly listen to the patient’s needs,” Lapinskes says. “You need me, you call me, I’m there.” With DPC, patients have more access to their primary care doctor, often with same-day appointments and longer visit times, resulting in better patient outcomes and satisfaction.
Med spas can also play a role in preventive medicine. Regenesis MD in Raleigh offers a range of aesthetic and wellness services that can complement traditional primary care. “No system of the body functions in isolation. The body is an integrative system, so our approach to healing it should be integrative as well,” says Bhavna Vaidya-Tank, M.D., a family physician and owner of Regenesis MD. “Everything is connected. Someone with an inflammatory disease will have inflammatory skin. Someone with poor gut health will have poor skin health. Fixing the root cause is so important, rather than putting a Band-Aid on the symptoms. Ever since I started practicing medicine over 20 years ago, I have thought that everything in our body is connected—and to be able to go somewhere where all the dots would get connected and everything makes sense would be a dream. So, I created Regenesis MD.”
By integrating med spa services into primary care practices, doctors can provide a more holistic approach to health care, addressing not only the physical health of their patients but also their mental and emotional well-being. This integration can also provide an additional revenue stream for primary care practices, making it a more financially viable option for doctors.
Lastly, medical nonprofits such as NeighborHealth Center have been founded to “meet the needs of the underserved in the Raleigh area.”
Daniel Lipparelli, chief executive officer at NeighborHealth, explains: “Unfortunately, many primary care providers will not see uninsured or Medicaid patients because they can’t sustain the clinic revenue with low or no reimbursement. Because of this, the options for care for these patients are minimal. This is why clinics like NeighborHealth Center are vital for the underserved population.”
Relying on funds from the community, city and state, NeighborHealth’s health care philosophy centers around the “whole person,” providing physical, mental/emotional and spiritual care to its patients through a model that allows for the underserved to rely on the nonprofit as a medical home, “regardless of one’s status.”
