Primary Care Versus the Rest

Recent postings have defended primary care versus urgent care and other care venues. These posts tend to exaggerate the benefits of primary care while pointing out the flaws of urgent, retail, corporate, concierge, emergent, and other venues.

Primary care should take a realistic hard look at the competition and the many serious issues facing primary care. It is hard as a primary care and health access advocate to post this - but real change begins with Primary Care Versus the Rest across Specific Measurable Achievable Realistic and Timely.

It is common for primary care to defend itself for areas such as continuity and integration – but insurance companies, employer preferences, and other changes insure patient migrations, lack of continuity, and disintegration.

Access Issues Facing Primary Care More (and less for others)
  1. Primary care has largely refused to adapt to consumers (evening, weekend, phone, internet)
  2. has increasing delays until patients can be seen
  3. is moving from most experienced to least experienced workforce in the next decades
  4. has substantial clinicians near retirement or departing primary care in the next few years
  5. has shrinking proportions of all sources entering primary care
  6. may well be less responsive to part time or other emerging graduate preferences
  7. is forced by insurance contracts and habit patterns to see the most complex patients while the least complex and most profitable are stolen away

Finance Issues Facing Primary Care More
  1. Primary care has rapidly increased in cost of delivery with no end in sight - HIT, techs, MU, updates of software and hardware, ICD-10
  2. is forced to hire more personnel or consultants to save costs for someone else - government or insurance
  3. has payment too low where most Americans live and need care (and are more complex)
  4. may have cost issues locating a practice where best for revenue generation
  5. is being strung along with the hope of more pay by government and by insurance (and by associations), but for decades the costs and responsibilities go up more than the rare if any pay increase
  6. is also facing more funds extracted by associations (dues, certifications) and increasing requirements for certifications that also are more costly and cut into revenue

And paying dues and other costs and investments does not protect, preserve, profit, promote, or otherwise benefit the primary care clinician or practice

The Primary Care Priority remains far too low
  1. PC has not been spared the rigors of cost cutting
  2. has not been spared stagnation in revenue
  3. has not been spared sequestration cuts and other across the board cuts – cuts resulting from other parts of government and health care that spend too much
  4. PC associations have not been effective in improving revenue for decades
  5. PC association lobbying and political attention is actually higher for non-primary care, because the nurse practitioner, physician assistant, internal medicine, and pediatric graduates are more likely to be found outside of primary care and more members and higher pay shapes the political focus
  6. NP Associations are focused on independence as a top priority which is why retail, convenience, urgent, and emergent workforce increasingly arise from nurse practitioner graduates
  7. PC associations receive no negative attention for failing in primary care – they are allowed to claim primary care while benefiting from non-primary care to a much greater degree
  8. Family Medicine remains 90% primary care, but is dominated by academic interests and various favored projects – such as Primary Care Medical Home Nirvana - not attending to the failures of payment and more members who are dedicated lifelong to primary care (family medicine had devoted an entire floor and millions to PCMH - mainly benefiting consultants
  9. Public Primary Care, academic training, and other public supported venues can undercut private primary care - including some of the most profitable locations

Those most devoted to primary care receive little recognition or respect
  1. While their association leaders broadly proclaim the primary care benefits that only their small and dedicated proportion provides
  2. While all manner of primary care solutions or cures are proposed - other than the actual cure which is more support for them and for their kind and what they do
  3. While also forced to be subjugated as employees to employers that often do not understand or appreciate primary care, or to become a small portion of a large operation with little visibility or priority 

The actual cure for primary care remains funding specific to more clinicians who stay in primary care permanently and deliver more services to more Americans including those most rapidly increasing in numbers and in need of primary care

Global Fails Local But Local Focus Succeeds Globally

Domino Decline By Design - as ERs Close, Those Nearby Face Challenges, as Small or Rural Hospitals Close or Practices Where Needed...

Declines in Health Care Delivery Despite Increases in Health Spending - If We Keep Accelerating Non-Delivery Costs, We Can Continue to Remain Behind Health Care Demand

Blogs indicate that primary care can be recovered and should be recovered.

Dr. Bowman is the North American Co-Editor of Rural and Remote Health. He was the founding chair of the Rural Medical Educators Group of the National Rural Health Association and the long term chair of the STFM Group on Rural Health.


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