The Real Value of Primary Care

In previous blogs we have spelled out some of the contradictions and deficiencies inherent to the ACA/CMS campaign to improve medical quality and value. Clearly something needs to change in health care, which is why these reforms are being instituted. Both financial value and medical quality are poor across the country, as insurance continues to pay more for hospitalization and high-cost tests/procedures than for home care and prevention; health outcomes have fallen far behind the huge expenditures that are often causing more harm than good; and both doctors and patients are frustrated. We have discussed how many ACA and CMS programs are very likely to fail, and at best will make a minor dent in value (with virtually no cost savings so far), while diminishing true medical quality (relying of quality indicators that often lead to poor care), all at the cost of decreased patient/physician satisfaction and increased doctor burn-out. Then what should primary care doctors be doing to influence the direction of health care reform? The answer lies not in the halls of Congress or CMS. Rather, it occurs in the exam room itself. After all, that is where the soul of medical care takes place, where doctors and patients delve into often complicated and impactful conversations, where decisions are made that influence both the economics of health care and the lives of so many people who place their faith in a doctor’s skills.

As a resident at University of Virginia, I was given one piece of advice by my wisest mentors that far exceeded all of the scientific and statistical jargon that I was expected to swallow. It was this: when a patient walks in your room and sits down, just look into their eyes and shut up. Let them talk. When they are done talking, then it is time to have a conversation. The key word is conversation; no part of the visit should include lecturing at the patient, telling them what they must do, or spouting statistics that obscure the complex needs and wants of the person sitting in front of us. We primary care doctors who care for the elderly and chronically ill confront a plethora of medical problems in virtually every patient who walks through our doors. To solve them all is not possible, and may not even be what the patient wants. As my mentor told me, unless you address the patient’s agenda, they will hear nothing else that spews from your mouth.

Sometimes it is difficult to allow a patient to walk out of the room having not resolved her high blood pressure, her failure to get a mammogram in the past three years, her decision to stop her statin, her lack of exercise. Sometimes it is painful to watch a patient walk out not having fulfilled any of Medicare’s quality indicators, a fact that will be sent to CMS through our computers and ultimately may cause our payments to suffer. Sometimes just talking about the patient’s incontinence and painful back seems insufficient in the wake of all of the medical issues with which she is inflicted. But once we address a patient’s own agenda, then we can certainly discuss some of the more difficult medical issues confronting the patient, if not at this visit, then certainly at the next. I may have her look over data about statins and mammograms; some is available on the internet, some in print (such as the book I co-wrote with Erik Rifkin, Interpreting Health Benefits and Risks, that patients can easily comprehend), and then on the next visit we can start to tackle some of these issues, again in the form of a conversation, not a mandate. In fact, many patients, after they see real data about many of our health interventions, choose not to pursue them. That is their choice, as long as they make it rationally, and often fewer tests and drugs lead to improved outcome, even though for us doctors it leads to failing grades on our quality indicators, with potentially deleterious ramifications to our pocketbooks.

So, what then is the value that we primary care doctors have to offer to the health care crisis? Put simply, it is the conversation itself. It is our ability to look people in the eyes, to allow them to set the agenda, to converse with them about medical issues and interventions using reliable data ultimately assessed by their own interpretations of personal risk/benefit and their own wants and needs. However, when we are forced to stare at computers and enter data, when CMS and the ACA have set much of the agenda by compelling us to adhere to their often perverse quality indicators, when visit times continue to shorten to pay for the escalating overhead, then none of the value we offer can exist. Being a primary care doctor is one of the most satisfying professions on this planet. We come to know our patients well over many years, we live through their peaks and valleys, they rely on us to help them with some of the most difficult decisions they will ever be forced to make, and we do our best to keep them healthy, active, and happy. I receive as much value as do my patients when the office conversation goes well. And for our broken health care system, the bond between doctor and patient when orchestrated correctly and given sufficient time to generate meaningful discourse, leads to fewer tests, fewer medicines, fewer referrals, less hospitalization, lower cost, and greater satisfaction, something that I document in Curing Medicare in great detail.

The ACA and CMS are trying to measure value and quality in all the wrong ways. They are talking about shared savings, offering incentives and disincentives that rarely work and typically decrease both patient and physician satisfaction and truncate our ability to talk. They throw metrics at us that have no correlation with our patients’ wants and needs, do not measure true quality and value, and only serve to squander our time in the exam room when there are so many more important issues about which we need to talk. The value upon which we must insist as primary care doctors is the ability to have a conversation; that is more difficult to measure, but ultimately it is what will work. It makes us and our patients more satisfied, and it saves the health care system money, while enhancing our patients’ health and well being. Most significantly, it is what we do best.