Practicing Adult Primary Care Requires Time

In September of 1979, the American Board of Internal Medicine awarded me “Board Certification in Internal Medicine” after I completed their training and testing requirements. In 2002, I took the board certification exam in the newly created specialty of Geriatrics and passed it. I answer to the titles of “Doctor,” “ Geriatrician,” “physician”. However, CMS and private health insurers instead lump me, and other medical doctors, into the broad category of “provider”. The term “ provider” is both insulting and demeaning since what I do in general internal medicine/ geriatrics is different than what a physician’s assistant or nurse practitioner does and involves several more years of schooling as well as observed and critiqued training.

Insurers added insult to injury by stripping me of my internal medicine designation and lumping me in with family practitioners, pediatricians and obstetricians. Those are all unique specialties with their own rigorous training requirements and post training testing. They too deserve to be recognized by name for their accomplishments. But how they practice medicine and how I practice medicine are not one in the same.

I bring this up as an introduction to a research paper published in the Journal of Internal Medicine that performed time/work studies and determined that to perform the preventive care, chronic issue care, acute problem care and administrative duties, when caring for 2,500 patients, a physician would have to work 26.7 hour per days. If you provided that physician with qualified support staff, and created a care team, you could reduce the required time to 9.7 hours a day.

Ten-hour workdays are long by anyone’s standards and the article didn’t specify whether the primary care provider was limited to outpatient office work or included caring for their hospitalized patients as well. At best, this team-based approach ensures that the patient spends less time face to face with their actual physician which, in my opinion, is not a positive step.

The paper cited the example of vaccinations and immunizations being something best handled by lesser trained team members and, providing patients access to educational reading material. Once again, I have no problem with trained staff administering vaccinations but as you have seen with the corona virus pandemic and monkey pox outbreak, patients have many questions about materials injected into their body and they want to speak to a physician.

As an alternative to teams seeing patients, the authors mentioned “direct pay practices” which keep their patient load to 1000 or less, charge a monthly administrative fee and only accept cash for services rendered. I propose even smaller panels of 500 patients with insurers and CMS covering the costs of membership.

Studies sponsored by a large concierge medicine franchise program, have shown that they reduce their patients’ hospitalizations, meet preventive guidelines and ultimately save CMS and private insurers money. As an independent concierge medicine physician for 18 years, I have seen similar results limiting the number of patients I care for to 400 and giving them time, availability and advocacy with a focus on prevention.

By practicing in the concierge medicine model, you retain your patients long term and develop strong relationships with them. Also, you learn quickly that taking care of fewer people, and the relationships you establish with them,  is extremely satisfying and rewarding – something which will attract future doctors to these types of practices.

The current system does not work. Independent internists found a solution 20-years ago called concierge medicine. It’s time to give that model a try. It would save private insurers and CMS hundreds of millions of dollars per year resulting from a focus on prevention and reducing costly ER visits and hospitalizations.  For employers, it would reduce absenteeism and presenteeism, improve productivity and serve as a terrific health benefit.

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