Primary Loss

A Doctor-Patient Mourns a Once-Key Health Care Bond

I'm on my fourth primary care physician in four years.

My first physician's practice dropped my managed care organization, feeling that it could not negotiate a rate adequate for the practice to survive. I was told to pick a new primary care provider from the organization's list. I'd barely met my chosen physician when, like so many others, my provider closed.

I was then offered the opportunity by my employer to choose a different health plan and a new primary care physician. This time I chose "point of service" coverage, which promised more provider choice. I met primary care physician number three. Three months later, I received a letter stating that she was turning her practice into a VIP program. As she shaved her practice from 3,000 to 200 patients, I could stick with her for an upfront annual fee of $1,500; she would still charge my insurance and I would still face co-pays and deductibles. Though reports indicate that this type of "boutique care" is growing and that it appeals to some, it struck me as excessively costly and exclusive.

That brought me to primary care provider number four. Meanwhile, as I bounced from one doctor to another, my children's pediatrician chose to leave practice, citing the pressure to provide "assembly line medicine" in the face of inadequate reimbursement, bureaucracy and rapidly increasing rates for malpractice insurance.

You might think that my bad luck was due to a lack of sophistication in negotiating health systems. However, I am a physician. As such, I've had the dubious distinction of having firsthand experience with limited primary care access twice over -- once as a consumer and again as a doctor.

Dueling Therapies

Primary care has been defined by the Institute of Medicine, the advisory group of the National Academy of Sciences, as "the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community." It is supposed to be the "medical home" -- the place where patients receive preventive care and help in negotiating our increasingly complex health care system. The primary care provider should know not just the condition of a patient's heart or kidneys, but the patient's overall health and how the patient functions in the context of family and community.

But in fact, an estimated 43 million Americans lack health insurance and another 36 million have no easy access to a medical caregiver because there are not doctors in their communities who are willing or able to care for them. In addition, among those that have a doctor, many report an erosion in primary care services.

In a large survey of adults published last year in the Annals of Internal Medicine, only 51 percent felt their primary care physician knew their medical history well. No more than that same razor-thin majority, according to lead author Dana Gelb Safran from Tufts University School of Medicine, felt their doctors knew much about their life circumstances.

Many families can provide examples of how lack of primary care has hurt them. Mine certainly can.

When my elderly father was hospitalized two years ago with a ruptured appendix and a subsequent heart attack, he had a surgeon who checked his wound, a cardiologist who checked his heart and an infectious disease specialist who checked his blood and tissue cultures. The surgeons took out the appendix, leaving a large open wound, and took him off the blood thinners prescribed by his cardiologist. The cardiologist recommended tests of his heart and restarted blood thinners, which made his wound bleed.