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Primary Care Providers

Primary Care Providers are in a constant struggle between their heads and their hearts. Almost all doctors and nurses came into their profession to help others, but at some point during medical school, it dawned on the doctors that primary care physicians make peanuts compared to specialists. Combined with enormous medical school debt and long working hours, it’s only the brave few whose hearts win out and who continue on to become PCP’s. Next time you see your PCP, give them a hug and thank them for choosing their specialty.

In their heads, PCP’s know that they get paid for seeing patients (office visits) and doing procedures. If they don’t do enough of both, they can’t stay in practice and then they can’t help anyone. So it’s in the PCP’s self interest to see lots and lots of patients and do as many diagnostic tests as possible during their long working days. They have to keep the doors open.

Primary care providers bill insurance companies for their services. They usually have little control over the fees they can collect for their services since they have virtually no negotiating leverage. This can result in deep resentment, since the fee schedules set by the insurers sometimes seem arbitrary and occasionally are so low that they don’t even cover the cost of performing the service. Despite this, they opt into insurance plans as ‘in network’ physicians since they feel they have no choice, which perversely allows the insurers to rationalize that their fee schedule rates must be acceptable. While Medicare fee schedules for primary care are set based on input from the American Medical Association, the delegates from the AMA are disproportionately drawn from the specialist community so PCP’s suffer in their reimbursement rates. The only control that PCP’s have over their own income is the volume of patients they see, the number of procedures they do, and the ‘payer mix’ they manage in their calendar. Managing their payer mix means discouraging or declining some new patient appointments from payers with very low rates (including many Medicaid programs), since the opportunity cost of not filling that schedule slot with a patient from a more reasonably paying plan is too high.

Primary care providers are the face of medicine to many of us. In many cases, they are our saviors. And for most PCP’s there is no greater joy than helping a patient stay healthy or return to full health. Yet our existing system still has many friction points where the PCP and patient’s interests are not aligned, but usually not due to any choice on the part of the PCP. Because they are paid by volume, and their fee schedule rates are very low (compared to specialty physicians), PCP’s can’t afford to spend quality time with patients. They’re often forced to question, examine, diagnose and treat in a few rushed minutes; when they’d prefer to spend more time with the patient, genuinely listen to them, and ensure that they get a complete profile. They simply can’t afford to. Further, many give into the financial pressure of doing virtually every diagnostic test they feel they can get reimbursed for, even if the diagnostic value is minimal or non-existent. Some rationalize this ‘just to be sure’, but some will admit that this is the only access they have to reasonable revenue, and the reimbursement for diagnostic procedures offsets the low office visit fees. From their perspective, the rules of the game allow it and this sort of balances out the total financial picture for the visit as a whole. Under some circumstances, it’s the diagnostic testing revenue that makes the difference between making and losing money on a patient visit.

Until recently, most insurance plans paid for all but a small co-pay for all primary care visits, which kept the PCP and the patient’s interests generally aligned (albeit at the expense of the insurer). More recently, high deductibles and refined definitions of 100% reimbursed annual physicals or wellness visits have resulted in patients paying far more out of pocket for primary care, which can be where the physician/patient interests collide. For example, a patient may schedule a visit for an annual preventative wellness physical – an office visit that is often very poorly reimbursed by their insurance company, especially now since they are required to cover 100% of the annual physical under PPACA. But when they arrive, they tell their PCP that they’re having trouble with their high blood pressure and would like to discuss a change in treatment. From the patient’s perspective, this is an annual physical with an ‘oh by the way’ question. From the PCP’s perspective, however, the visit just changed from being an annual physical to a problem visit, which requires more of their time and attention and, accordingly, has a higher reimbursement rate. Further, the problem visit may justify additional diagnostic testing. BUT it also means that it’s no longer 100% reimbursed by the insurer, and if the patient hasn’t met their deductible, what they thought was a ‘free’ annual physical covered by insurance suddenly results in an out of pocket expense for multiple hundreds of dollars.

The professional associations for PCP’s are not nearly as well organized as those of specialists, and they have little lobbying effort in congress to protect their interests.


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