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Primary Care In Crisis: A Physician's Take On Reform

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This blog reviews how the role of primary care practice has diminished greatly over the past 40 years.

When I became a physician in the 1980's primary care medicine entailed a physician specializing in pediatrics, family medicine, or internal medicine who served as the main point of contact for a panel of patients.

The primary care physician evaluated patients for their annual check-ups, monitored patients with chronic conditions, and was also available for same-day or same-week visits when someone was sick.

The primary care physician was able to address more than 90% of the care of sick patients in their clinic, and occasionally would refer patients for evaluation by a specialist.

In rare cases, when the required level of care could not be handled in the clinic, such as when a patient required intravenous therapy, patients would be sent to an Emergency Department (ED) for evaluation and treatment or sometimes even directly hospitalized, when indicated.

As a resident in pediatrics, I lamented when patients chose to come to the ED for primary care issues, because this used up precious resources at the ED, and also we could not provide continuity of care there.

For instance, if I saw a child with an ear infection for which I prescribed an antibiotic in the ED, I was unable to see them again 3 days later to ensure that the infection was improving.

The main issue with primary care in those days was what to do when in the evenings and nights when the primary care office was closed. Most practices had an on-call physician who would take phone calls at night and determine whether patients could wait until they were seen in the clinic on the following day. The few practices who did not provide overnight on-call coverage were thought of as poor practices in the medical community.

The role of the primary care physician was thought of as so important, that Health Maintenance Organizations (HMOs) insisted that patients first be seen by their primary care physician to determine whether the patient required evaluation by a specialist.

Unfortunately, over the past 40 years medicine has devolved into such a state that instead of providing timely care, the primary care provider provides rudimentary care and triages complicated patients to specialists, Urgent Care, or EDs.

Some of the reasons for this devolution include:

An insufficient number of primary care physicians that partially is related to the fact that primary care physicians are paid much less than specialists

Healthcare organizations that have insisted that physicians see many more patients per day for the purpose of generating more revenue

Many physicians have burned-out and left the medical profession as a result of the increased work burden imposed by healthcare organizations

Physician extenders such as Physician Assistants and Nurse Practitioners have become essential for primary care delivery, and yet these professionals do not have as much training as physicians and thus cannot provide the breadth of care that a physician could deliver

Young medical professionals have become much more focused on their own quality of life and healthy work/life balance thus limiting their work hours, as opposed to older physicians who placed patient care as their top priority

Many physicians have left traditional medical practices and instead have turned to delivery of concierge medicine, for which patients pay annual fees beyond the cost of their medical insurance. Thus, there are fewer physicians available to provide care to patients who are covered by private or government medical insurance.

How does primary care function today in many practices?

Recently, my wife developed a viral illness like that which affected thousands of Americans this winter. She felt very weak and was unable to eat or drink much. I suggested that she visit her primary care physician, who saw her three days after she called for an appointment, when a cancellation opened a timeslot.

The physician, who was part of a well-reputed large health care organization, performed a brief physical exam and ordered a blood test, which she said was normal.

My wife was instructed to go to Urgent Care if her condition worsened. Over the next two weeks my wife was seen in Urgent Care or an ED on three occasions, and finally was hospitalized with severe dehydration and malnutrition. It turned out that the primary care physician did not even note signs of dehydration in the blood test she performed during her only encounter with my wife during her illness.

Last week, I called my own primary care provider, who works for a large medical organization different than my wife's, for evaluation of a sudden new health issue. I was told that the first time I could be seen for this condition would be in a month.

The receptionist with whom I spoke also volunteered that if I was uncomfortable with waiting that long, I could go to Urgent Care. Fortunately for me, I am a physician, so I am in a better position of evaluating whether my symptom warrants an immediate evaluation than most other people.

Not surprisingly, in this new way of medical practice Urgent Care centers and EDs are overflowing with patients who do not require that level of care. This can be best demonstrated during holiday periods or while the Super Bowl is being played, when emergency facilities are almost empty.

Further complicating the situation is that healthcare delivered in an urgent or emergency care settings is much more expensive. Not surprisingly, healthcare facilities are not incentivized to change this system because they make much more money from delivering emergency as opposed to primary care.

I should note that there remain a minority of private primary care practices that still see patients in a timely and comprehensive fashion. Such practices do not generate as large of an income for the practice or participating physicians, which limit their scope.

When practices are owned by health organizations such as hospitals, they tend to be profit driven rather than patient centered.

What can be done to change the system?

The problems of today's primary care delivery system include an insufficient number of physicians, and an emphasis on financial gain rather than optimal patient care. For instance, a primary care practice can be more financially viable when it does not need to be staffed with enough health care providers to offer good coverage on nights, weekends, and to deal with ill patients in a timely manner. Instead, such a practice sends its patients to Urgent Care or the ED.

To solve this issue, as I discussed in a previous blog, I believe the primary care system could be transformed over the next 10-20 years to be administered by Medical Technicians (MTs), who would be guided by AI. Only in cases when their evaluation and management is insufficient to address patients' needs, would a physician need to be consulted.

The advantages of such a system would include a significant decrease in cost of training of the MTs, as compared to training physicians, advanced nurse practitioners, or physician's assistants, and a concomitant increase in availability of primary care access because a single primary care physician could be replaced at the same cost by several MTs who could staff primary care facilities efficiently.

I should note that most primary care, including evaluating vital signs, doing basic physical examinations, interpreting basic lab results, making basic diagnostic decisions, making basic behavioral health recommendations, and reassuring patients, does not require advanced degrees, especially in a world in which AI could help to alert MTs to abnormal findings.

Takeaway

Our current healthcare delivery system is broken. We need to think outside of the box to find solutions to this crisis.

Quick Access To Primary Care Reduces Suffering. Make Sure Your Doctor's Office Provides It.Expert Opinion

by Jeffrey Millstein, For The Inquirer

Published April 3, 2025, 6:00 a.M. ET

A good friend shared a story with me that highlights the fallout of poor access to primary care on short notice. Generally healthy and in her mid-50s, she developed severe, sharp lower back pain shooting into her right leg.

When she called her primary care office, she received an all-too-common reply: No appointments were available that day. So she went to an urgent care clinic for blood work and x-rays, and she was prescribed oral steroids and anti-inflammatories.

But her pain intensified over the next 24 hours. She called her primary care office again, and this time was instructed to go to the emergency room. After eight hours, and another set of blood tests and x-rays, she was still suffering, with only minimal improvement.

» READ MORE: How a primary care physician can help you navigate the health-care system.

The following day, she made herself an appointment at an orthopedics practice. There, she was diagnosed with sciatica, given a muscle relaxant and a small supply of opioid painkillers to use sparingly. The orthopedic specialists also offered her a follow-up appointment to assess her progress and provided a contact number for questions. Finally, one week later, she began to improve, with her pain lessening.

All told, she endured three fragmented visits for medical care, hours of wait time, excessive testing, and days of suffering with pain and worry. A same- or next-day appointment with her primary care doctor, followed by a quick check-in by phone or messaging in an online patient portal, would most likely have achieved the same outcome without the hefty emotional and financial price tag.

Access to primary care is challenging these days, and it is worth the effort to find a practice that can be your health-care home base. Your primary care practice can provide preventive care, help manage your chronic health conditions, coordinate referrals to specialists (medical or surgical), and recommend resources like social services, nutrition counseling, and mental health care.

The ER is always the best place to go if you are experiencing certain acute symptoms, like chest pain, shortness of breath, sudden weakness or slurred speech. But when other urgent, non-life threatening problems arise, the primary care office should be your first touchpoint for three important reasons:

It helps to be seen and evaluated where you are known. The essence of primary care is continuity. It is where you are cared for when ill or just trying to stay well. Primary care teams get to know patients over time — your medical history, communication style, care preferences, and fears stemming from past trauma. All of this is invaluable when evaluating new symptoms.

Your primary care office has access to your medical records. Your medical record keeps track of previous illnesses, test results, chronic conditions, current medications, and preventive care. It is a vital resource that helps your doctor know what you have been through, and where you may be vulnerable to help ensure accurate diagnosis and safe treatment.

You should have the opportunity to follow up if things change or are not improving as expected. A visit to urgent care or the ER is often an isolated encounter. The assessment may involve more testing than you typically receive at your primary care office, since this is the one chance the clinician there has to evaluate you. Unlike in primary care, they do not typically offer you a follow-up visit to see how you are doing, since they are busy handling serious and life-threatening conditions. So if you go back to an urgent care clinic or ER, your evaluation will often begin from scratch, as if you were not previously evaluated. This is disconnected, inefficient, and expensive.

We can do better in primary care to improve access on short notice. At my practice, every clinician keeps some appointment slots blocked for same-day care only. Other offices may offer walk-in visits without an appointment, designate a certain clinician as the "provider of the day" for urgent needs, or offer on-demand virtual care. Even when you can't see your own physician, the provider you see will have access to your medical record, current prescriptions, and other information that will help them give you the best care.

There is no "one size fits all" approach to getting into a primary care provider on short notice — just be aware of which option your practice offers, and that you are comfortable with it.

Urgent care clinics and emergency rooms provide excellent care, especially when your needs are appropriate for them. For most non-emergent problems, though, primary care is your best first stop. If you have trouble accessing primary care on short notice, give that feedback to the practice. Fewer doctors are working in primary care, which requires creative solutions — and your ideas matter.

Jeffrey Millstein is an internist and regional medical director for Penn Primary and Specialty Care.

Long Wait For A Rushed Doctor's Visit? Maybe You'll Get More With A 'membership' Fee

Dr. Rebecca Starr is an internist specializing in geriatric care. When she opened her own practice, she chose a concierge business model, she says, because she wanted to offer patients longer appointments, including time to talk about nutrition and other subjects, but be able to charge enough to make the business work.Karen Brown/New England Public Media hide caption

toggle caption Karen Brown/New England Public Media

Michele Andrews had been seeing her internist in Northampton, Massachusetts for about 10 years. She was happy with the care, although she did start to notice it was harder to get an appointment.

This story was produced in partnership with KFF Health News.

"You'd call and you're talking about weeks to a month," said Andrews.

That's not surprising, as most workplace surveys show the supply of primary care doctors has fallen well below the demand. But Andrews still wasn't prepared for the letter that arrived last summer from her doctor, Christine Baker, at Pioneer Valley Internal Medicine.

"We are writing to inform you of an exciting change we will be making in our Internal Medicine Practice," the letter read. "As of September 1st, 2024, we will be switching to Concierge Membership Practice."

Sponsor Message

Concierge medicine is a business model in which a doctor charges patients a monthly or annual membership fee - even as the patients continue paying insurance premiums, copays and deductibles.

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In exchange for the membership fee, the doctor limits their overall number of patients, so it's easier for each patient to be seen quickly, and spend more time talking to the doctor, if needed.

Andrews was floored when she got the letter. "The second paragraph tells me the yearly fee for joining, um, will be $1,000 per year for existing patients. It'll be $1,500 for new patients," she said.

More physicians are converting their practices to the concierge model, particularly in primary care. One trade magazine, Concierge Medicine Today, estimated there are about 12,000 concierge practices in the U.S., and medical practices are converting at an increasing rate. Membership fees can range from $1,000 to as high as $50,000 a year.

Many doctors who made the change have said it resolves, at least on an individual level, some of the pressures they face in primary care, such as too many patients to see in too short a time.

But critics counter that concierge medicine only helps patients who have the extra money, while at the same time shrinking the overall supply of primary care practitioners in a community. It can particularly impact rural communities already experiencing a shortage of primary care options.

Andrews and her husband had three months to either join and pay the fee, or leave the practice. They left.

"I'm insulted and I'm offended," Andrews said. "I would never, never expect to have to pay more out of my pocket to get the kind of care that I should be getting with my insurance premiums."

In an interview, Dr. Baker said fewer than half her patients opted to stay, shrinking her patient load from 1,700 to around 800 — which she considers much more manageable. She said she had been feeling so stressed that she had considered retiring.

"I knew some people would be very unhappy. I knew some would like it," she said. "And a lot of people who didn't sign up said, 'I get why you're doing it.'"

Another patient at Baker's practice, Patty Healy, said she didn't even consider leaving.

"I didn't question it," Healy said. "I knew I had to pay."

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As a retired nurse, Healy knew about the shortages in primary care, and she was convinced that if she left, she'd have a very difficult time finding a new doctor.

Healy was also open to the idea that she might like the concierge model.

"It might be to my benefit, because maybe I'll get earlier appointments and maybe I'll be able to spend a longer period of time talking about my concerns," she said.

This is the conundrum of concierge medicine, according to Michael Dill of the Association of American Medical Colleges.

The quality of care may go up for those who can and do pay the fees, Dill said. "But that means fewer people have access," he said. "So each time any physician makes that switch, it exacerbates the shortage."

Blue Canyon offers "direct primary care" in Northampton, Mass for patients who pay $225 a month. Direct primary care is a type of concierge medicine that does not accept insurance. Patients must pay the bill out of pocket and seek reimbursement from their insurers afterwards. Karen Brown/New England Public Media hide caption

toggle caption Karen Brown/New England Public Media

The Association estimates the US will face a shortage of 21,000 primary care doctors within the next decade, given the growth of the population and its medical needs.

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Dill pointed out that the impact of concierge care is worse in rural areas, which often already experience physician shortages. For example, western Massachusetts already has fewer doctors per capita than many other regions in the state.

"If even one or two make that switch, you're going to feel it," Dill said.

Dr. Rebecca Starr, an internist who specializes in geriatric care, recently started a concierge practice in Northampton, Massachusetts.

For many years before that, she consulted for a medical group where patients only got 15 minutes with a primary care doctor, "and that was hardly enough time to review medications, much less manage chronic conditions," she said.

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So when Starr decided to open her own medical practice, she decided she wanted to offer longer appointments, including time to talk about nutrition and general well-being — but still bring in enough revenue to make the business work. To her, the concierge model was the only way to accomplish that.

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"I did feel a little torn," Starr said. While it was her dream to offer high-quality care in a small practice, she said, "I have to do it in a way that I have to charge people, in addition to what insurance is paying for."

Her patient load will be capped at 200, Starr said, much lower than the 1,000 or even 2,000 patients that some doctors have.

But within the first year of starting her practice, she still hasn't hit her limit.

"Certainly there's some people that would love to join and can't join because they have limited income," Starr said. Starr declined to disclose the amount of her membership fee.

Joanne Rome, of Florence, Mass, told NPR that when she contacted Starr's practice on behalf of her mother, she was quoted a fee of $3,600 a year.

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But for many doctors making the switch, the concierge membership model is the only way to have the kind of personal relationships with patients that attracted them to the profession in the first place.

"It's a way to practice self-preservation in this field that is punishing patients and doctors alike," said Dr. Shayne Taylor, who recently opened a practice offering "direct primary care" in Northampton.

Direct primary care is similar to concierge care in that it charges a recurring fee to patients – but direct care bypasses insurance companies altogether.

Taylor's patients – who pay her $225 a month – still must have health insurance to cover things like X-rays or medications. But Taylor doesn't accept insurance for any of her services.

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This means patients must pay their bill out of pocket, and seek reimbursement from their insurance company afterwards. The reimbursement may not cover the full cost of the bill, especially since doctors like Taylor do not belong to insurer's approved provider networks.

"We get a lot of pushback because people are saying, 'Oh, this is elitist, and this is only going to be accessible to people that have money,'" Taylor said. "But ultimately, the numbers don't work. We cannot spend so much time seeing so many patients and documenting in such a way to get an extra $17 from the insurance company."

While much of the pushback on the membership model comes from patients, advocates, and health policy experts, some of it comes from other physicians.

Dr. Paul Carlan, who runs Valley Medical Group in western Massachusetts, said his practice is more stretched than ever. One reason is that the group's clinics are absorbing some of the patients who have lost their doctor to concierge medicine.

"We all contribute through our tax dollars, which fund these training programs," Carlan said, referring to the fact that the federal government pays the salaries of doctors during their residency training after medical school.

"And so, to some degree, the folks who practice health care in our country are a public good," Carlan said. "We should be worried when folks are making decisions about how to practice in ways that reduce their capacity to deliver that good back to the public."

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Michelle Andrews, the patient who did not follow her doctor into concierge care, eventually found a new doctor. But she's still angry at the system — and at concierge doctors.

"You're not fighting the system," she said of the doctors who are converting their practices. "This is a work-around."

But Dr. Shayne Taylor said it's not fair to demand that individual doctors take on the task of fixing a dysfunctional healthcare system, in which insurance companies determine what doctors should be paid for certain services, and how long they spend with patients.

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"It's either we do something like this," Taylor said, "or we quit."

In other words, she said, serving only 300 patients is still better than serving zero.

This story comes from NPR's health reporting partnership with New England Public Media and KFF Health News.

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