Does Anyone Care About Primary Care?

June 4th, 2024 Tom DiLiegro

Dr. Goldberg was a crotchety old WWII veteran. He practiced out of the first floor of a 3-decker in Somerville, MA. His white coat wasn’t so white, and he had a cigar in his mouth when he treated his patients. Dr. Goldberg was an old fashioned doctor, black bag and all. His bedside manner left a lot to be desired, but he was cheap, effective, and accommodating. When I asked if I was getting a shot, he said “no,” before immediately jabbing my right arm. If he said “yes,” it would have meant  tension, crying, and resistance, and nobody had time for that.  He cared for all of us and never said a word or turned us away, even when we couldn’t pay him. This was our primary care experience before Dad’s health plan moved to an HMO model, forcing us to the sterile, suburban, office setting we’re all familiar with today. Dr. Goldberg was replaced with a 7-minute Doctor visit after a 90 minute wait in a climate controlled waiting room with a great variety of magazines to choose from. 

The primary care physician’s (PCP) experience is as bad, if not worse, than what we deal with as patients (i.e. customers). Those employed by health systems have been reduced to commission sales reps, incentivized to refer to higher margin specialists within the system. Their days are full, to say the least, and they are probably not doing things they thought they’d be doing when in med school. 

It begs the question, does anyone really care about primary care? Those crafting legislation those who implement policy say they do, and so do health insurers, but if you dig deeper you’ll see it’s all lip service. 

The ACA, for example, mandates $0 preventive care to be included in “qualified” health plans. But $0 is applied to a short list of treatment codes conducted in the primary care setting. Anything not on that list falls beyond what is considered “preventive.”


Do bureaucrats and politicians care about primary care?


In the health insurance space, there’s this term called “weaponizing” the plan design. It’s a fancy  way to incent certain behaviors and plan usage over others. The incentive, in many cases, is this thing called the copay. The copay was meant to be a penalty. Something intended to introduce “skin in the game” from plan members; lower a copay for this, to drive that behavior, and raise the copay for that, to dissuade the other behavior. It’s a penalty of sorts. The theory is visible every time you review your health plan. The primary care copay is ALWAYS less than the specialist. Nothing particularly wrong with that, but again, in this day and age, most PCPs are employed and their employers want higher margin specialists and treatments. It’s the healthcare equivalent to a teaser rate. 

My favorite example is from a health plan who had a $0 PCP copay built into their plan. They marketed their dedication to prevention and believe in primary care based on this aspect of their plan. Fast forward, the $0 copay is gone, replaced with something more standard in the industry. What changed? They compromised on their messaging, put an expense on the plan member, and put  the physician’s office into the accounts receivable business. 


Do health insurance companies care about primary care? 


The truth is, for the overall health and wellbeing of your employees, the elimination of health insurance friction for what should be the most utilized service of your plan aside from prescription drugs, and for a more satisfied and engaged workforce, having a parallel primary care benefit to what might already be covered by your health plan, is the single best investment you can make toward your employees and group benefits strategy. And no, an embedded telemedicine program offered by your health insurance carrier or TPA doesn’t count. 

The ultimate enhancement is Direct Primary Care (DPC). DPC is the ultimate hack for health plan satisfaction. There are costs associated, but in the long run, if employees fully embrace the solution, it is the silver bullet for cost control and engagement. As great as DPC is for one reason or another, it might not be the best option for your employee population. The good news is there are stand alone virtual options that are robust enough to have a similar impact as a brick-and-mortar DPC clinic. 

These solutions are paid for on a fixed monthly basis, care is $0 to employees, and claims “experience” is shielded from insurance so utilization can’t be used against you at plan renewal. 

Adopting a primary care focussed health plan will lower your costs and improve satisfaction. But the idea is cheap, execution is everything. It cannot be done successfully, but just “quoting” options and spreadsheeting plans. You require a team like ours who not only advocates for primary care centric plans,plans like this, but we are also clients of a local clinic. 

If Dr. Goldberg was still alive, I have little doubt he would have little patience for what has been done to his profession and he would join the DPC movement. He would have to sacrifice his cigar and tidy up his appearance, but to deliver the care his patients deserved, there would be no other way.