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Will the Doctor See You Now?

Primary care save lives and improves health — if you can find it

decorative illustration"Who is your primary care provider?”

That is a question millions of Americans hear every day — at the specialists’ office, at urgent care, at the pharmacy and sometimes even at the emergency room. The answer is often, “No one.” Nearly a third of Americans lack a primary care provider, according to a 2023 study by the National Association of Community Health Centers.

Considering the tremendous known benefits of primary care, the inability of many people to see a primary care physician is a national health crisis with significant impact on individual health and the life expectancy of Americans.

Ideally, primary care providers are like orchestra conductors for your health, ensuring that all the different elements — preventive care, management of prescriptions, management of chronic diseases, lifestyles and behaviors — work together harmoniously. They treat common illnesses, like sinus infections, shingles or urinary-tract infections, while also keeping an eye out for serious issues like cancer.

In a perfect world, primary care providers also would refer a patient to a specialist if needed. The reality, however, is much different. It can take months to get in to see a primary care doctor. A specialist can often be seen next week. The after-hours urgent care clinic can see patients the same day. And if you don’t have insurance or the right insurance? Perhaps you end up in the emergency room.

Or perhaps like Loraine Barron, you turn to Dr. Google.

Barron, who lives in Overland Park, Kansas, felt a sharp pain in her lower abdomen one evening in May 2023. She dismissed it as indigestion, but it continued to worsen, becoming so unbearable she went to the emergency room at 3 a.m. a day later. The doctor on duty ordered a CAT scan, which didn’t show anything alarming. She was sent home in excruciating pain with some anti-gas medication and was advised to call her primary care physician.

The next day Barron called her primary care doctor’s office, but she was told they couldn’t fit her in for a month and half. They recommended she go to urgent care.

In the meantime, Barron had gone online and suspected her symptoms might mean she had developed shingles. The following day she went to an urgent care clinic and told them she thought she had shingles. The urgent care doctor prescribed her Gabapentin (a nerve medication) and sent her home.

Three days later, she called her doctor’s office again, and said she was sure she had shingles. She spoke with a nurse who reiterated that it would be a month and half before she could see her primary care physician, and no other doctors were available. She received a prescription for pain medication and was told to return to urgent care if her condition worsened.

“A few days later I tried to call my primary care doctor again, because I wanted to make sure the various drugs I had been prescribed by the ER doctor, urgent care and the nurse were okay to take together and with my other medications,” Barron said. “But I was told my doctor wasn’t available and was told again to go to urgent care if I continued to have pain.”

At one point, she got an appointment with another primary care doctor from a different health system who had an opening. Barron said the new doctor talked to her for just a couple of minutes and ordered an endoscopy, another CAT scan and an X-ray to rule out a hernia.

About seven weeks after her initial symptoms, the shingles pain was starting to ease, but Barron never had a chance to talk to her original primary care doctor throughout the entire ordeal. Although her shingles are now gone, Barron is concerned that after all this, no one has her full medical history anymore or is familiar with her health background.

“I guess this is the way health care works now, and I need to figure how to navigate this new system where you talk to random nurses, ER and urgent care doctors who don’t really know you or your medical history,” Barron said. “I feel like Dr. Google has become my primary care physician.”

Brandon Comfort portrait
Brandon Comfort, M.D.

Improving outcomes for individuals and communities

Stories like Barron’s are unfortunately not unusual, said Branden Comfort, M.D., associate professor of medicine at the University of Kansas School of Medicine and an internal medicine physician with The University of Kansas Health System.

“This is a topic I am passionate about, and it’s daunting. It is a huge, huge issue,” he said.

Comfort himself is a primary care physician, and he has seen what good primary care can do to improve outcomes for individuals as well as entire communities.

“The research is clear. Multiple studies have shown the benefits of primary care,” Comfort said, pointing to a 2019 JAMA study showing that the number of primary care physicians in a community is directly related to mortality of its residents. “I also see it anecdotally. In my own practice, we had a patient who came to us with chronic uncontrolled diabetes. This person had been going in and out of hospitals for seven years.”

Comfort said that since he began treating the patient, the diabetes is now under control and hospital stays are a thing of the past.

Chronic diseases like obesity, diabetes and high blood pressure cause multiple complex health issues, and it is an area where the intervention of primary care providers can really make a difference. According to the American Hospital Association, an estimated 133 million Americans suffer from at least one chronic illness, such as high blood pressure or heart disease. An estimated one-quarter of Americans have more than one chronic illness, and numbers are on the rise.

“The work we provide is not rocket science, but the reality is that you can prevent a number of catastrophic things by controlling chronic diseases,” Comfort said.

Another issue Barron correctly identified with her shingles experience is the integration of prescriptions. While it helps if patients use one pharmacy for all their prescriptions, one of the key responsibilities of primary care providers is to oversee multiple prescriptions for different ailments, ensuring that one treatment doesn’t become another ailment’s cause.

According to the Health Policy Institute at Georgetown University, nearly 70 percent of all adults in the United States use prescription drugs, including 75 percent of people aged 50 to 64. The average number of prescriptions filled also increases with age, with those aged 50 to 64 using on average 13 different medications.

Comfort notes that many of those people on multiple prescriptions are the same ones with chronic conditions. Without a primary care provider to ensure that the prescriptions are integrated, conditions can worsen. While it may be easier to get into a specialist, the specialist typically isn’t looking at prescriptions or other issues the patient has.

“We focus on comprehensive care for our patients, and that includes preventive care, acute care and post-hospital care,” Comfort said. “We run the gamut.”

Michael Kennedy portrait
Michael Kennedy, M.D.

Where are the primary care providers?

If the benefits are so clear, why don’t more people have primary care providers?

“The root of the problem is that there are not enough primary care providers,” Comfort said, noting that it is an issue with many causes, some systemic to the United States’ health care system and some related to the demands of the work itself.

“One of the barriers to access of primary care providers is how the U.S. health care system works,” Comfort said. “In most countries there is a pyramid, with primary care providers as the foundation and specialists at the top of the pyramid with fewer providers. In the United States, it is almost reversed. It is an inverted pyramid, with fewer primary care providers at the bottom and more specialists at the top.”

Michael Kennedy, M.D., professor emeritus of family medicine and former associate dean for rural health education in the KU School of Medicine, has thought about these issues a great deal.

“Primary care has been eroding for a number of years,” Kennedy said, noting that primary care medicine is focused on so-called cerebral medicine, meaning that much of what the primary care physician has to offer is their professional expertise and their time. Other specialties focus on procedures, which are easier for insurance companies to quantify.

“It has always been difficult to quantify the doctor-patient relationship,” Kennedy said. “I think insurance companies adopted a ‘manufacturing model’ for the care of patients. This works well if you are providing very specific types of patient-care activities, like measuring blood sugar and adjusting medications. But when it comes to managing disease or managing personal behavior change for patients with chronic disease, this is much more difficult.”

Kennedy also noted that the time constraints doctors are under pose another challenge.

“Insurance companies invented the 15-minute office visit as a widget for which to quantify physician services,” he said. “Everything revolved around the documentation of the visit with the proper number of elements documented to generate a level of care. This then determined the reimbursement.”

Kennedy said that his medical students have noticed what he called the “deprofessionalization” of medicine, where the relationship between doctor and patient is minimized and the documentation for insurance companies takes on an outsized role, often requiring additional time at the end of the workday.

“Because students witnessed this deprofessionalization, many do not seek out primary care medicine due, in part, to the burden of documentation and paperwork,” Kennedy said. “When you think about it, it is a ridiculous situation.”

Comfort agreed that primary care can be a hard sell to medical students.

“On average, primary care physicians make less money and arguably the work is harder. You might need to address multiple issues with one patient in a visit, from diabetes to obesity, high blood pressure or other conditions,” Comfort said.

There also may be less immediate satisfaction in seeing patients who have complex issues that aren’t going to be resolved in one visit.

“Many medical students are attracted to the idea of ‘fixing the problem.’ Primary care doctors don’t necessarily fix the problem in one visit, but we have an enormous impact over time,” Comfort said.

Impacting patients’ health over time and developing relationships is part of what brings Moya Peterson, Ph.D., APRN, joy in her practice. Peterson, who is a clinical professor in the KU School of Nursing, directs a clinic for adults with Down Syndrome where she serves as the primary care provider for an entire population. Patients come great distances to see her, and she values the relationships she builds.

“For me, when a patient gives me a hug, or parents thank me and say that I have filled the gap for them — it all becomes worth it,” she said.

In her role as a professor, Peterson encourages students to consider primary care as advanced practice nurses.

“As advanced practice nurses, we have the ability to take care of patients when and where they need it.  If there is a physician available, then we make a great team.  If not, we can still step in and care for folks who need the care.”

Peterson knows that, like medical students, those pursuing advanced practice nursing careers see the allure of specialization.

“But primary care is where the need is for physicians and the same is true for advanced practice nurses.  Kansas needs primary care providers all over the state and advanced practice nurses can provide that,” she said. “We need to encourage nurses to go to school and enter primary care, so that we can take care of the people of Kansas.”

Many primary care providers in Kansas and elsewhere are advanced practice nurses, and there may be an even larger role for these nurses in the future. Comfort notes that advance practice nurses in his clinic play an important role.

“Nurses are definitely part of the answer,” Comfort said. “Where we have really seen the value of advanced practice nurses is with chronic disease management.”

Moya Peterson portrait
Moya Peterson, Ph.D., APRN

Addressing the shortage of primary care

The American Medical Association (AMA) predicts that the United States will be short between 17,800 and 48,000 primary care physicians by 2034. The good news is that the shortage of primary care providers has gotten the attention of many different sectors in health care, and several ideas have emerged to address the problem.

The AMA has suggested adding more medical student loan programs, increasing slots in graduate medical education and expanding telehealth. In the state of Kansas, medical students who pursue primary care in underserved areas and serve for a specific amount of time can be eligible for a program to pay back their medical school tuition.

Other changes on the horizon include how providers are paid. Comfort notes that the Centers for Medicare and Medicaid Services is trying to incentivize primary care more, and there may be more momentum to shift from a fee-for-service model to one that is value-based, where providers are compensated for persuading patients to modify their behavior in ways that translate into direct health outcomes, such as managing high blood pressure or quitting smoking.

Primary care alternatives

Due in large part to the primary care shortage, a number of non-traditional entities are jumping into the $4.3 trillion dollar U.S. health care market.

One of those alternatives is concierge care, popular with celebrities and corporate executives. With concierge care, patients pay a flat monthly fee for unlimited office and telehealth visits, as well as direct care from a doctor without worrying about copays and other charges. There is no insurance or corporate health system involvement — just doctors and patients. The monthly fees can be hundreds to thousands of dollars a month, but it brings direct access to doctors, the coordination of care and an emphasis on wellness. A 2020 study by the Robert Woods Johnson Foundation found that concierge care was being used by one out of five wealthy Americans (defined as the top 1% of the income bracket). An obvious concern is that this approach is out of reach for most and doesn’t address the issue systemically..

For the not-so-wealthy population, huge retailers are stepping into the void to offer their customers faster access to primary care. Walmart has been opening store-based clinics and exploring buying a stake in primary-care chain ChenMed. Amazon purchased One Medical for $3.5 billion and now offers access to primary care visits for their Amazon Prime members for $9 a month. Drugstore chains CVS and Walgreens are leaning further into health care delivery, and retailers as diverse as Kroger and Best Buy have health care divisions.

More recently, Costco began offering its members access to medical care through a deal with online marketplace Sesame. The clinicians who contract with Costco set their prices and patients pay them directly, not through insurance. For example, for just $29, Costco members can book an online primary care visit with a doctor — often on that same day.

David Goldhill, chief executive officer of Sesame, told the Seattle Times in 2023 that the goal is to provide value-conscious health care to people who are having difficulty accessing primary care.

“Health care is increasingly becoming a consumer business,” Goldhill told the newspaper.

Kennedy is skeptical about the concept that patients should get their primary care at a membership club where they purchase their car tires and enormous bottles of sugary drinks or at a drug store that sells cigarettes.

“Some of these companies that claim to be interested in health care constantly demonstrate a major conflict of interest when it comes to people's health,” Kennedy said. “I think it is hypocritical. In my mind it clearly demonstrates that they are not interested in the health of the public, they are purely interested in dollars, even to the detriment of the health of the public.”

Kennedy also has concerns about the over-reliance on telehealth for primary care. A recent panel discussion Kennedy facilitated at the Kansas Rural Health Conference addressed that very issue. 

“One of the questions that I asked the panel was, ‘Do you think primary care can be done well via remote platforms?’ Without exception they all said that primary care is best done in person.”

Kennedy notes that workforce issues and access to care may limit in-person availability, but he encourages patients to rely on telehealth for follow-up care or minor urgent care rather than primary care.

“I think the best option is a hybrid between telemedicine and in-person visits. Schedule an appointment to see a new primary care provider,” he advised, admitting that there will likely be long waits. “After you are established with a primary care provider, many offices have a telemedicine appointment option for subsequent appointments or urgent visits. While you are waiting to be seen, you can fill in with the doc-in-the-box option.”

Comfort thinks that over time, insurance companies and governments will see the benefit of in-person primary care, leading them to be part of the solution.

“I’m optimistic for the future,” Comfort said. “We know primary care works, and we know primary care saves lives and improves the health of our communities.”

University of Kansas Medical Center

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