Stresses of primary care

Primary care is stressful. By the time the last patient leaves the office at the end of the day, I feel like an old dog run over by a truck. And it's not really the end of the day. Charts are piled on the desk, phone messages beg to be answered, and authorization requests wait to be completed.

A portion of primary care stress comes from managed-care hassles. The article by Sommers and colleagues usefully quantifies the number and types of these hassles. For those of us in primary care, it all sounds familiar.

The difficulties of primary care practice go beyond these hassles. There isn't enough time to do what's needed, a reality that frustrates patients and takes much of the fun out of medical practice. Phone calls interrupt smooth patient flow. The immediate needs of patients in acute distress take precedence over the routine but highly important care of chronic illness. Drop-ins and same-day appointments are double-booked because appointment schedules are already full. An unexpected hospital admission can throw off the entire day.

When managed-care hassles are added to these day-to-day tribulations, they become the straw that breaks our backs. Half the physicians surveyed by the authors were forced to add 40 useless minutes to their workday.

Many managed-care hassles are the result of selective contracting: the policy under which HMOs and preferred provider organizations contract with some providers and some drug companies and not with others.¹ In this article, 61% of hassles involve physician referrals and drug formularies. Specialty referrals in themselves are not the problem; all referrals require time to gather information needed by the specialist. The hassles appear when specialty net-works are limited or when each managed-care plan contracts with a different set of specialists. Reasonable drug formularies per se are not overly troublesome; what drives physicians crazy is the chaos of different formularies from different managed-care plans, with each formulary changing each year.

What can be done about managed-care hassles, particularly those caused by selective contracting? I offer 3 possible solutions.

First, managed care could be eliminated, allowing patients to receive care anywhere they like. The risk with this is that the primary care model might also be eliminated, with patients being returned to the old system of care by multiple specialists without primary care coordination.

Second, a single insurer could be created so that all referrals, formularies, and procedures are the same for every patient. This would suggest a single-payer system, which offers huge advantages but is unlikely to be legislated.

Third, more integrated systems—such as the Kaiser Permanente system—could be established, thereby simplifying medical practice by offering most or all services within a single institution.

None of these solutions will transport primary care physicians into medical nirvana. Many stresses weighing primary care down will remain untouched. To improve primary care for its physicians and patients, far more is required. Primary care teams should be designed that include a sufficient number of care-giving personnel, who can free up time for physicians. Computerized registries and reminder systems would make chronic illness care simpler and more effective. New scheduling systems could ease patient access and better use physician time.

Primary care needs fundamental redesign. Eliminating managed-care hassles is necessary but not sufficient to calm the stresses and improve the quality of primary care.