The Precarious Future of Primary Care

The Precarious Future of Primary Care

It is not a new dilemma that primary care has the lowest funding in health care and oftentimes has the highest overhead.  Primary care services are “high touch” and involve relationships built across time.  At Edmonds Family Medicine, we have the privilege to treat multiple generations within a family…this is very rewarding on a personal level for the physicians, providers, and staff.  It also is comforting to patients to have a familiar feeling about the people and place of EFM.  To achieve high marks in patient satisfaction, we have invested in caring staff who have great qualifications.

So what is the question about the future of primary care?  Primary care services do not receive the higher reimbursement associated with some other healthcare services (surgeries, hospital stays, some medications, etc).  The large healthcare systems can use profits from these other services to cover the business losses in primary care.  The losses in primary care come from traditional Medicare and Medicaid allowable amounts being less than the expenses of the practice.  It makes sense that most primary care offices have become employees of large healthcare systems where they can be subsidized and not be caught in the reality of expenses not covered by reimbursement. Independent of employment by a large healthcare system, primary care offices are going broke.

The country is now facing a shortage of primary care physicians.  This is likely to worsen in coming years as more primary care physicians retire and close up shop while young medical students chose more lucrative careers in specialty medicine.  We applaud those medical schools who are emphasizing primary care and are working to place more physician residents into family medicine residency programs.  We also welcome Advanced Registered Nurse Practitioners and Physician Assistants to help bring primary care services to the communities we serve.  It is our sincere hope that primary care can survive.  Why?  Because primary care is focused on keeping the population as healthy as possible.  As a nation, we need to have all folks realize their role in their own health.  Better health with less expensive healthcare services will help rationalize the services available to all.  Primary care has been at this mission for decades.

The Focus of Medicare Advantage

First, it might be valuable to understand the phrase “Medicare allowable amount”:  this is the dollar amount per each service that we are allowed to collect (usually Medicare pays 80%  of the “allowable” and the patient or supplement policy pays the other 20%).  It does not matter if we raise our fee, the only amount we can legally collect for traditional Medicare services is the allowable amount.

Back to Medicare Advantage plans, these are funded differently than the traditional Medicare structure.  The federal government contracts with health insurance plans (examples:  Aetna, Humana, Regence, United Healthcare just to name a few) to create a network of healthcare providers (physicians, ARNPs, hospitals, surgery centers, etc) in order to serve the Medicare Advantage enrollees.  The mission:  to keep the enrollees as healthy as possible.  How does this differ from traditional Medicare?  Medicare Advantage doesn’t just cover a “hands off” annual wellness visit, Medicare Advantage covers the complete physical exam (traditional Medicare only covers the “hands off” portion).  Many Medicare Advantage plans offer gym memberships and give enrollees perks or funds as a reward for taking care of their chronic disease.  Teaching patients to keep themselves healthy instead of just funding more emergency room visits or more hospitalizations means everyone wins.  Getting out in front of diseases is not easy and it takes a lot of facilitating, educating, coordinating, motivating patients to take care of themselves each day.  This is the focus that Edmonds Family Medicine wants to be part of and we believe it is the right focus for our patients and our communities.

Medicare Advantage plans actively measure quality and patient satisfaction.  Edmonds Family Medicine believes this is terrific and we are proud to have high scores.  We put time and energy into improving each day.

Steven Lopez, President of Optimal Insurance Choice, states the position of Medicare Advantage this way:

“Additional benefits on top of what traditional Medicare offers are commonly integrated into the Medicare Advantage plans as well. They’re known as enhancements and typically include things such as routine vision exams and hardware allowances, fitness memberships, preventive dental, routine hearing check-ups, acupuncture, over the counter allowances of several hundred dollars per year for pharmacy incidentals, and potentially more. As technology continues to evolve, Medicare Advantage Plans are as well by beginning to offer web-based technology that allows the patient to interact with a provider in the comfort of their home without ever having to check in to a primary care facility, urgent care, or emergency room. All these and more can sometimes number in the several thousands of dollars of additional benefits provided to the patient. The information is available within the plan designs if the patient is able to take the time to properly consider these options.”

Mr. Lopez continues, “In regards to retiree plans:  We’ve also found that in many instances when an individual is evaluating their Group Retiree choices and private-market Medicare Advantage options, they’re pleasantly surprised when learning of the significant savings in annual premium when enrolling onto a Medicare Advantage Plan. There have been countless scenarios where the individual has been able to reduce their premium by approximately $7,000-$8,000 per year, which they can then apply in other areas of their life for a little extra savings and financial peace of mind.”

Why don’t retiree benefit packages include more Medicare Advantage options?

We think this is a good question.  We pose this question to employers and others when we have an audience with them.  It appears to be a matter of inertia.  The employers and unions seem hesitant to emphasize keeping retirees healthy even though it might stretch the benefit funds further into the future.  Please join us in asking if Medicare Advantage can be added to the retiree benefit options.  (and if you are paying for your Medicare supplement plan out of your pension check, please consider how this impacts your ability to stretch your own funds…)

As long as we are asking questions about retirement benefit programs…why are retirees prohibited from ever leaving the supplement plan?  If a retiree wants to “try out” a Medicare Advantage plan for a few years, why do they lose the ability to ever re-join their retirement supplement plan?  Is this a marketing ploy so that retirees are afraid to ever leave as they will “lose” their hard-earned benefit package?  Does the retirement benefit administration believe that Medicare Advantage will make the person sicker somehow and turn them into “a bad risk”?  It seems like the retirement program is saving some premiums if a participant leaves for a few years….so if they are saving money, why not let the retiree back in at a later time?

The choices made by EFM to limit our Medicare involvement to Medicare Advantage

The points made above about Medicare funding for primary care are real.  If we did not have commercially insured patients, we would have had to shut our doors years ago.

The point about the value of relationships with patients across time is real.  We get to know our patients and we do not wish to say “goodbye” at their 65th birthday.  We want to continue the relationship.

The point about wanting to focus on the “right stuff” is real.  Keeping people healthy is our highest and best achievement.  Quality matters.  Knowledgeable and helpful staff matter.  7 day/week access for urgent care matters.

So, we found ourselves with a few tough choices…one option was to fold into a larger system where primary care is subsidized by funds from higher reimbursing services; another option was to not serve Medicare and Medicaid patients; one option was to have different reimbursement (higher due to high quality, satisfaction, and great access) from Medicare Advantage and to be able to focus on “the right stuff” more.  We chose to keep our doors open and to ask Medicare patients to enroll with Medicare Advantage so we can afford to provide primary care services to the whole community.  We still treat traditional Medicare patients in our Urgent Care Walk-In Clinic although we request that the need truly be “urgent”.

It was not an easy decision and clearly we did not communicate this well to all.  Yes, we have made exceptions…when a patient has just received a diagnosis of a new cancer, we did not wish to hassle them with changing insurance.  When we found out about retiree supplement premium issues that might cause financial hardship, we tried to sound this out (in particular, we contacted Regence to attempt to get more comparison information about PEBB retiree premiums because the anecdotal  stories from patients were all over the board).  We pressed ahead and adjusted as we learned more.  We are saddened by those who have accused us of “hating seniors” or “kicking them out”.  We miss those patients who chose to keep their supplement and go elsewhere for primary care but we understand and we wish them the best.

What changes are still ahead?

The road ahead for primary care is still precarious.  When a large multi-specialty medical group like the Everett Clinic feels they must merge into a larger publicly-traded organization in order to meet the future changes in healthcare, this gets everyone’s attention.  There has been a high degree of consolidation of hospitals and physicians in the area during the past few years.  We believe this will continue for the foreseeable future.

How does traditional Medicare change over the next few years?  Without going into a long explanation, the MACRA legislation will change traditional Medicare.  We believe that Medicare Advantage has proven to be successful enough that the federal government will allow Medicare Advantage to continue. Our Medicare population of patients grows monthly as many of our long-term patients turn 65 and choose Medicare Advantage plans.

Can patients who previously received primary care at Edmonds Family Medicine come back if they are on a contracted Medicare Advantage plan?  Yes, we welcome our patients back within five years.  If you have not been seen at EFM in the past 5 years, we will have our Medical Director review your situation.

Please feel free to send us your questions or comments on Facebook.  Thank you for your interest in being healthy and in what is happening with the healthcare system.


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