What's causing the PCP Shortage in Seattle?

By Daniel S. Frank, MD

I don’t recall exactly what heinous crime my brothers and I committed back in 1975, but as punishment, our parents dragged us to an “experimental theater” in Los Angeles and forced us to watch a play about the failures of the Soviet economic system. It was performed as a musical with actors in whiteface. Shy of having four simultaneous root canals from a group of first-year dental students, I can’t imagine a worse 90 minutes.

And yet, buried in that play is the answer to why your PCP can’t see you until sometime in the next century. It did not have to be this way. If only I had taken my ticket to that Soviet play and sent it to William Hsiao, PhD, the Harvard economist who created this mess, we all would have been spared the nuclear meltdown of primary care, and I would have been spared from going into the theater. 

We Destroyed the Marketplace for Primary Care Services 

Back in the 1980s, Medicare decided to change how it paid physicians. The agency commissioned a study, led by Dr. Hsiao, that listed everything a physician could possibly do (read a chest X-ray, perform open heart surgery, take Wednesdays off to play golf) and assigned each activity a number for how much work is involved. Medicare would then take the total of that work number for all of medicine, divide it into how much money they had sitting around, and from that, decide how much to pay doctors for everything they did. The list of services and the time, effort, training, and expense to perform them was called the Resource-Based Relative Value Scale, or RBRVS for short. Clearly, Dr. Hsiao’s mastery of economics was second only to his ability to come up with good acronyms. All health insurance companies in the US also adopted this same system. 

Dr. Hsiao’s mistake was to pay doctors much more for doing procedures, such as major and minor surgery, injections, and so forth, and way too little for what we call in medicine “cognitive work” and what other people call “thinking.” For example, back in 2003, removing a tiny basal cell skin cancer on someone’s arm might take 15 minutes and would pay $120, but spending an hour with a complicated geriatric patient with dozens of medical problems would pay $90. Putting back a dislocated shoulder which might take 15 minutes would pay $300, but a doctor would have to spend 3 hours seeing a slew of patients to generate that much revenue for the office. 

In later years, there were some adjustments to the system, but they have not been sufficient, and this is one horse that has not only left the barn, but has galloped off the ranch, leaped the fence, and already starred in two seasons of a Disney remake of the Mister Ed TV series. 

You don’t need to dive into the minutiae of the RBRVS to see this impact. You can just look at the salaries being offered in Seattle for primary care physicians (starting around $250,000) versus dermatologists ($500,000) or radiologists ($500,000). You can imagine medical students starting their careers with hundreds of thousands of dollars in debt from eight years of schooling not wanting to pursue primary care. 

If Dr. Hsiao, instead of getting his PhD from Harvard, had spent $20 on Father Guido Sarducci’s “Five-Minute University,” he could’ve gotten an A in economics just by remembering the one rule of that discipline: “Supply and Demand.” It would have saved us all a lot of grief. 

We Killed the Supply of Primary Care Providers (PCPs)

Father Sarducci would be proud. You can’t get an appointment with a primary care doctor because there is an inadequate supply, and the inadequate supply is due to primary care doctors making half as much money as the specialists. They make half as much because we are the victims of Soviet era centralized price controls with zero opportunity for the free market to set pricing for primary care services. In the few areas in medicine where the free market prevails, such as plastic surgery, I guarantee you will not be kept on hold for 20 minutes and then scheduled for four months out. 

Perhaps our nation would be happier under a single-payer, centrally-controlled national healthcare plan. The Kaiser system here in Seattle is a good model for how that would look, and for patients who want a national single-payer model for healthcare, I heartily recommend they enroll. 

If we stop the analysis here and conclude the problem is one of supply, we are making the same boneheaded mistake that every PhD Poindexter in health economics makes. It is the same error made by every policy wonk, every health insurance company, every HR benefits person, and by many patients. We are forgetting the most important thing about healthcare: quality matters.

We Forgot that Quality is the Most Important Element in Medicine

On January 15, 2009, when a completely unknown and thoroughly anonymous US Airways pilot named Sully Sullenberger, III walked through LaGuardia Airport, he had no idea that he was two hours away from becoming the most famous pilot in the world. No one zipping past Sully that afternoon, all decked out in his captain’s hat with those epaulettes on his shoulders, would have distinguished him from any other pilot at the airport. We want to believe they are all good. In fact, we want to believe they are all as exceptional as we now know Sully to be. Yet, we don’t need to stand at the smoldering ruins of an airplane that just impaled itself into a mountain to know this is false, that there is a range of skill among pilots–and physicians–that we hate to think about. 

“They’re all good.” It’s a lie and we know it. Health policy “experts” (and I use the term loosely, like you might use the term “meets most expectations” in a performance review to refer to someone you’re about to fire) see physicians as interchangeable “providers” in a machine and want us as patients to view them exactly the same way. 

Borrowing from Woody Allen’s joke about dinner at a Catskills resort, the food is terrible and the portions are too small, we have the same problem in primary care. It’s not just the lack of availability, but the poor quality of the encounter when you finally show up. This poor quality is driven by two factors. First, the doctors who go into high-paying specialties, such as dermatology, plastic surgery, and radiology are, on paper, better as medical students than the doctors who go into primary care. And by “better on paper,” I mean they have higher test scores, attend better medical schools, get higher grades, and more impress their professors. You know, better. 

We Treated Primary Care Providers Like Assembly Line Workers

The second problem is the speed at which these primary care physicians are expected to work. Good medicine takes time. I don’t care if you dropped 60,000 euros on a degree from Le Cordon Bleu in Paris, if you’re working the breakfast rush at Denny’s, we’re not going to see any soufflés blasting out of that kitchen. No doctor wants to work under these conditions, but the answer to low payments from insurance companies is to insist physicians see more patients in less time. But just like Lucille Ball on the chocolate factory assembly line, as it speeds up, well, quality suffers. 

If you’re a primary care doctor in Seattle, a pulse and a license will get you hired, but the high cost of living in the Seattle-Bellevue area and the domination of the local healthcare marketplace by large, soulless hospital chains further drives away these physicians. Of the doctors here in the primary care workforce, probably half would quit medicine today if they could afford it. Early retirement, going part time, and switching to non-patient care roles further pull primary care doctors out of the action. 

You might think solving this problem would be easy: just have primary care doctors see one-third as many patients and pay them twice what they make now. This would only cost the system about $400 billion above the $4.5 trillion we’re paying for healthcare. But there’s a second problem. Two generations of physicians have come to this profession thinking that a career in primary care is for morons. It’s funny because the opposite is actually true. In a bygone era, the best physicians were generalists in medicine and surgery, and the idiots did anesthesia. Practicing primary care, as it should be practiced, is far more intellectually challenging than limiting your work to a single disease or a tiny handful of surgical procedures, but this specialty is often a last choice among top medical students. 

Another approach is to expand the primary care workforce with nurse practitioners and physician assistants. Occasionally, one does find such a non-MD clinician who functions at the level of a physician, and research shows that these providers, when working alongside physicians, produce equivalent patient outcomes, but this is more an indictment of the low quality in primary care than an endorsement of non-physician providers. Melissa Schorn Kester, DNP in our office performs above the level of virtually all primary care physicians in the community, but she just happens to be an unusually talented and driven clinician. I don’t think there are enough brilliant nurse practitioners or physician assistants to solve this national problem. Perhaps at Lake Wobegon where everyone is above average, or at Lake Woisme where everyone is in the top 5%, we could do it, but not here. Quality matters, and right now in primary care, we have bad food and small portions. 

Can We Throw Money at the Problem and Make it Go Away? 

Does the concierge medicine model solve the problem? Well, in terms of getting an appointment the next day or not waiting on hold, it certainly should. But an equal concern is the low skill level in the primary care workforce as a result of Dr. Hsiao’s centralized planning and price fixing. It has driven the high performers out of primary care for the past 30 years. Just to grab one anecdote, a patient of mine in a concierge medicine practice at the Mayo Clinic saw her “concierge” primary care physician. She needed a minor in-office surgery performed, an easy gynecological problem addressed, and a medication refilled. She was referred out to three different specialists and told none of those things could be done by that concierge PCP at the Mayo. I took care of all three items immediately and in a single visit. Just giving doctors more time with patients might not pay off if there is a significant skill deficit that needs correction. 

For those who can afford it, I do think the concierge model is the best option to gain access to primary care. But is that doctor actually a gifted clinician and how can you tell? All airline pilots in those fancy uniforms look great to me, even though they would fly the plane just as well in boxer shorts. Picking out Sully from the crowd is pretty dang tough for us as laypeople, and the same is true for choosing doctors. Yes, we need a PCP who will answer the phone, but we also want that individual to be able to land on the Hudson with no engines. 

In a pool of physicians, you occasionally find an exceptionally talented clinician for whom primary care is more like a calling than a job, a physician who could have been a radiologist (we have two of those) or some other narrow, high-paying specialist, but chose primary care because this was how that doctor wanted to spend his or her professional life. It’s someone who was driven to become a “real” doctor. 

I feel fortunate at MedNorthwest, that after 15 years of recruiting, we have assembled such a workforce. However, our office skimming off the top 1% of primary care clinicians to do concierge medicine is not going to solve this problem on a population-wide basis. These gifted physicians eventually fill their practices, and then it’s game over for everyone else. Telling a typical primary care doc used to blasting through 20 patients a day to suddenly start practicing at our level is a nonstarter. The full scope of primary care, at MedNorthwest at least, managing complex internal medicine problems, performing skin biopsies, injecting all sorts of joints, doing bedside ultrasound, performing minor surgeries, managing mental health, overseeing and supervising the work of specialists, not referring every issue to another doctor, it’s a high bar.  A broad scope of practice is one sign of an exceptional generalist in medicine, and a great personality doesn’t hurt either. But there are only so many doctors out there like that. And then you have to ask, what is the value proposition in concierge medicine if not done this way? Is it just getting an appointment? 

This Problem Cannot be Fixed for Everyone Right Now

I understand how and why Dr. Hsiao and the RBRVS put us into this mess and destroyed the primary care workforce. Sure, I can solve the problem for a thousand patients at MedNorthwest who want to throw a few hundred bucks at it every month, but I can’t solve this problem for the rest of Seattle or the entire United States. It is going to take a generational change in how we develop and deploy the primary care workforce to fix what has been broken. It’s going to require elevating the skill and scope of practice in primary care so that it is not seen as a backwater specialty, ensuring that doctors have a reasonable workload and enough time to see and think about patients, and compensating doctors and specialists proportionate to their talent and work. 

And there I am, back in 1975, squirming in my seat, bored to high hell, not understanding that the central control of a vast economy destroys wealth, quality, and service. Not understanding the impossibility of speaking out against the Soviet system, that even this play’s level of dissent was barely tolerated. Son of an entrepreneur, grandson of an entrepreneur, I stared at those actors flailing around the stage with their outsized, theatrical expressions of frustration and thought, “I don’t get it. If they have shortages and can’t run the government factory, why not just start your own factory and do it how you see fit?” Why not, indeed. 

The opinions expressed in this article are solely those of Daniel S. Frank, MD and under no circumstances do they represent the official views or policies of MedNorthwest, well, unless you agree with them, in which case, sure, these are the official views and policies of MedNorthwest, a Washington Professional Limited Liability Company.