There is a good story to tell about using more primary care providers (PCPs). They are fairly low cost providers who can provide a lot of touches to patients with chronic conditions. These frequent, low cost touches should allow chronic conditions to be managed more effectively. The relationship and trust built will lead patients to head to their PCPs instead of the emergency room. Everyone is healthier and the total cost of care decreases.
This is a great story.
It is increasingly looking like it is not a true story.
A new study from Virginia is being discussed in an NBER working paper:
We conducted a randomized controlled trial, enrolling low-income uninsured adults to determine whether cash incentives are effective at encouraging a primary care provider (PCP) visit, and at lowering utilization and spending. Subjects were randomized to four groups: untreated controls, and one of three incentive arms with incentives of $0, $25, or $50 for visiting a PCP within six months of group assignment. Compared to the untreated controls, subjects in the incentive groups were more likely to have a PCP visit in the initial six months. They had fewer ED visits in the subsequent six months, but outpatient visits did not decline. We also used the exogenous variation generated by the experiment to obtain causal evidence on the effects of a PCP visit. We observed modest reductions in emergency department use and increased outpatient use, but no reductions in overall spending.
This is strong evidence. It is in an randomized control trial. It is a study where the study population is prone to have avoidable emergency room visits and non-regualr care. Everything is set up to see significant impacts of PCP care coordination.
And then nothing much.
This is important. The PCP care coordination story is a story that sounds good. It sounds plausible. And we have been investing a tremendous amount of time, effort and intellectual firepower into encouraging more primary care coordination.
And the evidence is shaky. It is either not there, or it is just bloop singles.
Grendel
One problem is how hard it is to get in to see the PCP. I know that 9 times out of 10, if I call for an appointment with my doctor, he is not available for at least 3-4 weeks. Usually I can get in to see a mid-level (PA or NP) but I don’t really trust them as much. Plus it’s usually just someone random that I’ve never met before who happens to be the one they stick all the “walk-ins” with.
And, on top of that, they’ll tell you in a heartbeat that if you’re having serious symptoms you should go straight to the ER. The people answering the phone and telling patients that are not really qualified to do triage so you’re left to your own judgement as to whether your issue is serious or can wait to see the actual doctor or if you can get by with a quick visit with a PA.
Nicole
That’s interesting, if disappointing. But that’s science for you. It’s not interested in the desired result.
It seems to me like the next step would be to loose the sociologists on this to see if there are identifiable reasons on the human interaction side why it’s not reducing costs. Is it getting access at odd hours, is it a reluctance to deal with a chronic condition like diabetes (I have had many folk with diabetes in my life who were pretty lax about taking care of it- I know, plural of anecdote is not data).
I also wonder- was the total length of time of study six months? That doesn’t seem like a very long time to build up the kind of trust they seem to want with a PCP so that people would go to them before anything else.
Not disputing the findings one bit; just curious if they would bear out over a longer time period with, I assume, more time to forge a relationship with a PCP. When you’re poor, I imagine most of your contact with the medical industry is when there is a problem and that shapes a certain mindset towards accessing care. I’m in my 40s, have had cancer and broken a bone and given birth and assorted other health issues, but, having grown up middle class, I am certain my regular checkups with my assorted dentists and pediatricians and PCPs and gynecologists still far outnumber my “have a problem” visits over the course of my life.
father pusbucket
“ED” means … ?
Starfish
The primary care physicians have too many patients, are constrained by hospital policies, and are quick to refer you to specialists. If I see a PCP twice a year does she remember who I am? I have a better relationship with the lady who cuts my hair because when I see that lady twice a year, I get to spend about a half hour with her each time, and we chat.
Nicole
@father pusbucket: Emergency Department, I am assuming.
Though the other one could fall under “chronic condition,” I would guess, and would be a fine reason to reach out to the PCP.
father pusbucket
@Nicole:
1. Thank you.
2. Nice one.
3. Yes, thank you very much, I assumed “E” meant “Emergency”, but was expecting “ER” and the “D” escaped me. :)
Michael
@father pusbucket:
ED=Emergench Department
Crashman
I see my PCP once a year for my check-up, and he’s great. But it’s so hard to get an appointment for anything else. During the rest of the year, if I have an issues, I go to the urgent care. I’ve probably been there 6 or 7 times in the last couple years (mostly for sinus infections) and it’s pretty convenient.
bupalos
If you don’t think PCP is a panacea, I don’t think you’ve really had PCP. I mean, it’s temporary and all, but as far as completely obliterating all your cares and worries, it definitely has you covered!
Dino Ramzi
Yes, they are.
Seeing a primary care physician once because someone gave you money is not the same thing as having a long-term relationship with a trusted advisor.
Another Scott
I realize it is dangerous to do arm-chair quarterbacking, especially about something as complex as heath care policy and studies, but …
Um, low-income, uninsured adults probably don’t have the money to pay for any treatment that a PCP recommends or prescribes, so why would one expect that ER/ED utilization would decrease???
“People got no jobs and got no money” as Atrios often said.
Around here, $50 probably wouldn’t even pay the whole bill for the PCP visit if one didn’t have insurance. :-(
Were these people also enrolled in some sort of insurance? If so, wouldn’t we expect utilization and costs to increase early on, while still having ER/ED visits because of pre-existing conditions that hadn’t been treated earlier? (As Nicole said,) Is it realistic to think that 6 mo is long enough to see an actual effect? Assuming one has blood work done at the first PCP visit, it may take 6 months to have any indication that the treatment is appropriate and working. Etc.
What am I missing?
Thanks.
Cheers,
Scott.
Nicole
That is a good point, about the challenge of seeing a PCP. Ours, who I have been with for 20 years because she’s awesome and I love her, now has a nurse practitioner doing the wellness checkups because her practice is so crowded (I know I have followed her through three different changes of office over the 20 years). Which I didn’t mind; I liked the nurse practitioner, but I can see how that would complicate the building trust thing.
Mind you, when my husband called into the office concerned he was developing asthma, they got him right in and dealt with a few other minor issues in the same visit. But he’s had the years with her so that he goes to her first with a problem, rather than the ER.
amygdala
@Another Scott: I haven’t gotten all the way through the paper yet, but the study group was enrolled in a safety net program at VCU in which, in addition to being assigned a PCP, they were assigned “free or low-cost care.” It was, as David points out, a randomized trial so if “low-cost” was prohibitive, it was for all the intervention groups.
At first pass, what I’m struck with is that there isn’t a cost savings in the short-term, but that it may still be possible that savings and/or improved quality of life could accrue over the longer term. That would be a more challenging, expensive study to do, though.
Also, there’s something to be said in many communities for offloading the ED, since so many of them are overextended.
Thanks to David for posting this.
*goes back to reading*
Nicole
@amygdala: Thanks for reading through it- it’s one of the big challenges, I think- that the savings in many things appear to be most apparent over the long-term, and that’s not of interest to the health industry (as David said in a post months ago about treatments for hemophilia- it’s cheaper for a company to kick the problem down the road, when odds are, another company will be dealing with it, than to pay to fix it for good now).
The Moar You Know
I absolutely don’t get this, it must be some Republican myth or something. I have never seen anyone go to the ER for anything save actual emergencies or opiate withdrawal (I’ve never seen that succeed as an opiate-getting strategy, so one wonders why they still try). Is this really a thing? People go for common medical issues? I just can’t believe it.
Argiope
Who is providing the primary care? Is it physicians, PAs, or advanced practice nurses? In intervention studies, details like this matter. I looked at the original paper and couldn’t figure out which professional group was actually providing the care. These providers are socialized and educated quite differently, and the process of care (how it’s done) is going to matter in utilization, not just the content (what’s done). I’m not sure it’s appropriate to conclude that PCPs don’t work, unless we control for who’s providing the care in the design.
amygdala
@The Moar You Know:
It does. The stories of people calling 911 to get a ride to the ED for a med refill or routine problem are probably overblown, but do occur.
The ED, like the criminal justice system, deals with a lot of what society would rather not: folks with chronic mental illness including addiction, the homeless, disabled, or elderly people just hanging on at home without family or other support. Urban EDs have their so-called “frequent fliers,” who are in multiple times a week, sometimes even more than once a day. It’s not unusual that it’s the social problems underlie some or even many of these visits, rather than an acute medical or psychiatric issue. Sometimes people are cold, hungry, lonely, desperate, and don’t know where else to turn. I doubt there’s an ED physician alive who hasn’t looked someone like this over and realized that a sandwich and a cup of coffee is really what the poor soul needs and wants, at least for that moment.
The VA has some systems of care for folks like this, as do some cities. The hospital I used to work at had a case management system that identified so-called “high-utilizers” and assigned them a case manager who knew what freeway overpass they lived under and would find them and take them to appointments, help them get scrips refilled, etc. It doesn’t always work, but when it does, it’s amazing.
Tenar Arha
My problem with PCP’s generally tends to be trying to build a relationship with one when I’ve had to change insurance every few years. Seriously, within the past decade I’ve had to move from United, to BCBS, to Tufts, & this year I’m considering a new health insurance provider because my old primary doctor already moved, & the existing practice isn’t taking more patients. Even though most doctors take at least a few insurance companies, the variations in networks & plans means building a PCP relationship may be impractical.
ETA Essentially my PCP just ends up being like a backup care coordinator and administrator for the health insurance company.
Dr. Ronnie James, D.O.
@The Moar You Know: No, it really is a thing. My hospital has a standalone ED in one of the poorest part of our county (already the poorest unhealthiest county in the state) and ~half the patients are walking in for what should be routine PCP office visits: sprains, STD checks, etc. Outside of business hours, they become the majority of patient encounters. My wife is an EM doctor and has seen this pattern in nearly all of the 15-20 emergency departments she works in (less so in more affluent areas). Personally, I think we should consider reclassifying emergency medicine doctors as PCPs but it’s problematic and the majority of them seem to object to it in principle.
Juice Box
As a retired PCP, my anecdotal experience has been that people who have gone without medical care for an extended period often need an extensive tune up. Undiagnosed depression and anxiety are as common as diabetes, blood pressure, and the usual primary care conditions. It can take a while to get those mental health issues diagnosed and stabilized. Being poor is really hard and can trigger multiple psychiatric issues.
US primary care trainer is not as extensive as European training and needs improvement as well. US PCPs could provide higher quality, more efficient care with better training.
Scheduling with PCPs can easily be addressed. Both my former employer and my own doctor’s employer have managed to solve the problem.
Dr. Ronnie James, D.O.
@Juice Box: Very true. I’d be interested to see if and how costs are affected over a longer term than 6 months. One of the main advantages of PCPs (full disclosure: I am one) in theory is preventing / screening for sequelae of chronic disease. These are catastrophic things (heart disease, stroke, amputation and, again, cancer) that don’t necessarily show results in 6 months. A patient who’s back online will also incur a number of lab costs, “catch up” screenings, and follow-up tests in the first 6 months which you wouldn’t expect to see routinely afterwards.