- Amna Nawaz:The American Medical Association says the U.S. faces a growing shortage of physicians, especially those in primary care fields, like internal medicine, mental health and pediatrics.By 2034, the group predicts a shortfall, as much as 48,000 primary care doctors, driven by population and demographic trends and burnout.Fred de Sam Lazaro found one doctor-patient model that may benefit both, one piece of the patient revolution. The story is part of his series, Agents For Change.
- Fred de Sam Lazaro:Deep in Wisconsin’s Northwoods, Kristen Dall-Winther is living her dream. From the pancake breakfast, to seeing her kids off to school, Dall-Winther savors these moments before heading to work at Birchwood Family Medicine, a clinic she started two years ago.
- Dr. Kristen Dall-Winther, Birchwood Family Medicine:I grew up watching “Dr. Quinn, Medicine Woman,” and, like, idolized her.And I ended up forming a relationship with Patch Adams, the doctor, not Robin Williams, of course, who played him in the movie, but really just got, inspired around what — how he delivers care in a way that really doesn’t take cost too much into consideration.
- Fred de Sam Lazaro:Her first stop after med school was the Mayo Clinic, where she spent 10 years, financially rewarding, she says, but at great personal cost.
- Dr. Kristen Dall-Winther:It was beaten into you in training that you just need to work constantly. I would work from 6:00 a.m. until midnight.And I would put my babies to bed, and they’d say, “How many charts do you have left tonight, mommy?”It’s what we have always wanted to do.
- Fred de Sam Lazaro:Now she has time for both family and patients.
- Dr. Kristen Dall-Winther:When I was at Mayo, I certainly knew my patients, but I had 3,000 patients that said, she’s my primary care doctor.And, here, our practice closes at 600. I have five times as much time with every patient.
- Fred de Sam Lazaro:It has had a cost, this time financial, a 60 percent pay cut, one she hopes to recover as the clinic grows to the 600-patient cap she has set.It’s now at just under 400.
- Dr. Kristen Dall-Winther:You changed your hair.
- Fred de Sam Lazaro:Adult patients pay $80 a month for what’s called a membership. It buys unlimited clinic visits, 24/7 access to Dall-Winther, typically using a secure app, and significantly discounted imaging and labs tests done right in the clinic, like a comprehensive metabolic panel, or CMP, a blood test to check a patient’s metabolism and chemical balance.
- Dr. Kristen Dall-Winther:The difference is astounding. CMP, a metabolic panel, at Mayo, they’re going to bill $134, around there, for a CMP. Here, it’s $4.50. And that’s true across the board for every lab, every X-ray or radiology exam.
- Fred de Sam Lazaro:The Birchwood clinic operates on a model that’s become known as direct primary care, practices that avoid dealing with insurance companies if at all possible.Across the United States, some 2,000 primary care clinics now operate on some variation of this model.
- Dr. Kristen Dall-Winther:Let me just check your others.
- Fred de Sam Lazaro:For patients like 25-year-old Russell Bacon, it’s the difference between having and not having health care. His job as a heavy machinery operator doesn’t offer health insurance.
- Russell Bacon, Patient:It honestly used to scare me to go into the hospital, not for the needles or the doctors or the sickness or anything, but just for the price of it.They don’t tell you how much you’re — they’re going to charge you, and it could be $100, or it could be $1,500. And that’s a tough pill to swallow sometimes.
- Fred de Sam Lazaro:But 80 bucks is affordable for you.
- Russell Bacon:Eighty bucks a month is very affordable. And the amount of care that you get with that $80 is unbelievable.
- Dr. Kristen Dall-Winther:Have any issues with blood sugar?
- Fred de Sam Lazaro:That level of care is what draws patients like Tiana Kristensen. She has health insurance, but opted to pay the clinic membership fee. Now expecting her second child, she values the more personalized care here.
- Tiana Kristensen, Patient:Not that we didn’t like the health care system we had before. Like, they did great. We had great physicians. We had good care.It’s just, being such a big system, you fall through the cracks.
- Fred de Sam Lazaro:It might bring more satisfaction to patient and doctor, but small clinics like these likely add further stress to a system that’s already stretched thin.
- Dr. Robert Berenson, Urban Institute:One of the major problems in health care delivery is the shortage of primary care health professionals. The Baby Boom generation, which makes up a significant portion of physicians, are retiring.
- Fred de Sam Lazaro:Robert Berenson, himself a retired primary care doctor, is now at the Urban Institute. Besides retirements, he says fewer medical graduates now opt for primary care. Aside from the daunting insurance paperwork, he says their work is valued far less than that of specialists by insurers, including the largest, Medicare.
- Dr. Robert Berenson:The Medicare fee schedule assumes that a dermatologist takes 29 minutes to freeze a wart with liquid nitrogen, a service that is not even a procedure that takes about 15 seconds. And the payment is as much or I think a little more than a physician spending 15 minutes with a patient with multiple chronic conditions.
- Fred de Sam Lazaro:And he says attempts to raise primary care reimbursement have proven difficult amid rising health care costs overall.
- Dr. Robert Berenson:When I discuss this issue with private health insurers and say, why don’t you increase the payment to primary care doctors, it will pay off in the long run, their basic answer is that we don’t focus on the long run.And so the Congress needs to step up in terms of Medicare, but it doesn’t. And that goes to the whole issue of election financing and all of those issues, which are above my pay grade.
- Fred de Sam Lazaro:So the trend is just the opposite of the Birchwood model. Large group practices now employ about two-thirds of all primary care doctors in America. Many are owned by insurers and even private equity investors.
- Dr. Kristen Dall-Winther:There are a lot of morally injured doctors who are living everyday with that conflict of what they believe and how they how they wanted to deliver care.But they’re up against a system where they feel trapped to some degree. And they’re having to just kind of play along to exist. The people that I see here, I do an exhaustive dig into their old records. It’s shocking and kind of horrifying at how common I find things that have fallen through the cracks. And that’s just the nature of doing medicine in 15-minute increments.
- Fred de Sam Lazaro:In a system of ever-larger health care organizations, Dall-Winther says she feels fortunate to be able to practice medicine, as it traditionally has been in America, in a small independent clinic.For the “PBS NewsHour,” I’m Fred de Sam Lazaro in Birchwood, Wisconsin.
- Amna Nawaz:Fred’s reporting is a partnership with the Under-Told Stories Project at the University of St. Thomas in Minnesota.
Direct Primary Care
bringing patients in, keeping insurers out
The U.S. faces a growing shortage of physicians, especially those in primary care fields like internal medicine, mental health and pediatrics. The shortfall is driven by population and demographic trends and burnout. We report on a doctor-patient model at a clinic in Wisconsin that may help the problem.