April 28, 2010 / 9:49 PM / in 9 years

Daily struggle: U.S. system strains primary doctors

WASHINGTON (Reuters) - With an average of 23 phone calls, 18 patients and 20 lab reports to deal with each day, Dr. Richard Baron of Philadelphia is pretty busy.

A doctor checks the blood pressure of a patient at the J.W.C.H. safety-net clinic in the center of skid row in downtown Los Angeles July 30, 2007. REUTERS/Lucy Nicholson

His practice of five primary care physicians looks after more than 8,400 patients, and he says the challenges they face every day in providing that care and getting paid for it lie at the very heart of healthcare reform in the United States.

Baron provides a snapshot of his busy practice in this week’s New England Journal of Medicine and says unless the system changes, doctors will continue to shy away from primary and general care and newly insured patients will have nowhere to turn.

“At a time when the primary care system is collapsing and U.S. medical-school graduates are avoiding the field, it is urgent that we understand the actual work of primary care and find ways to support it,” Baron writes.

“Our snapshot reveals both the magnitude of the challenge and the need for radical change in practice design and payment structure.”

For instance, it is almost impossible to be reimbursed for an everyday service such as a simple prescription refill, said Baron.

“For a patient, they call up and say ‘My bottle is empty. I am out of whatever. Can you refill it?’.” Baron said in a telephone interview.

“The first question you got to ask is, is the patient on that medication? What is the dose? If a prescription is a cholesterol drug, you might want to ask when was the last time they got a cholesterol measurement? What was it the last time we measured it?” he added.

“There are all these things we have to do to take care of patients that don’t happen at visits.”


Baron said his practice, like many U.S. practices, is paid via a patchwork of Medicaid, Medicare — the U.S. government health insurance plans for the poor, disabled and elderly — as well as private insurance.

Electronic health records have helped but his office still employs four medical assistants, five front-desk staff, a business manager, a billing manager, a health educator and two full-time clerical staff. “We saw patients from 7 a.m. to 7 or 8 p.m. on weekdays and from 8 a.m. to noon on Saturdays,” he adds.

Currently doctors are usually reimbursed only for a patient visit, but Baron does not advocate being paid per phone call or per prescription. “The administrative cost of billing for it and somebody auditing it and saying is that sufficient clinical engagement to justify billing for it — I think that would be a colossal waste of resources,” he said.

Instead, how about an annual fee per patient, asks Baron.

He said he could save a health plan $800, for instance, by telling a patient in a quick phone call he does not need a colonoscopy that year because he had one three years ago with an all-clear.

“If primary care were more accessible and available and engaged, then patients would be more inclined to go to the primary care doctor than to an emergency room or a specialist,” Baron said.

“That would represent substantially less cost overall to the delivery system.”

Editing by Cynthia Osterman

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