What do we value in primary care?
“Your numbers are horrible.”
That’s what Dr. Michelle-Linh Nguyen, an internal medicine physician at the University of California-San Francisco, heard from her attending physician once during residency. As Nguyen writes in an essay in KevinMD, this feedback left her shocked and disillusioned– but the event soon sparked her to question why we put so much stake into primary care metrics when they often aren’t measuring what matters most.
She writes, “Ideally, core measures would represent the values of patients, support primary care providers, and promote care that is valuable to patients, communities, and physicians. Unfortunately, pairing metrics with payment can create an environment where physicians and clinics are led to approach primary care as a checklist of measures rather than focusing on relationship-building and responding to the concerns of patients and the local community.”
Nguyen notes that primary care is often undervalued within health systems as well. Rankings like the Lown Institute Hospitals Index that measure value and civic leadership could give credit to hospital systems that have a more equitable pay balance between generalists and specialists, and minimize administrative burden for their primary care physicians.
“A hospital systems’ support of their primary care physicians and clinics speaks to their dedication to serving their patients and communities over making profit.”Michelle-Linh Nguyen
One result of our current payment model is that doctors who spend more time with their patients actually make less money, a pattern that disproportionately affects women. A recent study on the gender pay gap in primary care shows that in 2017, female primary care physicians spent 20 more hours with patients than their male colleagues at the same practices. But because they had fewer patient visits and spent more time with each patient, their average pay was $39,000 less.
Rather than rewarding doctors for seeing more patients and hitting certain targets, we should be rewarding them for taking the all the time with their patients that they need to build trusting relationships. This will require a significant shift in how we pay doctors: moving away from fee-for-service payment and reevaluating the metrics we currently use to determine quality.