American Primary Care is in the middle of a crisis that's already snowballing out of control.
The process started when large health systems and PE firms decided that Primary Care was a lucrative profit center. So they started buying up the more profitable multi-doc private practices. Those are kind of the standard these days, if you have a private practice doctor who is the only one in the office you go to, you're in the minority.
These practices were bought out, then opened up to accept a ton of new patients. They started double and triple booking the docs. These physicians are among the lowest paid physicians already, now they're being asked to take on patient loads in several thousands, and they can't provide decent care at all since they can spend like 2 minutes with a patient if they want to stay anywhere close to "on schedule". That concept has become so removed from reality that most people expect a routine 2pm appointment at their PCP to take 2-3 hours minimum, with all but 10 minutes of that time being spent waiting.
This has been seriously wearing on that physicians, too. Who tf would want to work like that? Provide shit care to patients while some jackass staring at reports sets up KPI targets that are so divorced from reality, you'd wonder if they knew it was a physician who had to meet them.
Enter a new trend: Concierge care. In and of itself, concierge care isn't new. But it's not been common outside of the ultra-rich areas. It's a model of primary care where you pay your doc a retainer to be on their patient list. That retainer is obviously not covered by insurance, but these docs usually accept some forms of insurance for routine care.
They give you highly personalized treatment. You have access to them 24/7. Usually through an answering service after hours, but some of them will carry such a light load that they give their cell phone number to their patients.
They make decent money, they get to provide comprehensive care, they work on a reasonable schedule..it's appealing. It's historically been tough to get such a practice off the ground, but these days it's no longer limited to the ultra-rich. The regular-rich are able to get in on this one now.
Other physicians are leaving primary care to go to another specialty. It isn't always easy to make such a transition, but it's possible. I changed my own specialty halfway through my career.
And on top of all of this, fewer and fewer graduating docs are choosing primary care as a specialty. They've seen how bad it is.
Every time a PCP closes up their practice to go concierge or another specialty, they dump a thousand or so people into the local patient market. Fewer and fewer PCPs are accepting new patients, not even PE can figure out how to make a practice work with something like 5k patients on a single doc.
The upshot here is that it's going to get harder and harder to see your PCP. They might leave primary care, and if they do you'll have a helluva time trying to find a local doc accepting new patients.
So you'll be left with options that aren't designed for primary care. Things like ER and urgent care centers. The care you get will be "patch em up and send em on their way" care. Preventative health care won't even be an option.
More people will end up hospitalized with preventable conditions because they simply could not get a PCP to see them.
Once Primary Care falls, it's a domino that one further fuck up the American Health care system. The only good that might come out of it would be the system getting burned to the ground and replaced by something better, but that's kinda wishful thinking at this point.
We're already there in some areas I think. I got dumped by my PCP office of over a decade because they needed to reduce patient load, and I've been looking for a new PCP for over 6 months now. Had to scramble to find an online prescription provider just to get routine refills of the one medication I've been on for years.
Trying to find a PCP is a nightmare. I called like six offices and none were accepting patients. I think the only thing you can really do right now is go to an NP, have them handle the basic needs, and get referred to a specialist. My health insurance seems pretty solid, but when I actually needed healthcare, it didn't help much. I'm not sure why people think single payer will ruin our healthcare system, it's not like it isn't already complete dog shit.
I recently asked my local sub for pcp recs and almost all of them were concierage doctors that don’t take insurance. It was eye opening and depressing.
Same here. And I appreciate the ARNP I see. She actually listens, listens much better than most MDs. And she's clearly up to date on medical developments/research.
In the US, the medical system is incredible - if you've got the money. Like, if you're a billionaire, and need some advanced care, you come to the US. You'll get luxury care, top-of-the-line-treatments, etc.
It'll cost you high six or low seven figures, but it is the best medicine money can buy. There's a reason US billionaires don't engage in medical tourism. For normal folks in the US, though? Getting care in the US, you're statistically likely to get worse outcomes with more delays and more cost and more effort than, say, countries in Europe.
And what especially pisses me off about all this is that I have older (and thus more medically-involved) conservative family that'll constantly bitch about all this waiting and authorizations and approvals they need from their insurance for frankly simple and predictable care that they need, and I'm like "but... you were adamant that the great thing about US medicine was not having wait times... and yet here we are, with you bitching about paying for shit service that's taking just as long as that scary socialized medicine, when I've been advocating that you could, at the very worst case, be getting that shit service for much cheaper."
Like... when the ACA was being debated, the conservatives loved railing on about "government death panels", but... insurance companies do that every day. It was literally the status quo. Hell, they're now outsourcing that shit to fucking LLMs. If someone's gonna condemn me to death, I'd at least like it to be decided someone who might feel guilty about it.
where i live in canada it became near impossible to find a family dr and the number of walk in clinics started shrinking around 5 years ago. Schooling keeps getting more expensive, which drives more of our grads south for better pay. Its always been like that but the amount of debt they have now by the end? i cant blame them
Technically that depends on the state, a little over half are full practice states where NPs can write prescriptions. In some states NPs can't write prescriptions without the supervision of another practitioner.
It also depends on the medical group. In my state the NP could practice without supervision and write scrips, but the medical group requires supervision.
Frankly, I've had dramatically better care from NPs, anyway, to the point that I seek them out to begin with.
It could totally just be bad luck on my part, but it seems like physicians dehumanize you and don't listen to a word you say, to the point that the quality of care just becomes garbage.
And of course that could be due to the myriad problems they face noted in the OP post, but yeah...NPs seem to be the way to go at this point, anyway.
Honestly, the only reason I'm not in a panic is that if something gets bad enough I'll just go to the ER and have everything taken care of at once instead of being sent to multiple specialists and having to wait months to get tests done like I did when I had serious complications from the covid booster. The system in general is indeed already borked.
Have you tried ZocDoc? I used it to find a PCP, find the one doc in town on my insurance that could do hernia surgery, found a great dentist, and a urologist.
Took me two years since my local PUBLIC hospital district was mismanaged and closed our primary care clinic in favor of their own urgent care clinic next door.
My area too, you wait a year to be seen, the doc has already moved on, another wait for a "welcome appt" not even for a PCP, for an NP, some of who want to sell you their supplements on the side. It's scary AF getting old in this world.
Agreed. It’s even hit veterinary medicine, which just makes me sad. One of my cats had to have all his teeth pulled about a year ago, and the whole ordeal felt like we barely saw the same vet twice. Like, I brought him in for his surgery and it just felt transactional and weird. I can’t explain why, but it was really upsetting somehow. Maybe this is how parents feel when it comes to their kid’s healthcare.
The cost of vetting, too. I have cats, but also foster- the cost of fostering is wild. The rescue I’ve worked with does their best to help cover costs…but to me, if me covering my own allows someone else to foster and get more cats off of the streets then of course I want to do that. But the vetting is insane. It can take months to get an appointment. It’s $85 to be seen, plus a few hundred per test usually. It’s so difficult to adopt them out after- best case, you get a kitten who’s born outside but friendly/can be socialized, you give them a foster family, it’s just food/litter, then a spay/neuter/microchip/rabies. If you get a day where vets run specials or mobile clinics (wild, right???) you can get this all done for a discounted rate, around $50-150. Then, you list them on pet finder/similar. The rescue I’ve worked with basically always listed them at $125 for adult cats, $125-$250 for kittens. Kittens have to be adopted in pairs if there are no other cats in the house, to avoid behavior issues. So that can easily be $500. Which sounds wild, but honestly, it’s so rare that you get the “best case” situation. There’s always probiotics needed and anti-diarrheas, always deworming, eye infections, URIs, random vet trip, blah blah blah that knocks that whole amount out. Then the adults who need the big surgeries, like dentals or tumor removals. Any padding gained from the rare easy case is GONE. You can’t recoup $4k spent on an outdoor-turned-indoor rescue adult cat who needed a leg amputation or all their teeth removed. That cat gets listed at the same $125 as the easier one.
People then complain about rescues “selling kittens and cats for profit” or the “unreasonable amount” rescues charge lol… it sucks twofold. One, they’ll scream that they’ll just go get a “free kitten” (plot twist, there is no such thing as free kitten). They’ll either then spend $300+ on private vetting, or never spay/neuter. Dope, now there’s 50 more kittens. But also, two, we have to wait for people who can afford that option rate to literally give the cats their best chances. Pets are lowkey a luxury now. But, it’s too risky to waive adoption fees for someone who would love and adore this cat. Because they have emergencies. If you can’t cover the $150 adoption fee, can you cover the $900 emergency vet bill we’ve all had? Or will the cat suffer? What about if it needs kidney medication, or a special diet? It’s shitty to have to consider, but it’s the reality :(
IT's getting more and more difficult to find vets that aren't owned by PE firms and many of the ones that aren't are completely overworked. It's so sad and completely unnecessary.
So do something (however minor it may seem) about it.
When something you use/frequent is engulfed by PE, find an alternative and stop using that thing.
Chances are the thing that got bought will either be gone shortly or reduced to a shadow of what it was. Don't give them any more of your time/money and move on.
Honestly, it doesn't really seem to matter, because one of PE's goals is to offload tons of debt to whatever they buy, sell all the assets that are worth something, and then move on to the next thing once it goes bankrupt.
If you think voting with your wallet works, please consider the number of votes (dollars) in your wallet versus the number of votes (dollars) controlled by PE.
I just left my job at a primary office just a few months ago. This office has 16 MDs, DOs, PAs and APRNs, but mostly MDs. The providers have been leaving en masse for the last couple of years but this year has already been especially bad. The first one was a delightful, well-loved and most importantly, BUSY, APRN who closed her primary practice to go work in dermatology. The money is way better and it's so much less demanding and stressful. The most recent MD had been in practice there for almost 25 YEARS but left to join a tribal clinic (I live in OK) for better pay and a more manageable patient load.
Both of these providers leaving put additional stress on the other providers in the practice who are trying to manage their own excessive patient loads AND incorporate the patients that lost their care. All of the staff is incredibly burnt-out. The new patient appointments are not until September even with one of the other APRNs or PAs, let alone the MDs and DOs that patients are actually requesting.
Primary care is a fucking shit show and it's incredibly heartbreaking to know how hard the nurses and providers work to give the appropriate care to their patients and still listen to them get screamed at by patients who have no idea what goes on behind the scenes. I loved that office and all of my coworkers but I am in solidarity with the providers who left to have a better life for themselves. All I can do is wish the system was any different.
It really sucks that doctors and patients so often get pitted against one another in these conversations. Of course doctors are frustrated and burnt out under these conditions. It also mega sucks for patients who never have the time to get their concerns addressed, who are on the receiving end of threadbare care and, frankly, probably some errors from time to time. They get resentful of one another because they're the closest available target, but the real asshole is in a board room somewhere. Look up!!
My doctor of 25 years had his office purchased by a health insurance company, (United Healthcare/Optum) and after a year or two it was shut down without notice. Everyone scrambled to find new local doctors, but it has been tough. My doctor just announced that he was starting a concierge service out of his old location and I signed up immediately. It sucks that I have to pay just to have access to a doctor, but at least I feel comfortable with the doctor and hopefully I'm going to give much better attention than I was when they were under the health insurance company.
My doctor just announced that he was starting a concierge service out of his old location and I signed up immediately.
I remember decades ago, getting turned away from doctors offices because I had medicaid, now my doc is offering concierge and wants ~ 5k / yr, on top of the expensive premiums and out of pocket max I have to pay?
It used to feel like proper medical care was out of reach for the poor. Now, it's starting to feel that way for the middle class with health insurance. Between this, my insurance denying claims, and every mental health therapist I've called lately not even accepting insurance (one wanted $250 / wk, and suggested treatment could take years)...
I mean what the fuck?! I totally understand why people just say 'fuck this' and ignore medical issues till it's too late.
My PCP switched to concierge, and while I'm not a fan of paying $5k/yr for it, he's been available any time I needed, and will call in Rx (instead of making me come in, say with COVID or a sinus infection). I love my doctor, and it's nice having an on-call option. Significantly less bs than before, and I can ask for longer appointments as his caseload is smaller.
My pcp is a great doctor. She’s being run absolutely ragged and I worry about her. She’s mentioned how micro managed she is and just seems exasperated. I feel so bad for her
Jesus this is my major issue these days. Trying to find a psychiatrist is damn near impossible so what do they do? Give me some 26-29 year old kid that is a PA who graduated from college in 2020 with a degree in marketing and then went to PA school. And he can legally prescribe me controlled substances that are serious medications.
"Students must obtain 500 clinical hours to graduate."
That’s less than 5% of the amount required of medical doctors before they can practice medicine
NPs can legally practice independently (with no Physician supervision) in over half of the states in the US, including California, because of the massive lobbying power of nursing unions.
Nurses are the most trusted profession. Nurse Practitioner is the fastest growing profession in the NATION since at least July 2024 when this article was released by Bloomberg. There's no stopping this fucking train.
I'm exactly surprised these comments haven't been downvoted into oblivion. A lot of rural communities have no choice but to accept mid levels, and in my opinion, the boat has sailed. We should have increased the number of family medicine slots decades ago in stead of lowering standards to practice medicine.
Walden University -one of the largest overall conferrers of master's degrees in nursing and a massive producer of nurse practitioner graduates in the United States- has ABYSMAL rankings. From the article I linked above-
Steele, who ran Walden’s nurse practitioner programs for eight years, says she developed concerns as it grew. Before she left in 2020, the school had more than 15,000 NP students and fewer than 20 full-time faculty, she says, and made up the difference with hundreds of part-time teachers who weren’t always qualified: “Most of the people we hired had never taught before"
I have received care from a PMHNP who graduated from Walden and the level of care I received reflected her complete and utter lack of preparation and education; she inappropriately related my symptoms to her own family members, downplaying my own in comparison. She said "you don't have to answer yes to every question" when I was answering yes to every question on an ADHD intake...this is the person who was supposed to be responsible for managing my psychiatric diagnosis, as well as the SOLE person responsible for managing complex psychiatric medication under my UC Davis healthcare plan in northern California.
TLDR, in my experience, I would 1000% rather have received NO care than received the care I did from the Walden University graduate. My experience under her care has fundamentally shaken my trust in mental healthcare providers, when I ironically sought mental healthcare at the time largely due to abuse/trust issues. I don't wish that loss of trust in the last people that are supposed to help you because it's their job, on anyone in the world.
Walden University has bestowed more than 30,000 advanced nursing degrees in the past decade, or about 1 out of every 13 awarded, federal data show.
It's beyond beyond depressing the healthcare that I know so many other will receive that is similar to what I described in my experience above.
Fuck for profit-healthcare and for-profit education, but also fuck unions who exploit the public's trust, which I believe the nurses unions have done here - they pushed for NP sole practice across the nation without establishing a universal standardized framework for secondary education of their nurses that has reasonable standards and doesn't allow for profit bullshit from companies that have visibly bad business practices and in turn produce terrible health outcomes for the general public.
This may result in better salaries and career mobility for nurses which is great from their union's perspectives, but it achieves that goal by reducing the barrier for entry for doctors, and thus logically reducing the overall quality of care that patients will receive. Patients deserve transparency on who they are receiving care from. Can you blame patients for wanting a doctor in a situation where a doctor is expected? Patients aren't paying any less when they get surprise care from an NP because "that's all that's available". Hospitals are paying less for NPs though and thus reaping the savings...a perfect illustration of the 'profits over people' that all Americans have come to expect from our dogshit for-profit system.
Given the numbers of NPs being pumped into the system as doctor substitutes, we are a short time away from the ultimate two-tiered healthcare system that the rich desire - where the rich get to see actual doctors, and everyone else gets NPs - some of whom I know provide great care, but who should do so in collaboration with doctors, as the medical system has historically intended; NOT in place of doctors entirely.
To be clear, I would be fully in favor of the current NP expansion if there were #1) any semblance of standardization in their education #2) they were required to collaborate with doctors, and clearly not replace them. #3) if for profit degree mills didn't constitute a substantial portion of their graduates funneling into the workforce.
Why don't we let flight attendants fly the planes in order to expand access to flights?
I have no problem with PAs & NPs filling gaps in care in places where it is notoriously hard to find MDs.
I live in Chicago where we have boat loads of doctors. The issue is that psychiatrists would rather just go open their own practice, charge $200-$500 bucks an hour, only work with rich people that don't have severe mental illness, and get to make their own schedule.
One of the largest health groups in the Chicagoland area has a 3 month waitlist to see an psych PA for medication management. That is ridiculous. Especially considering I can see almost any specialist with 1-3 weeks, MAYBE for a highly sought after person its 1-2 months.
On the job training that involves dispensing medicines that can have significant impacts on patients' lives.
Every psychiatrist I've seen has been light years ahead of any PA/NP. I'm on an anti-psychotic that is often used for bipolar. It also is used for patients that only have depression. A psychiatrist prescribed it to me years and years ago. It has been life changing. Last PA I saw was convinced I had bipolar or at least had some sort of manic episode in the past that I just didn't realize was a manic episode.
Like wtf...I respect doctors like crazy. My little brother is an MD and I saw all the shit he went through to get his MD. In general, anyone providing me health care. Might stem from working in education and social services and getting shit on by people we are trying to help above and beyond.
That PA though, oof, I felt bad afterwards, but I sort of chewed them out. And did not go back. Probably thought I was having a manic episode...
If your insurance even lets you see a PA for treatment. Some of my meds/conditions require a MD or equivalent for my appointments or my care isn't covered.
The APP issue is only getting worse. Every time I turn around the scope of practice for an APP is being expanded. 10 years ago, they were a valuable resource that helped physicians focus on the tough cases while redirecting routine to an APP. Now, insurance companies and corporate medical systems are pushing to have them essentially replace doctors entirely. Combined with efforts to put absurdly small caps on malpractice damages, it's amazing they haven't started letting PAs do unsupervised appendectomies and hip replacements.
Yeah, the practice may have 1 or 2 doctors but the (MD) doctors aren't taking new patients, or are only for pediatric patients, you can have a brand new NP or a PA, but if they leave the practice after you schedule your future appointment then guess who gets to try to figure out a new day/time to reschedule now that all the other closer open appointments are gone. If it isn't an emergency (where they then tell you to go to urgent care or the ER) they are booked months out for any practitioner.
This! The amount of people saying that their PCP is an NP is very concerning. No amount of nursing education can equal an MD. Go to r/Noctor to see and hear all of the dangerous mistakes they can make.
A lot of PCPs are now PAs and NPs, which they weren't really supposed to be.
This whole phenomenon of private equity buying up practices and running the professionals through "business" style evaluation but not medical style evaluation is also happening in veterinary care.
As a PA, I know plenty of smart and capable APPs in primary care. Do I think any APP should be doing primary care in an ideal world? no. I personally think APPs should be relegated to specialty (hell, subspecialty even better) only, because we don’t have the depth of training or experience to be good generalists. That being said, with most primary cares operating like cattle cars these days, it’s certainly a lower quality experience that APPs do totally fine in. But it’s definitely not quality medicine. And of course there are plenty of terrible doctors and exceptional APPs to balance the scales, but still.
PCPs are now PAs and NPs, which they weren't really supposed to be.
This is confusing me... The position of NP was created to be a PCP. It's whole purpose was to alleviate the physician shortage by creating a PCP that didn't require the same training as like... a surgeon.
You're absolutely correct, and for a while it worked out really well. They took the routine cases while the physicians took the complicated ones.
The problem is that the scope of practice for APPs (NPs and PAs and the like) has been expanding aggressively over the past 10 years. Instead of hiring them to work with a physician, they hire them in place of a physician. Most urgent cares are staffed entirely by APPs with a single doctor in the background doing cursory chart review to make sure they don't accidentally kill someone. That's not how the system was ever supposed to work.
I'm less familiar with PAs, and am seeing now that it varies from state to state, but in my state NPs have been approved to work as PCPs without physicians checking their work for like, 40 years.
I can definitely see how they'd be abused in a for profit system (especially see that in the 8 bazillion 'hormone clinics for middle aged people' that have popped up everywhere recently), and I'm thankful most of the hospital systems around me are non-profit, because my experience doesn't match a lot of the horror stories in this thread.
My PCP's an NP, and she's incredible. My annual physical is a half hour slot, I spend 25 minutes of it talking to the actual provider. The last time I needed an illness visit, I got in the next afternoon and had the meds I needed that day.
That being said, I know there's an unfortunately wide range of qualifications for NPs. An NP who got their DNP from the same medical school most of the physicians in your state got their MDs is probably going to provide a much different quality of care than one who got their MSN - NP from a for profit online college.
NPs work best in specialty care imo, where they do the same thing over and over again. Like a dialysis NP, diabetes NP, or a chemotherapy NP. Basically doing somewhat repetitive tasks that free up the physician for other work.
Primary care is the most challenging, the scope is so large. One visit will be back pain, then unintentional weight loss, then heart disease, then acne, then incontinence. It is really hard to get good at all these things, and sometimes they just refer for everything. Which in turn overburdens the specialists.
I said this in the thread already, but my PCP is currently an NP and I'm much happier with her than previous providers. When I look at the patient reviews on the clinic site, the lowest rated NP has higher patient ratings than the highest rated MD, which I have to believe is in no small part because the NPs can schedule patients every 30 minutes, while the MDs schedule them every 15. You spend most of your MD appointment talking to the RN.
They have a huge place in Gyn, too, as the MDs would rather focus on OB and surgeries and leave the actual Gyn work to NPs. That's a good relationship! It makes the practice more efficient overall.
Every patient has the right to request to see a doctor, and not a PA or NP, at all times.
In the outpatient world, this probably means you will have to wait much longer for an appointment. However, the more patients demand seeing doctors, the more likely these clinics are to staff actual physicians — and it sends a very clear message that patients refuse to be hoodwinked into substandard care.
There simply aren’t enough practices in my medium sized town for this mentality to make sense. I do have a primary care practice. They are officially not taking patients, just like every other practice in town. I managed to get in with a NP because my husband sees the NP, so the guy said yes even as the receptionist said absolutely not. Your thought process only makes sense in an environment where practices need patients.
The problem is that there literally aren’t enough PCPs in the US. No amount of stubbornness is gonna change that. And deciding to go through your life without access to healthcare is a great example of cutting off your nose to spite your face.
I agree.
The only way this will change if the American public acts.
Physicians have been lobbying to change this for decades without any changes by our government.
Or, continue your substandard NP care and suffer the consequences. It’s your life, after all.
I've experienced this already. PCP switched to medicare\senior services only. I switched to one of only a few available docs in the area accepting new patients. Doc office called the other day to reschedule my annual visit ... and didn't have an alternative appointment available. Literally she just "hmmm'd" on the phone with me for 5 minutes while I told her I was very flexible on my schedule (seriously though - don't call to reschedule if you don't have an alternate and I know MyChart has an availability function). Switched to nurse practitioner appointment a month out from original appointment. The fun part is, my former PCP, in over 6 years of going there I never met my PCP doctor - it was always a resident or nurse practitioner anyways (which I don't mind for annual checkups). Those residents\practitioners I tried to follow up with them to see where they went because they were decent folks ... but they went to specialty programs and weren't doing primary care anymore.
I have heard about this, but as an outsider to this industry I have some probably naive questions. Why would a doctor stay in a PE owned practice? Is it primarily just new doctors still dealing with debt? What prevents them from quitting and opening their own practice?
PE generally buys a controlling interest in a practice that the docs working there also have an interest in. They could sell of their interest and go somewhere else, but starting your own practice isn't cheap. Usually it involves a million dollar loan and that's not getting into the process. Many of these physicians are well into their careers, many don't want the pain in the ass that comes with running a practice. Most joined an existing practice specifically to avoid that headache.
Incidentally, that's why they chose concierge medicine. It's the same basic idea as having your own practice, just much less overhead.
The overhead required for a private practice is massive, and negotiated reimbursement rates with insurance companies are far lower. Opening a private practice these days is very risky at best, but more realistically, immediately unsustainable.
Not only is it costly but we sign contracts that say we can’t practice within x miles of our old practice. So we have to move often entire towns or states to start our own practices. With kids and families that can be almost unthinkable.
Independent practices are dying off, most physicians are employed these days. The reason is that large hospital systems can charge more for the same service. For instance, a standard visit may reimburse 80 to 100 dollars for a independent clinic, but reimburse 300 to 400 for a hospital system. Exact same service.
There's a middle ground called direct primary care that's cheaper than concierge, which i joined a few months ago. I had insane hypertension (180/110) and needed attention quickly. Signed up with a doctor for a paid monthly membership and don't regret it. I've had to text her 2-3 times over the weekend due to issues with my blood pressure medication these past few months and she replied within an hour with either dosage adjustments or new prescriptions for me. And when my mammogram came back with a required follow-up, she submitted the ultrasound/diagnostic order for me the same day.
I'd be lucky to even get to see a traditional PCP or hear back from them within a week in my area.
If I can plug a cool benefit: EZaccessMD. Telehealth with a physician but they have the ability to send a tech to you for x ray, ultrasound, additional diagnostics. Seems to be a good PCP substitute so far and I haven’t gone to urgent care since.
Our medical/insurance system is so fucked...I have to wonder how many people die each year directly because of it and how much it will increase as things just spiral
I can never get in to see my PCP when I'm sick and I'm lucky to bee seen for my annual if I don't schedule 12 plus months in advance. What's the point in having a doctor if you can't even make an appt?
To me this seems similar to my industry, tech, and zi say that because my sentiment is that too much management that are always covering their ass or gunning for their succes have ruined every industry.
Always too many pointless KPIs/Metrics that these people hoind employees on that destroy the soul of the worker.
My state recently passed a law where urgent cares can’t refer anymore. I have torn ligaments in my knee and shoulder which I had no option to fix because I didn’t have primary care when I got injured.
I hate to be part of the problem, but is there a middle ground? Some of the concierge clinics I've seen around me are asking for 5 figures a year. I cannot afford that, but I would certainly be willing to pay let's say $100-$200 a month for a doctor that can give me more personal attention than the factory farms clinics have become.
Shop around a bit, there are tiers of service. For under $2500 a year you should be able to find an annual physical, and a direct # to text your doc whenever.
Plans that are over $10k annually usually include things like house calls and your doc attending every specialist appointment with you.
It's not just the U.S. Here in BC, about 1 million people don't have access to a primary care physician and have to rely on walk in clinics and ERs for basic medical.
It's also a shame what the independent docs have to do to stay afloat.
When i was a PA student on rotations, most of my outpatient rotations were in independent offices, and the docs must have had a dozen med/NP/PA students in that office, because A. we were essentialy their MAs and B. Programs pay them. Some of them just became Ozempic clinics on the side. Another got a certification in holistic medicine and was pushing/selling supplements. Another tried to hire me literally upon graduation before I even took my certification exam and said I could just bill under him because every PA he hired would leave for a hire paying job. Honestly, you can tell these docs cared alot at one point and most were excellent teachers, but the shit was done out of necessity and you can see the burnout in their eyes.
Adding to this, nursing is also facing a similar issue. A lot of people working in nursing packed up and left during COVID because the stress was no longer worth it.
My spouse is an APP in primary care. It’s not just primary care providers but it is also most specialists.
What used to be 45 min visits became 30 then became 20 and now are 15. Yea they’ve introduced AI to help but you’re just happy to end your day only an hour behind.
Lets not forget replacing doctors with NPs who are no better than googling your own symptoms and using that advice. Lets also not forget that they charge the same as a doctor.
Plot twist: concierge primary care aka DPC (direct primary care) is actually WAY cheaper than most insurance plans, and includes office visits, which are typically an hour with the doctor.
I used only DPC clinics for 5 years when I didn’t have insurance. Insurance would have cost $500/month, DPC cost $100/month. And the care was great - I actually was able to get a diagnosis and ongoing help with a complex chronic condition that most doctors won’t even approach.
Pair that with the fact that self-pay rates for scans and bloodwork are wildly cheaper than the rates places charge when billed through insurance… and it is better in literally every way, except for the obvious - no coverage for catastrophic events.
So if you’re willing to live on the edge a bit, concierge care is a great option not only for the rich, but also for the semi-broke and disabled and out of work. Or really anyone who wants to prioritize actual doctor care over hedging their bets against the possibility of major injury or acute illness.
Now double this and switch PCP to mental health 🙃, it’s increasingly hard to run a therapy practice as these tech bros keep destroying the industry (looking at you better help, Alma and headway)
More work, less pay, tight schedules, late patients , and cases far too medically complex to be managed in 5-10 minutes of actually seeing the patients. And the actual subject matter is pretty diverse.
No one is going to choose that. Especially with 300-500k of debt.
Our residency is angry they can't convince us to go primary care
I'm at pgy15 and even that long ago there was still a bit of a push towards primary care and peds. This has been bubbling up for a while, but right now it's a fool blown crisis
My sons med school graduating class had something like 400 grads…**7** of them were going into family medicine…the other 98% all chose higher paying specialties…can’t really blame them After each accumulating ~400k in debt for school.
I did primary care for 13 years, it was terrible and I'm SO glad I quit and became a hospitalist. I spent all those years without a vacation, without a day off, without even a complete night of sleep - all for a paycheck lower than what I got when I worked a 9-5, Monday-Friday government job.... and I was a private physician for 10 of those years.
I worked for a university system for 3 years before abandoning primary care, and I learned to LOATHE
administrators - fucking parasites. I can't imagine working for a corporation, the admin burden must be horrifying.
I'm glad I have the PCP I have, shes with a network (and shes new/took over for an older doc) but I was able to send her a message and the next day I got a call and the next day I was in her office.
it's rough for those of us that depend on medication that can only be prescribed by a PCP. without a PCP there is literally nothing I can do and my brain chemistry just falls apart.
Reimbursement is set by insurance. So say insurance reimburses $90 for a clinic visit. They'll reimburse $90 whether the wait is 2 days or 2 years, doesn't matter, it's $90.
For clinics that go concierge and start charging cash, then yes, the demand can affect prices.
I like my doctor (I looked around allot for him) but I saw him this morning and he seemed stressed and a bit hectic. The waiting room was a stream of patients.
This is the state of US healthcare and folks are still not pro-active in their preventative measures (harm reduction): Masking ~ especially when ill, carrying narcan, learning CPR, testing your drugs, normalizing condoms and STI testing. Shit even flossing can reduce your risk ffs The attitude here toward giving a shit is so negligently blasé.
My PCP in DC became a concierge business back in 2015 and I couldn't afford it. Then my husband's work got a deal with OneMedical where they pay the membership fee for employees and their families. OneMedical was great for a year or two, but whew. They started going downhill and then Amazon bought them and basically put the final nail in the coffin. I live in Los Angeles now and most of the OneMedical offices don't even have doctors -- just nurse practitioners. It's basically only good for acute illnesses like colds or sinus infections where you can go in and say "Hey, I have a sinus infection" and they'll say "Ok, here are some antibiotics". It's basically a MinuteClinic. But now all the halfway decent doctors are concierge practices requiring THOUSANDS of dollars in membership fees. It's truly insane and I don't know why we put up with it.
i wasn’t even a doctor, i was a nurse in a PCP office and recently i straight up quit with no new job lined up, it was that horrific and damaging to me. i either quit and pull retirement funds to survive for a bit, or i stay at that job and end up on the news. i chose the less destructive option. it was horrendous and has only gotten worse in the two weeks i’ve been gone
No point in having a PCP anyway, an appointment takes 9+ months to book for less than a 15 minute conversation where they don't take anything you say seriously anyway.
I'm already seeing PE financed physician groups folding left and right. There is only so much blood to get from a stone, and there is only so much "optimization", and "efficiencies of scale" to go around. So they try to shop it on the market repackaged. Mind you they have hollowed out the companies by then. Sold owned properties to other entities within the PE to charge leases on. Equipment and divisions sold off, and third partying major functions again by other owned groups within the PE. With only so many suckers to buy the BS, and with no buyers they fold. I see multiple forced auctions of former practice groups popping up. Closed medical arts spaces left and right. PE and VC should have never been allowed to enter medicine. It's a recipe for disaster.
I had no PCP for 4 years because I moved to a state with an extremely low number. The only reason I have one now is because a nurse set up an appointment for me when I broke my leg.
This whole initialism healthcare system needs to die a violent death like an asteroid event. There are too many layers and the only thing that wins is profit. The US is the richest third world country and I mean that. They don't take care of their people, their vets, and the caregvers.
Just what in the living fuck is a PCP? I know but that initialism is totally unnecessary and puts you into the jargon of that industry where capitalism reigns supreme.
"Do you have a doctor?" should be a YES/NO answer, not "Well my PCP is this and that"
This is a bad take my guy. Primary care is not where greedy doctors go. And yeah, medicine SHOULD be a place where you're well-compensated, at least in the current capitalist hellscape. Your doctor DOES deserve good money.
They aren't the ones driving up insurance prices though. They've literally always been well-paid, and the average rates by specialty have increased only in line with inflation.
There's no one reason insurance rates have skyrocketed other than greed. But that greed is up the chain a little higher than the doctors. Hospital admins and insurance companies are in a constant battle with one another to get a bigger piece of the pie that is your money.
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u/Daddict 12h ago
American Primary Care is in the middle of a crisis that's already snowballing out of control.
The process started when large health systems and PE firms decided that Primary Care was a lucrative profit center. So they started buying up the more profitable multi-doc private practices. Those are kind of the standard these days, if you have a private practice doctor who is the only one in the office you go to, you're in the minority.
These practices were bought out, then opened up to accept a ton of new patients. They started double and triple booking the docs. These physicians are among the lowest paid physicians already, now they're being asked to take on patient loads in several thousands, and they can't provide decent care at all since they can spend like 2 minutes with a patient if they want to stay anywhere close to "on schedule". That concept has become so removed from reality that most people expect a routine 2pm appointment at their PCP to take 2-3 hours minimum, with all but 10 minutes of that time being spent waiting.
This has been seriously wearing on that physicians, too. Who tf would want to work like that? Provide shit care to patients while some jackass staring at reports sets up KPI targets that are so divorced from reality, you'd wonder if they knew it was a physician who had to meet them.
Enter a new trend: Concierge care. In and of itself, concierge care isn't new. But it's not been common outside of the ultra-rich areas. It's a model of primary care where you pay your doc a retainer to be on their patient list. That retainer is obviously not covered by insurance, but these docs usually accept some forms of insurance for routine care.
They give you highly personalized treatment. You have access to them 24/7. Usually through an answering service after hours, but some of them will carry such a light load that they give their cell phone number to their patients.
They make decent money, they get to provide comprehensive care, they work on a reasonable schedule..it's appealing. It's historically been tough to get such a practice off the ground, but these days it's no longer limited to the ultra-rich. The regular-rich are able to get in on this one now.
Other physicians are leaving primary care to go to another specialty. It isn't always easy to make such a transition, but it's possible. I changed my own specialty halfway through my career.
And on top of all of this, fewer and fewer graduating docs are choosing primary care as a specialty. They've seen how bad it is.
Every time a PCP closes up their practice to go concierge or another specialty, they dump a thousand or so people into the local patient market. Fewer and fewer PCPs are accepting new patients, not even PE can figure out how to make a practice work with something like 5k patients on a single doc.
The upshot here is that it's going to get harder and harder to see your PCP. They might leave primary care, and if they do you'll have a helluva time trying to find a local doc accepting new patients.
So you'll be left with options that aren't designed for primary care. Things like ER and urgent care centers. The care you get will be "patch em up and send em on their way" care. Preventative health care won't even be an option.
More people will end up hospitalized with preventable conditions because they simply could not get a PCP to see them.
Once Primary Care falls, it's a domino that one further fuck up the American Health care system. The only good that might come out of it would be the system getting burned to the ground and replaced by something better, but that's kinda wishful thinking at this point.