However, it is first worth defining the significance and importance of primary care in the overall context of healthcare. Starfield¹ defined primary care as the provision of integrated, accessible healthcare services by clinicians who are accountable for addressing a large majority of personal healthcare needs, developing a sustained partnership with patients, and practicing in the context of family and community.

Two important topics that were discussed involved: –

• The forecast shortage of doctors and nurses not just across the US but also in our area.

It is clear from what was said that the forecast shortage of both doctors and nurses “is real.” as panelist Gina Teegarden put it, “It is not going to go away, and it is also the case that there are not enough instructors in our nursing schools, so the shortage is far-reaching.”

• The impact of primary care practices being acquired by hospital groups and insurance organizations.

Although not all large organizations are the same, as Dr. Joseph Repay, MD, mentioned during the debate. He said, “While the large organizations, like the Mayo Clinic and others, also aim to offer continuity and a seamless process when requiring specialist care, the data hasn’t necessarily been borne out.  There is inevitably a greater rotation of physicians and nurses in large groups that can depersonalize patient care.”

The New York Times article² by Reed Abelson (A Times Reporter on Healthcare since 1995) also addressed these issues, summarized below.

Reed states in her article on May 12, 2023, and May 8, 2023, “It’s no surprise that the shortage of primary care doctors —critically important to the health of Americans — is getting worse.”

She asks, why are multibillion-dollar corporations, particularly giant health insurers, gobbling up primary care practices? With its sprawling pharmacy business and ownership of the major insurer Aetna, CVS Health paid roughly $11 billion to buy Oak Street Health, a fast-growing chain of primary care centers that employ doctors in 21 states. And Amazon’s bold purchase of One Medical, another prominent doctors’ group, for nearly $4 billion is another such move.

The appeal is simple: Despite their lowly status, primary care doctors oversee vast numbers of patients who bring business and profits to a hospital system, a health insurer, or a pharmacy outfit eyeing expansion.

And there’s an added lure: The growing privatization of Medicare, the federal health insurance program for older Americans, means that more than half its 60 million beneficiaries have signed up for policies with private insurers under the Medicare Advantage program. The federal government is now paying those insurers $400 billion a year.

Many doctors say they are becoming mere employees. “We’ve seen this loss of autonomy,” said Dr. Dan Moore, who recently decided to start his practice in Henrico, Va., to have more say in caring for his patients. “You don’t become a physician to spend an average of seven minutes with a patient,” he said.

The absorption of doctor practices is part of a vast, accelerating consolidation of medical care, leaving patients in the hands of a shrinking number of giant companies or hospital groups. Many already were the patients’ insurers and controlled the distribution of medicines through ownership of drugstore chains or pharmacy benefit managers. But now, nearly seven of 10 doctors are employed by a hospital or a corporation, according to a recent analysis from the Physicians Advocacy Institute.

But what is the likely impact of this significant trend, and how will it affect patient care?

• Companies say these new arrangements will bring better, more coordinated patient care. Still, some experts warn that the consolidation will lead to higher prices and systems driven by the quest for profits, not patients’ welfare.
• Companies say they favor the fixed fees over the existing system that pays doctors and hospitals for every test and treatment, encouraging doctors to order too many procedures.
• Under Medicare Advantage, doctors often share profits with insurers if they take on the financial risk of a patient’s care, earning more if they can save on treatment. Instead of receiving a few hundred dollars for an office visit, primary care doctors can be paid as much as $14,000 a year to manage a single patient.
• Experts warn that these significant acquisitions threaten the personal nature of the doctor-patient relationship, especially if the parent company has the authority to limit services from the first office visit to extended hospital stays. Once enrolled, these new customers can be steered toward chains of related businesses.

Many of these points were also addressed during Engage Estero’s Healthcare Public Forum.

As mentioned earlier, it is worth restating that not all companies that have amalgamated primary care into their organizations should be “tarred with the same brush!” But can anything protect the integrity and importance of retaining private primary care practices in the future?

Senator Elizabeth Warren, Democrat of Massachusetts, urges the Federal Trade Commission to take a closer look at some of these large deals, which regulators have so far not blocked on antitrust grounds. “I fear that the acquisition of thousands of independent providers by a few massive health care mega-conglomerates could reduce competition on a local or national basis, hurting patients and increasing health care costs,” she wrote to regulators in March.

This consolidation of medical care may also run afoul of state laws that prohibit what is called corporate medicine. Such statutes prevent a company that employs doctors from interfering with patient treatment.

Once many primary care doctors become involved with these large organizations, many become concerned about the pressure to enhance the bottom line. “They are trying to run it like a business, but it’s not a business,” said Dr. Beth Kozak, an internal medicine doctor in Grand Rapids, Mich. Dr. Kozak said she has to work longer hours, not to provide better care, but to supply additional diagnoses for patients, which increases federal reimbursements under the Medicare Advantage program.

However, it can also be argued that large companies which take over primary care practices provide more tech and more team-based care, which is a significant investment in enhancing patient care.

In her article, Reed points out that it may be too soon to determine whether consolidated care will improve patients’ health.

“So far, when you look across the industry, the record of these acquisitions has been mixed,” said Dr. Sachin H. Jain, the chief executive of SCAN Group, a nonprofit based in Long Beach, Calif., that offers Medicare Advantage plans.

And the investments may continue the rapid disappearance of the doctor still sought by so many people for ordinary care, including a recent report showing fewer medical school graduates going into the field.

There is nothing to prevent this trend from continuing unless the Federal Trade Commission becomes involved- which seems unlikely. But it will be up to individual patients to determine whether they feel satisfied with the level of primary care offered, whether within private practice, a large-scale organization, or a concierge service. It is essential to continually determine, through personal experience, whether the service offered is providing; –

1. enhanced access to healthcare services.,
2. better health outcomes.
3. a decrease in hospitalization and use of emergency department visits.
4. no obvious up-charging for unnecessary investigations or treatment options.

If serious questions surround these fundamentals, then it should be time to make a change.

References

1. Starfield B. Primary Care: Balancing Health Needs, Services and Technology. New York, NY, USA: Oxford University Press; 1998.
2. Corporate Giants Buy Up Primary Care Practices at Rapid Pace, Reed Abelson, the NY Times May 8^th, updated May 12^th,