As a primary care physician, I’m often referred to as the “gatekeeper” of medicine. I have never liked this term, but I’ve had a hard time explaining why.
When I think about a gatekeeper, I think about someone guarding something of value. I picture myself in a white coat with a sword or a baton guarding a huge gate. Behind the gate are specialists, imaging studies, and other medical diagnostics. It makes primary care physicians seem like a barrier or an obstacle to the “truly valuable” side of healthcare rather than the most valuable players.
Equating primary care physicians to gatekeepers continues to devalue primary care. It’s no secret that high-quality primary care has been shown time and again to improve health and lower healthcare costs for communities. Every other nation that invests in primary care has been able to reap these incredible health benefits, but here in the US, we are struggling to catch up.
Our healthcare system, largely based on an insurance-backed, fee-for-service model, handcuffs the role of primary care. In this system, constricted by 15-minute appointment times and burdened by patient panels too large to manage, primary care becomes little more than a screen-and-refer service. We don’t have the time or resources to truly practice our craft and partner to keep patients healthy. When we can do our jobs well, we decrease the need for unnecessary referrals and low-value, expensive diagnostics.
However, the large healthcare systems that now employ more than 70% of primary care physicians make the most profit from specialty referrals and diagnostic services. The mantra at my healthcare system was that primary care was a necessary expense in order to “feed the beast.” With ever-shrinking insurance reimbursements, it was never expected that primary care would generate profit for the system. In fact, the clinics in my system that broke even were celebrated because the status quo was that primary care would be a net loss to operate. We gained our value from our ability to refer our patients to services in the system. We were praised for ordering the most imaging studies and referring internally to our own specialists. We were penalized for “leakage,” meaning that we referred to services external to our system, even if it was in the best interest of the patient.
Rather than have the primary care physician perform a knee injection, which most of us are appropriately trained to do, we were encouraged to refer these procedures to orthopedics. The irony was that many of these referrals resulted in the procedure being performed by a physician assistant or nurse practitioner who has less training than the primary care physician! These referrals were a win for the healthcare system, but an enormous loss for the patient and for our healthcare dollars as it results in delayed and more expensive care.
When we embrace a healthcare model that allows primary care to flourish, then there will be no need to “guard the gate.” Direct Primary Care (DPC) is this model. In DPC, our mantra is that we can take care of 80% of your medical needs – reducing the need for high-cost and low-value referrals. Imagine a US system where 80% of patients’ needs were handled at the primary care level – the health benefits and cost savings would be substantial. To my colleagues out there, you are so much more than a gatekeeper, you are a Primary Caregiver. You ARE the value of medicine – let us never forget that.