In short
The state of U.S. primary care and why about a third of Americans lack a regular primary care doctor; what primary care does, barriers to access, and policy/solution ideas for “finding a primary care physician.”
Guests (backgrounds)
Dr. Lucy McBride, primary care physician in Washington, D.C., author of Beyond the Prescription; Dr. Allison Hufstetler, family physician and medical director at the Robert Graham Center for Policy Studies in Primary Care; Dr. Zachary Bittenger, family medicine physician at Ohio State University Wexner Medical Center.
Key claims
Primary care provides prevention, chronic disease management, procedures, and continuity (“quarterbacking” care). The system is hollowed out by payment incentives favoring hospitals/procedures; prevention gets <5% of spending. Shortages, administrative burden, and corporate/concierge models worsen access. Insurance cuts (Medicaid/ACA subsidies) reduce access and delay care.
Notable examples
Call centers overseas when patients can’t reach doctors; young adults (18–29) often skip wellness visits; concierge fees like $2,500/year; patients using OB-GYN as primary care; coordination gaps between cardiology and gastroenterology; urgent care/temporary coverage when doctors retire.
Written by AI. May contain mistakes. Listen to the episode to check what was said.
Chapters
Tap a time to open that second in VOThe Importance of Primary Care
0:00 to 0:12
Discover the current state of primary care in America and the lack of access for many.
“Support for this NPR podcast and the following message come from Carvana.”
The Importance of Primary Care
0:15 to 2:58
Discover the current state of primary care in America and the lack of access for many.
“When was the last time you went to the doctor?”
Understanding Primary Care's Role
5:04 to 7:36
Explore the functions and importance of primary care doctors.
“McBride, just right off the top, the people we heard from in that recording there, I know I should go to primary care.”
Barriers to Primary Care Access
7:39 to 11:59
Examine the reasons behind the lack of primary care providers in America.
“Well, I mean, the statistics are alarming.”
Personal Experiences with Primary Care
12:03 to 14:01
Listen to personal stories about the significance of having a primary care physician.
“So how has that affected access to primary care?”
Experiences with Primary Care
14:01 to 15:19
Listeners share their challenges and experiences with primary care doctors.
“and I was without a primary care doctor, and I had terrible experiences getting shifted around to different primary care doctors.”
Role of Gynecologists in Primary Care
15:20 to 17:42
Discussion on why some women rely on OBGYNs for primary care and the implications.
“and I don't have a primary care doctor and it's starting to worry me a little bit.”
The Bridge Function of Primary Care
17:43 to 22:08
Exploration of how primary care doctors coordinate care between specialists.
“Primary care, everybody knows that the primary care doctor can spot something and refer you to the specialist.”
Concerns Over Concierge Care
22:09 to 24:04
Discussion on the rising costs of concierge medicine and its impact on access to care.
“This concierge model, this word has come up already in the hour.”
Navigating Healthcare Gaps
24:05 to 26:17
Advice for patients on maintaining care during transitions between doctors.
“Amber says, my primary care doctor is retiring at the end of the year, and my next yearly physical is in late September 26.”
Show all 20 chapters
Impact of Policy on Primary Care Access
26:18 to 28:00
Examining how healthcare policies affect access to primary care for underserved populations.
“We covered it, caused a government shutdown.”
The Crisis of Primary Care Access
28:00 to 30:19
Primary care access is a significant issue in America, driven by workforce challenges and job dissatisfaction.
“You know, everybody in America deserves access to a primary care medical home where your doctor knows your name, not just your diagnosis codes.”
Listener Insights on Access Issues
30:19 to 30:53
Listeners share their personal experiences and frustrations with finding primary care doctors.
“Watch the full It's Been a Minute episode on YouTube or listen in the NPR app or wherever you get your podcasts.”
Evolving Nature of Annual Checkups
30:53 to 33:55
Experts discuss the changing dynamics of annual checkups and the shift towards telehealth.
“Bettinger, I want to come back to you for just a moment because you said something before we took a break.”
The Importance of Human Connection in Care
33:55 to 36:44
The conversation emphasizes the value of in-person visits and establishing rapport with patients.
“to the wine they're drinking at night to take the edge off their caregiving responsibilities.”
Challenges of Medicare and Preventative Care
36:44 to 40:52
Discussion on how Medicare's limitations affect seniors' access to adequate preventative care.
“I'd love to see a Lifetime movie of the week where it's patients and doctors, not long lost exes back in town after going to medical school, you know?”
Solutions for Primary Care Improvement
40:52 to 42:00
Experts propose solutions for improving primary care access and workforce sustainability.
“How do we balance patient expectations, our performance, our training?”
Addressing Primary Care Workforce Challenges
42:00 to 43:36
Discussion on improving primary care through workforce expansion and redesign.
“work with their patients over the course of time to provide that continuity and access.”
Incentivizing Primary Care and Reducing Burdens
43:36 to 45:04
Strategies for incentivizing primary care careers and reducing administrative burdens.
“Primary care doctors in Canada have these types of challenges.”
Doctors' Insights on Patient Care
45:04 to 45:51
Doctors share their insights on the importance of patient relationships and care.
“why the heck won't you cover my patient's prescriptions?”
Transcript
Automatic transcript. May contain errors.0:00Support for this NPR podcast and the following message come from Carvana. Selling your car? Carvana has offers so good, they're almost inexplicable. Sell your car 100 % online in minutes. Visit Carvana.com today.
0:21When was the last time you went to the doctor? Not necessarily for something big, not for a broken wrist or something with your heart, just for a checkup, a regular annual visit to make sure everything's okay with your health. For about a third of Americans, it's probably been too long. In 2023, more than 100 million people in this country did not have a regular primary care doctor at all, according to the National Association of Community Health Centers. That includes a lot of you. I have not been to a primary care doctor. I was a child. The last time I went to a doctor was in 2002. Two reasons.
1:02One is I don't have health insurance and I don't want to spend the money. I've been trained as an EMT. I try to take care of most issues on my own. I would like to get preventative care and assessments, but it's not a priority compared to eating and putting gas in the car. The reason I don't have a primary care physician is because the one that I had at Advantage Care Physicians left, did not send out a goodbye letter to her patients, and the entire network of ACPNY is very corporately managed. They squeeze as much as they can out of their doctors and nurses, and so the result is that you don't really feel taken care of, especially in between appointments.
1:47If you try to reach your doctor, you end up at a call center overseas. Thank you to 1A listeners for those messages. The outlook is especially bleak for young people here. More than a quarter of people aged 18 to 29 polled in a national survey this summer said they don't have a primary care doctor. And over half who did have a doctor say they skipped it or didn't schedule an annual wellness check in the last year. But the blame shouldn't fall solely on patients. Primary care doctors are getting squeezed by the current healthcare system. There's a growing shortage of primary care doctors, and that can mean wait times of months just to get an appointment.
2:27For today's installment of our series, In Good Health, we're unpacking the state of primary care and what to do if you don't have access to it. I'm Todd Zwilich in for Jen White. You're listening to the 1A podcast. We'll be putting your questions to our panel when we come back from this short break. Stay with us.
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3:47Welcome back to the 1A Podcast. I'm Todd Zwilich. We're talking about the state of primary care and what to do if you don't have access to it. Joining us in the studio, Dr. Lucy McBride. She's a primary care physician right here in Washington, D.C., and the author of the new book, Beyond the Prescription, A Doctor's Guide to Taking Charge of Your Health. She's also on Substack. It's called Are You Okay, Dr. McBride? I know you're okay. Thanks for coming on the program. Thanks so much for having me. Great to have you. Also on the line, Dr. Allison Hufstetler. She's a practicing family physician and medical director of the Robert Graham Center for Policy Studies in Primary Care.
4:26Dr. Hufstetler, great to have you. Thanks for having me. And also with us to round out the panel, Dr. Zachary Bittenger. He's a family medicine physician at the Ohio State University Wexner Medical Center. Dr. Bittinger, welcome to 1A. Thank you for having me. And as always, when we talk for your health and in good health on this show, a quick note, our experts are not a replacement for seeing your own doctor, and they can't give you personal medical advice. So make sure that you still consult with your doctor on anything you hear. And if you need a primary care doctor, we'll have some tips later on finding one where you live.
5:03Dr. McBride, just right off the top, the people we heard from in that recording there, I know I should go to primary care. I would love to be able to go. It's just not worth the money. I can't afford it. One person said, I'd rather spend the money on food and bills. What is going on in your specialty? I think people are dismayed and despairing that they can't get in, that they don't actually understand what primary care could do for them if they had someone to partner with them to shepherd them through sickness and in health. I don't blame people for wanting to pay the bills, put food on the table before they go to primary care, when primary care in this country has been hollowed out by our broken and flawed payment system.
5:49Dr. Hufstetler, let's just start with some basics here. What do primary care doctors do? And what's the role they're playing in the health system now, today? Primary care doctors can do a lot. And I say that for the full scope that we practice. Many family physicians will see kids from the time that they're born, and they'll help people die a dignified death. And we do everything in between. So from pediatric care, well visits, preventive care, We do lots of procedures. If you need things frozen, we can take them off of your body. And then we do a lot of chronic disease management. So people that have complex diseases, we take care of them over the course of their life.
6:28And the thing that is really special about primary care and family medicine is that continuity, long-term relationship that you have with your doctor. Hopefully you start when you're healthy and then you make it through the rest of your life with the same person or the same team. Dr. Bittenger, the primary care doctor in many cases is the family physician, like you, could be the internist often, might be an osteopath in some cases. How has the profession changed over the last several many years? How is primary care changing and access to primary care changing? Well, I think a lot of it has to do with the overall physician shortage, like has already been mentioned.
7:07I think that there aren't enough doctors in general, and that's what we're dealing with in family medicine. I think a lot of that has to do with the corporate nature of medicine, like some of those kind patients called in about. And so I think a lot of us are trying to offer what we can, but we are also suffering from those same problems just along with our patients. So I think we're trying to offer what we can while still keeping ourselves afloat so that we don't accidentally burn out and become another statistic of physicians that drop out of the specialty or medicine in general? Well, I mean, the statistics are alarming.
7:42We've mentioned some of them. Dr. Hufstetler, a third of Americans don't have a primary care doctor. That's 100 million people or more. What, in your experience, is preventing people from establishing this consistent care? We heard from some people, yes, I would just rather spend the money elsewhere. For some people, it's probably inertia. I feel fine. I don't feel like I need it. Let's be honest. It's not always a systems problem. It can be a you problem. But in your experience, why is that number so high, 100 million? Absolutely. And that number's going up. So when we look at the most recent data, we saw 29%, 29.7 % of adults don't have it.
8:19And 25 % of kids don't have a primary care home, which is astonishing. It continues to go up over time. And there are two sectors of people that I would say exist. Those are the ones that want primary care and can't find it. And those that like you said, aren't interested. They're healthy. They don't think that they need it right now. But I would posit that everyone deserves and should have a high quality primary care doctor. So what are the reasons you can't find one if you want one? Well, we have a shortage. There are not enough of us. We're not geographically distributed very well. We are clustered around cities and very limited in rural areas.
8:52And we're overburdened. Most of us don't see patients full time anymore because it's administratively very challenging to do so. And for the people that, So the people that are practicing don't have quite the breadth of time to see patients that we used to. We got this note from Jay who says, Recently, our doctor seemed overworked and incentivized to get us in the door and out the door as quickly as possible. Our annual checkups don't allow us any time to go over our health and how different conditions have changed. And our doctors get annoyed if we have questions or new issues. Even those of us with primary care doctors are getting worse and worse service over time.
9:28Dr. Lucy McBride, what's going on here? So most of us went into primary care to teach, listen to patients, guide them through their lives. But in order to keep the clinic alive, patients have to see more patients. We have to see volume. And the truth is that prevention is not the priority in the U.S. healthcare system. Damage control is. The money proves it. Less than 5 % of healthcare dollars goes to prevention, primary care. The other 95 % flows to hospitals, procedures, prescriptions, admin. So that imbalance sets off a chain reaction in which no one is really winning except the people's bank accounts in the industry, right?
10:14You're talking about structural incentives and structural problems in the system that are just not tilted toward prevention and primary care at all. Exactly. So primary care doesn't pay as well as specialty professions. So fewer and fewer graduates of medical schools and residency programs are going into primary care. If you're strapped with$200 ,000 or$250 ,000 in debt after medical school, you're going to choose a field that pays you. So the doctors who do stay in primary care get crushed. We have to see more patients to keep the clinic's doors open. And then the ones who stay are burned out or leaving medicine altogether.
10:53together. Dr. Bittinger, there was a survey at your Wexner Medical Center at The Ohio State University. One in four young adults don't have a primary care provider. What are the barriers there beyond just psychology? Okay, a young person might feel fine and I'm going to live forever, so I don't need it. We get that part. What are some of the other barriers for young people? Well, I think the first one might be that it's a very transitory age, right? We have our young adults as they maybe move away to college, maybe they move away to trade school, maybe they join the workforce, maybe they move to an entirely new city.
11:29And so they might not make it a priority to see a new doctor, especially if they are well. I think not to sound like a broken record, a big piece is cost. In those same exact situations, our young adults might not have all the resources in the world to see a new doctor. And so they might put it off, even if they do take some medicines, maybe if they do have some health problems. And those are the situations where we're really failing our young adults to set them up for success into the rest of their lives. Coming up, more than 2.6 million Americans have lost health insurance coverage in the last year with the end of COVID-era Affordable Care Act subsidies.
12:07So how has that affected access to primary care? And we're hearing from so many of you. John wrote this. Another major recent issue is that a lot of primary care doctors are moving to concierge practices. I've had two of my physicians move to this much more expensive option just in the last year. It makes finding a new doctor, even if you have good insurance, that much more complicated. Dr. McBride was pointing to herself when I mentioned concierge practice. So we'll talk about it. Finding a primary care doctor in America. Stay with us.
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13:23Over the past couple of months, over 100 ,000 new listeners started tuning in. Find out why. Listen to the It's Been a Minute podcast from NPR today. Welcome back to the 1A podcast. I'm Todd Zwilich. For today's installment of our In Good Health series, we uncover the problems with primary care and why a third of Americans don't have access to this essential piece of our healthcare puzzle. We got this message from one of you. Take a listen. I am very lucky that I do have a primary care doctor, and I am just thrilled with him, but there was a period of time where he went and went off to college to teach, and I was without a primary care doctor, and I had terrible experiences getting shifted around to different primary care doctors.
14:09They moved, their office moved to a faraway town. So I love my primary care doctor. I hope he never retires. And I recommend everybody to him. Having a good primary care doctor is so important. It helps build trust and continuity of care. And it makes all the difference in the world. We got this note from Elise who says, I was raised that once you hit puberty as a girl, your OBGYN becomes your primary care doctor. Since I am a woman, my OBGYN and my teams treated my ovarian cysts, breast aspirations, and sinus infections. I'm chastised for not having a primary care doctor. However, every problem I have is considered a woman's problem.
14:54So I'm just sent to the OBGYN anyway, and we got this message as well. I'm a registered nurse, actually, and I have never in my life had a primary care doctor. Whenever I had any kind of an issue, which I've had very, very few in my life, I've always used my gynecologist. but unfortunately he retired and now I'm 80, still practicing, still working, and I don't have a primary care doctor and it's starting to worry me a little bit. Dr. McBride, your response to why some women, many women, use the OBGYN as their primary care doctor and it seems for some women for most of their lives. Sure. And I think GYNs are trained in many of the primary care aspects that people like me as internal medicine doctors are as well.
15:52I think, however, there is different training. You wouldn't want me delivering your baby, I promise you. And I probably wouldn't want my GYN managing my high cholesterol and coronary disease. It's not to say that they can't. It's to say that there is different training. That said, when you're trusting your gynecologist, when you have a relationship with a doctor and they're providing the services that you need, I say go for it. Dr. Hofstetter, are there problems that can arise not just on an individual level but on a systems level when patients over-rely on doctors for services that are not necessarily part of their practice?
16:33I've done this. I've been to the dermatologist for a regular checkup and I've said, oh, hey, by the way, there's this other small thing. It's easy. Can I just get the prescription? He says, yeah, sure. Of course. And that is a normal process, I think, for humans to say when they're in the office, oh, can you also handle this, this, and this? We call it the door handle issues as the person asks on their way out. The good about that is, yes, you're developing a trusting relationship with a specialist and that's fantastic. I would never fault someone for going to their OB, especially in a reproductive age female.
17:05But when people are doing things outside of the scope, they are overlooking things at times. So for example, if your cardiologist orders your screening colonoscopy and it comes back with seven polyps, is that cardiologist the one that's going to be able to handle, manage, and recommend next steps outside of what the gastroenterologists do? And those guidelines are different. We follow different guidelines than some of the specialties do. And so having someone to be able to follow up appropriately, manage next steps, and combine that with the rest of the picture of your health is really critical to prevention down the line and saving money down the line.
17:42Dr. Bittenger, talk about that a little bit, the bridge function of the primary care doctor. And that bridge goes both ways, right? Primary care, everybody knows that the primary care doctor can spot something and refer you to the specialist. And one point that Dr. Hufstetler is making is that once you've seen the specialist, you need someone to coordinate increasingly complex care. You need a pro to do that, right? So can you talk about the bridge function? Absolutely. I think when it comes to my role as a primary care physician, I look at it both ways. I say to my patients, you know, I know costs are high.
18:19Seeing a specialist is oftentimes going to be more expensive than seeing me. So there are lots of things that I can do for folks short of seeing a specialist that maybe delays that or maybe completely resolves the issue before we need to see somebody. And then as we accumulate more specialists, more medicines, things get complicated really fast. And as everybody probably knows, we love football here at Ohio State. And so I call it quarterbacking people's health. I can see the whole field. I can see all the specialists we're seeing, all the medicines, and I can put the pieces and the parts together to make sure that people understand the whole picture of their health.
18:55We got this note from Jose who says, I have Kaiser as my health provider, and I have zero issues seeing my primary care doctor. I scheduled it in the app. I go to the appointment. I just choose not to go because I feel fine. Nothing is irregular, out of the ordinary with me, so I don't see the point in regularly going regularly. And, Dr. McBride, you are nodding vigorously. Right. I think people have conceptualized health as sick care, right? Take my three 20-year-old children. they think about health as like the strep test or, you know, I got a rash in the summer. When health is about so many of the elements in your life that you can't measure in a blood test, it's about the conversation.
19:36It's about preventing illness. It's about building trust, building rapport. And me as your doctor, empowering you with tools and guidance to be healthy mentally and physically. That is not something that you necessarily feel now. It's preventing downstream illness by establishing that rapport early and often. All right, you talk about that rapport. We got this message from one of you. My personal doctor is a very pleasant fellow. He's part of the Bon Secours Network out of Richmond, has done a fine job of taking care of me. But my biggest concern lies in a slight digression here in that I have found that many of these doctors are so specialized that they don't see beyond the boundaries of their own lane.
20:30The primary care doc doesn't talk or communicate frequently or well with the cardio doc, and the cardio doc doesn't communicate with the gastroenterologist, et cetera, et cetera. And Dr. Hufstetler, if the cardio doc and the gastroenterology doc aren't communicating well with each other, it is very easy to miss something in a complex case. Talk about that dynamic. I have to assume you see it every day or often. What's your role there? Absolutely. And there are things that primary care practices and doctors can do better. And it sounds like this person experienced one of those cases where there should have been more coordination.
21:10In the best case scenario, your primary care doc does 95 % of things. And then you're going to specialist for 5 % of things, right? And then when you come back, you have seen your specialist, your primary care doc has read the note, and then in really complicated cases has even talked to them or messaged with them. And we combine notes. We look things together. That is the ideal. The ideal is you go to see them. We know what's happened. You know what's happened. And then my favorite conversations are, tell me, patient Smith, Mr. Smith, what you thought of your visit with the cardiologist. What did you learn and how can I fill in the gaps?
21:47And by filling those gaps together, we can make sure that the patient, the person that's most important, understands what's happening with their health. And I love Dr. McBride. This is empowering the patient to take control over their own health. We got this note from Colette who says, I've been diligently getting an annual physical exam with my primary care doctor. However, Now she requires a$2 ,500 annual visit fee just for the privilege of being her patient. This concierge model, this word has come up already in the hour. This concierge model is also super problematic, and my insurance premiums continue to rise, and my doctor is adding higher fees to stay in practice.
22:28Dr. McBride, when we mentioned concierge care before, you were pointing at yourself. You're doing this. What about concerns like Colette has,$2 ,500 just to get in the door? I completely understand, Colette. It makes complete sense. It's expensive. And health care is already so difficult to access. Here's the problem. Doctors who are in the system are facing choices they don't like. The menu options are stay in the system, treat symptoms, diagnosis codes, and body parts, even though we want to establish rapport and help you understand your whole health and privilege the relationship between patient and doctor.
23:08Or leave the system altogether, leave medicine altogether, which is happening in droves. By 2037, we're predicted to have an 87 ,000 deficit in primary care doctors. There's probably more. Or do what I've done, which is have built my own practice, which I did in 2024, in order to have fewer patients instead of thousands and thousands of patients, hundreds of patients. So I can see that 80-year-old patient who's been discharged from the hospital, who has chest pain and is grieving the loss of his wife, and spend more than 15 minutes. That is part of the problem. I'm part of the problem. I'm also trying to be part of the solution by modeling what doctors can do when we privilege our patients and our relationship with our patients.
23:52This is also why I wrote my book, to help people empower themselves given the confines of the average medical appointment. Getting so many concerns from 1A listeners all across the country. Dr. Bittenger, here's a good one for you. Amber says, my primary care doctor is retiring at the end of the year, and my next yearly physical is in late September 26. I'm currently searching for a new doctor, but my health insurance won't cover another physical for a full calendar year. What can I do now to ensure that my asthma maintenance medication will be available to me in the lag time between January 27 and October of 27 when insurance will cover my next appointment.
24:35Yeah, it's a horrible example of so many of the holes that patients can fall in. And when it comes to medications like that, it's vital. You know, keeping your asthma under control, your blood pressure under control, your diabetes under control, those are things that keep people out of the hospital, to keep them in a great state of health. I think the first thing is to contact your doctor's office. Even if they're retiring, many of us set up fallback options for a coverage option so that a fellow physician is looking after our patients in the meantime to at least keep the wheels turning. But I think it's also not wrong here and there to see a place like an urgent care.
25:13You know, we don't like it necessarily, but sometimes we have to do we have to do. And sometimes those places can fill in gaps where people really need to be taken care of when we can't do it. Yeah. I mean, Dr. Bittenger, I got to imagine there's a director of an ER near you who hates what you're saying right now. You know, I mean, it's the reality, but they probably hate hearing it. It fills in a valid hole in our system, right? Because we've talked a lot today about how us in primary care are overworked and we're not available the way that we want to be. And so when people do have a blip in their health or they need a quick medicine refill and they've done their due diligence and tried to connect with their primary doctor and they didn't hear back in a way that they really felt they needed, I don't blame them for going to a shorter option to at least make sure they feel safer in the meantime.
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26:02All right, let's talk policy a little bit. Dr. Huffstetler, you're a family doctor, of course. Most of your time is spent on public health research, also specifically on how policy affects primary care. And there's been a lot of it lately. More than 2.6 million Americans lost health insurance coverage last year with the end of COVID-era Affordable Care Act additional subsidies. It was a big political fight. We covered it, caused a government shutdown. As I understand it, 10 or 11 million more Americans will lose Medicaid coverage under the cuts that Republicans passed and Donald Trump signed in Congress last year.
26:40how is this affecting people's access to primary care across the country? You're 100 % correct in your assessment of decreased access based on insurance. And in the United States of America, we have a health system that equates insurance coverage to health. And because of that, when you cut insurance, you are not able to provide people with the ability to get to their primary care clinician. So when I see a patient in practice, I have to bill for that somehow, right? That's the only way I can economically maintain a practice. And so patients that are losing access to Medicaid will have to become self-pay and will have to rely on their own income, which just disincentivizes them from coming when they're healthy.
27:24And we know over the course of time, prevented care, I'm sorry, delayed care is going to cause many more downstream effects than just getting the care when you need it. So these policy decisions have major impacts on the health of the population. And we will see, I suspect, a major deferral in care coming with Medicaid cuts throughout the states that are implementing them now. Well, what's the impact of that, Dr. McBride, deferred care, especially among low-income and poor people across America who rely on Medicaid? It's more disease. It's more cardiovascular disease. It's more kidney disease.
27:57It's more diabetes. It's more depression, anxiety, despair, the diseases of despair that you can't measure in a blood test. It is catastrophic. You know, everybody in America deserves access to a primary care medical home where your doctor knows your name, not just your diagnosis codes. This is a right, not a privilege. And there are solutions I'm sure we'll talk about. There is no mystery as to how to solve this problem. We just have to do it. We got this message from one of you. I was able to find a primary care physician because I was a retired physician and lucky for me. But the reason that no one can find a primary care doctor is that no one wants to do that job anymore.
28:48I did it for 36 years, but by the time I was finishing my career, corporate medicine was making it kind of not a very fun job. You have to see new patients in 20 minutes and do a complete physical in 20 minutes, and it's pretty hard for anyone to go into that field anymore. Dr. Bittinger, what would you tell the fourth-year med student about choosing primary care? We need them. We need them. How do you convince them? That's the exact role that I serve in my department is how do we drive interest in our students these days in our field? And I think there's lots of answers. I think the first is, by and large, lots of us get paid enough.
29:32We can't let our fear of our loans overshadow our passions. And that's the other piece is how do I show how cool my job is that I know so much and I help so many people. I love working with students so I can show off how great family medicine and primary care can be for us and for patients. 1A listeners are writing in from across the country. I mean, the board is lit up. We got this note from Elise. I believe in my great diamond state of Delaware, there are about 2 ,500 people for one primary care doctor. Do not get me started on trying to find a primary care doctor who's willing to take on all of my prescriptions and still treat me.
30:10access, access, access, and incentives. It's what we're talking about with Americans trying to access primary care. More to come. Stay with us.
30:40our hand and shows us the way. Watch the full It's Been a Minute episode on YouTube or listen in the NPR app or wherever you get your podcasts. Let's get back to today's installment of our series, In Good Health. We're talking about primary care and why so many Americans simply don't have access. Dr. Bettinger, I want to come back to you for just a moment because you said something before we took a break. Part of your job is convincing young doctors, doctors in training, that they should go into primary care. You said, don't let our loans dictate your passion. Talk about the incentives in place for young doctors and what's preventing.
31:21What do they say when you say that? They say, gosh, that sounds nice, but I owe 200 grand. What do you want from me, Bittenger? What do they say? Yeah, it's a strong argument that they make, but the truth is that life is long. We've got lots of time to build our financial wealth, to pay our loans, and there are still, at least as of this moment, programs that help pay off our loans. I myself, I'm a part of the PSLF program to help my loans get forgiven because I work for an academic health center. And then I think it's also looking at the career itself. What do young physicians want out of their future?
31:59And what I tend to point out is the breadth of what I can do in my skill set that I can help in an airplane emergency. I can deliver a baby in an elevator, but also that I get to build relationships with patients long-term. Those are things that you might not be able to do in every specialty. And so I want my students to really evaluate what they want their career, which is hopefully long to look like. We're hearing from so many of you. People have specific questions about what's happening and trends in primary care and in healthcare. Monica asks this decades ago, when you went to your primary care provider for an annual checkup, you'd get a physical exam where you undressed, your provider actually examined your skin, your abdomen, checked reflexes.
32:41Now they only seem to listen to your heart and lungs. They feel your thyroid gland a little bit. Maybe they look in your ears. And I just heard that the annual visits are going to be moving to telehealth. In other words, basically doing this over Zoom, Dr. Huffstetler. Monica says, I would love to hear from your guests about this trend. Is it just so that insurance companies can save a little bit of money? Dr. Hofstetter. I think people are going to be mad at what I'm about to say. However, it's important to know that for people who are asymptomatic when they come in for their annual exam, the physical part, when I lay my hands on you, is very unlikely to yield any relevant findings.
33:23And that is so hard for people to hear. When you come in and you're sick, yes, I should absolutely be listening to you, touching you, thinking through what the problem is. But when you are a healthy person, listening to your lungs and your heart is actually just kind of what I do to make you feel like I have touched you, to make you feel good about that visit. However, looking in your ears, checking your reflexes, they aren't going to actually yield much. It's much more important to spend time in the conversation about prevention and what we can do to keep you healthy. Dr. McBride. I agree. I really do.
33:51I also think so much of the in-person visit is about establishing eye contact, establishing rapport, you know, having those silences where the patient realizes you're listening and paying attention to the wine they're drinking at night to take the edge off their caregiving responsibilities. Their worries about their weight and their difficult time accessing, you know, a gym or healthy foods. I think that in-person care is ideal not only for the physical exam, which is, as you said, less and less relevant in a wellness visit, but for that human connection. I fear that AI, which we'll talk about I'm sure later, is going to further hollow out primary care so that that in-person human-to-human engagement is no longer a priority.
34:44Dr. Bittinger, are you as willing as your colleagues to part with in-person exams as trends in telehealth seem to want you to? Well, I think it's a balance, like many things are. Like Dr. Hofstadler said, the truth is that well visits, truly well visits, don't generally tell us much when we do a physical exam. That's actually why Medicare well visits actually don't have a physical exam portion. And so I just try to be transparent with patients about such things to the best of my abilities. But I also think that telehealth has its limitations. I can't examine your hurt knee if you're not in the office.
35:20I can't necessarily get a read of your blood pressure from home. And so I think the in-person visit is so valuable for us to make sure that we're still examining patients. We're still talking face-to-face to make sure we're taking our problems seriously. We got this note from M who says, as a Mexican-American woman, I have never found a doctor that cares and takes me seriously. I'm 41 and still searching for a doctor that listens. And Gerard asks, how does access to primary care docs break down by race? Dr. Huffstetler? Well, when we've looked at data about patient and clinician concordance, meaning if you are a black female and you see a black female physician, you have better health outcomes, which is fascinating.
36:08There must be something in that relationship that builds some trust. So I would say that in the healthcare system that we have currently, we don't have the demographics to support that. I can't get every person, someone who looks or identifies the same as them. The key is it's kind of like dating when you find your primary care doctor, you're going to go in, you're going to have a conversation. And if you don't like that person after you meet with them, go find someone else. And yes, that's going to require you to wait a little bit longer, but you have to trust and be willing to talk with the person in front of you.
36:40Otherwise, I'm never going to be able to help you in a meaningful way. So date your doctors. I'd love to see a Lifetime movie of the week where it's patients and doctors, not long lost exes back in town after going to medical school, you know? That would be something. It would be very entertaining to watch. All right, we got this from Bob who says, I'm on Medicare. Medicare only allows for a wellness checkup rather than an annual physical. The wellness checkup is a very light version of the annual physical that I had been used to. We seniors, being more likely to have health issues, should be getting more in-depth medical preventative care as we age rather than what Medicare provides for.
37:18I would love to hear your guests' thoughts on this. Dr. Bellinger. Yeah, they make an excellent point. I talk with so many of my patients as they near that age, that 65 threshold to say, you know, you're going to get lots of things covered, hospital stays, visits with me, but things you really need like hearing, vision, dental care, your prescriptions, they're not. And so I try to prepare them. I try to look at medicines ahead of time to say, well, this might be expensive once we go onto Medicare. This kind of specialist might be expensive onto Medicare. And so that is, it's just a broader policy problem.
37:56It's how do we fund Medicare so that our older adults get what they need and that us in primary care then get fairly reimbursed for the hard work we do on their behalf. Dr. Bittinger, I called you Bellinger. Sorry about that. Cody Bellinger is a famous baseball player, and that's probably what I had in my head, but sorry for promoting you to baseball Hall of Fame star. You're Bittinger. Let's get that out of the way. Dr. McBride, you've said that primary care in some ways has become a glorified referral mill, that people want to see a specialist and they kind of mill through the primary care office, right?
38:30Yeah, yeah, yeah, yeah, yeah. Just give me my referral because I got to send it to the authorizing insurance agents, right? How did we get to this point where referring patients out to specialists has become the gold medical standard and frankly, probably a huge part of the quasi-administrative functions that you all are expected to do. Well, because like I said at the top of the hour, 95 % of healthcare dollars goes to hospitalizations, procedures, specialty care, sort of damage control. And when primary care doctors don't have time, we are more likely to prescribe and refer than we are to have the conversation about preventative care, about the patient education, sort of empowering you with information.
39:13But primary care, as it was conceived of, was supposed to be a hub for problem solving where issues are solved in-house, like diabetes, weight management, infections, you know, those things we can handle in-house. But if you don't have time and you've got a patient who has, you know, heart disease and diabetes and kidney disease, you're more likely to refer out when you don't have time to countenance all those issues in one setting. It's not so much that patients are demanding it. It's more that we are pushed as primary care physicians to refer out as opposed to solving problems in-house. Michelle sends this note, even a person as conscientious about the primary health care as my spouse has had challenges in the last few years keeping a doctor.
40:00Younger docs are not beating down the door to become adult primary care physicians, as Dr. Bittenger has spoken to, which I think may be viewed as somewhat unglamorous, definitely less lucrative. Thankfully, wonderfully competent and highly trained nurse practitioners are stepping in to fill the gaps. Dr. Bittinger, that's part of the dynamic, right? You're trying to convince young docs to go into primary care, but there's also an army of qualified nurse practitioners who are there to help. Yeah, and I mean, I think in this day and age in our country and our healthcare system, it's all hands on deck.
40:35You know, we'll welcome anybody in to lighten the load and see the patients that are literally sometimes dying to be seen. I think at the same point, we've got to make sure that we're training such folks adequately, that we're holding them to high standards, because I've had many quality conversations within our system about the rightfully high expectations that patients have. So how do we balance these? How do we balance patient expectations, our performance, our training? And it's a complicated picture. So let's try to talk some solutions here, Dr. Hufstetler. We've talked about many, many, many problems.
41:15What would good effective policy around primary care look like? I think that cutting ACA enrollment and cutting Medicaid in terms of access probably isn't it, definitely isn't it. What would good policy look like to start to reverse some of these trends of 100 million Americans not having regular access to primary care? Cool. So the instinct I think most people would say is just pay primary care doctors more or build a system that incentivizes more primary care. And perhaps money is one part of the solution. And I agree that primary care spend being four and a half percent of total health care spend is a problem.
41:54but perhaps we should redesign a system that actually allows primary care clinicians to work with their patients over the course of time to provide that continuity and access. And what that looks like is expanding the workforce and de-incentivizing procedural care from a payment perspective and allowing for the recruitment and retention of medical students into the primary care workforce. So we've talked about these three things already, but really they They are essential to provide structural team-based care that allows a patient to go through their lifespan with one or two physicians realistically.
42:28Because I might retire sometime. And I would gather that the people on this panel also will retire eventually. But keeping the same person for as long as you can and having that sustainable work day for each clinician. And that takes removing primary care from the current system. It has to come out and be separate. You have to allow for its structural redesign. Dr. Bittenger, what's your diagnosis for fixing some of these problems? Oh, yeah. I love all of my colleagues' points there. Those are the exact same points I make to students, to my colleagues, to my family, to my friends, anyone who will listen.
43:04I think the addition that I would make is further incentivizing our students to go into our field by even lessening their cost load. I would also make sure that we continue talking about insurance coverage. We got to make sure that all policies approve and fully cover what we do in primary care because, you know, it's great if we grow our workforce, but patients still got to see us. And so we got to make it affordable. We have a debate in this country about universal health care. Some people call it Medicare for all. Is it like this in Canada? Primary care doctors in Canada have these types of challenges.
43:40I mean, are there an equivalent number of 10 million Canadians who don't have access to primary care, Dr. Huffstetler? There is a different system in Canada. So more people have access, but there are still wait times. There is still a hurried system and there is still referral out. Now it takes a little bit longer in their system. However, there are pressures in other countries like this. And maybe I won't say Medicare for all because I don't think that that's realistic. But what about primary care for all? Dr. McBride is once again nodding vigorously. Enthusiastically, amen to everything that's been said already.
44:13I think, how do we get out of this mess? Three things. pay primary care doctors for conversations with patients, for the rapport, the trust building, the education, the empowerment of patients to live their lives on their terms, with their goals, with their risk factors in mind. Two, expand primary care residency slots and loan forgiveness programs so that medical schools incentivize students to choose the field. And then three, strip away the administrative burdens that eat into doctors' hours. It keeps us on our screens instead of looking at faces. This is where AI, and I know everyone's probably groaning about the idea of AI in medicine, this is where AI could really help us.
44:58So much of what we do in a day as primary care doctors does not require an MD. And it's already helping me in my practice draft letters to insurance companies to say, why the heck won't you cover my patient's prescriptions? Some states are already experimenting with mandating that a bigger share of health care goes to primary care. That is the path forward. That's Dr. Lucy McBride, primary care physician, author of the new book, Beyond the Prescription, A Doctor's Guide to Taking Charge of Your Health. Also with us was Dr. Allison Hufstetler. She's a practicing family physician and medical director at the Robert Graham Center for Policy Studies in Primary Care.
45:37She says, finding a doctor, date your doctor. Be willing to push back from the table and move on. And Dr. Zachary Bittinger, he's a family medicine physician at The Ohio State University Wexner Medical Center. I want to thank you all for joining us for this hour. It's been really informative. Well, what should we cover next on Id Good Health? That's up to you. What health issues need more attention? You can email us, 1a at wamu.org. You can also talk to us through our app, 1a Vox Pop. Today's producer was Haley Blassingame. And this program comes to you from WAMU, part of American University in Washington, distributed by NPR.
46:13I'm Todd Zwilich. Jen will be back with you tomorrow. Let's talk more soon. This is 1A.
46:37This message comes from IXL, a learning platform for helping kids build confidence and get up to speed fast. One subscription covers math, science, and reading for all children in a household. Receive 20 % off at IXL.com slash NPR. I'm Jesse Thorne. After a really good show, it felt like you wanted something. On Bullseye, rapper Isaiah Rashad on how he winds down after a night on stage now that he's in his 30s. So it's like it's hard not to celebrate with. I think I'm going to just get a salad. Self-care is important. That's Bullseye. Find us in the NPR app at MaximumFun.org or wherever you get podcasts.
From the publisher
Not necessarily for something big, not for a broken finger or the flu. Just a checkup. A regular annual visit to make sure everything is ok with your health.
For about a third of Americans, it’s probably been too long. In 2024, more than 100 million people did not have a regular primary doctor at all, according to the National Association of Community Health Centers.
The outlook is particularly bleak for young people. More than a quarter of people aged 18 to 29 polled in a national survey this summer said they didn’t have a primary care doctor. And over half of them who did have a doctor said they skipped or didn’t schedule an annual wellness check up in the past year.
But the blame shouldn’t fall solely on the patients. Primary care doctors are getting squeezed by the current healthcare system. There’s a growing shortage of primary care physicians. That can mean wait times of months just to get an appointment.
For today’s installment of our series, “In Good Health,” we’re unpacking the state of primary care—and what to do if you don’t have access to it.
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