In a typical visit to your primary care doctor or nurse practitioner, you can expect a mere 10–12 minutes of face time with your doctor, who interrupts you within about 18 seconds and never fully listens to you. They do not have time to listen fully or think appropriately about each of the 20 or more patients they see every day.

After 55 years as a physician, I recognize that 12 minutes is fine for some problems or checkups, but it is not enough time to listen to a complicated history, give it real thought, and then develop an appropriate action plan. It is not enough time to deal with anxiety, which is the inciting cause or result of about 40% of doctor visits. It is not enough time for a patient with two chronic diseases and taking a half-dozen prescription medications who comes in with a new problem. It is certainly not enough time for an older patient with mobility, vision, hearing, or cognitive impairments.

This short shrift causes additional follow-on problems: excessive laboratory testing, sometimes unnecessary and expensive imaging, and referrals to specialists when more time with the history would suffice to make a diagnosis and decide on a treatment plan. All of this leads to increased healthcare costs for insurers and patients.

The numbers behind those numbers might shock you.

Most primary care physicians (PCPs) have a “panel” of 2,000 to 2,500 patients, meaning the number of people who utilize this PCP for their primary care. A rough rule of thumb for a patient panel ranging from young and healthy to older and frail with multiple issues is that about 1% per day will need an appointment. This equates to 20–25 visits per day and, therefore, brief visits.

Here’s an out-of-the box solution

This crisis in patient care has spawned a new approach called direct primary care (DPC) or concierge practice. In either of these, the doctor has a panel size of 400 to 800 individuals so that the PCP has the time needed with each patient to give top-level care.

It’s essentially like hiring a private doctor, but sharing the costs with a few hundred other patients.

Each offers superior care, greater patient satisfaction, and less physician burnout. Much better care results in fewer referrals for tests, imaging, or specialists, fewer visits to the ER, and fewer hospitalizations. The patient is more satisfied, the doctor is less stressed, you have many fewer copays, and the total care costs are much lower.

Perhaps not necessary for everyone, but certainly highly appropriate for those with any level of chronic illnesses like diabetes, heart disease, or lung disease or the dysfunctions of aging like reduced mobility or cognition. And with added attention to maintaining wellness, the likelihood of developing a chronic disease later is greatly reduced.

A frequent criticism is that DPC or concierge care requires out-of-pocket expenditures above insurance costs. This is an important issue, a tradeoff of dollars versus health. I will delve into these competing forces below.

Here is a true story that reflects many of the issues

My wife and I were having lunch with some friends. The lady, I will call her Susan, asked if I knew a particular neurologist. I did not, but I wondered why she had asked. “Well, if you knew him, maybe you could get me an earlier appointment. Right now, I must wait nearly two months to see him.”

I was gratified that she thought I had that kind of pull (which I did not), but I was curious and asked why she needed to see him. That prompted this story.

Susan was 64, married, insured, a successful professional, and in generally good health. She began to have a strange sensation in her right chest, described as a shooting sensation, almost electrical or vibrational. It stretched from high up in her right chest down to a narrow line over her rib cage and onto her abdomen. It seemed to be immediately under the skin, starting intermittently and ending at no set time.

She visited her primary care physician (PCP) and described this sensation, adding that she was concerned that it might be her heart. The doctor asked additional questions and performed an exam and electrocardiogram. All were normal except for the description of the sensation.

Her PCP was now running out of time for this fifteen-minute visit. Here was a fork in the road with two paths. One path would be to spend more time with her and search for the underlying cause. Given that Susan indicated a concern about her heart, the PCP chose the path of sending her to a cardiologist for further evaluation.

The cardiologist did a history and exam related to her heart and found nothing abnormal but suggested a stress test and an echocardiogram. (Do you hear the healthcare cash register ringing?) Both were normal. The cardiologist said it was not Susan’s heart that caused the problem, but since the sensation crossed over to the upper abdomen, it may be a good idea to see a gastroenterologist. (Check the cash register again, plus think of her increased anxiety.)

The GI doctor also took a history and exam and found nothing. Nevertheless, among many other tests, the doctor ordered a CT scan of the abdomen. Everything was normal except for a small cyst in her uterus. The radiologist read it as a benign cyst but — feeling the need to be cautious — recommended Susan visit a gynecologist. (Now, the cash register went into overdrive.)

The gynecologist also said it looked benign, but “to be on the safe side,” she could remove it laparoscopically. Susan would be “out of the hospital the same day and feeling fine in a day or so.” The cyst was just that, a benign cyst, but not before being told that it was “unusual,” so it was sent to a specialty pathology lab for confirmation. It took a week for the result; imagine her rising anxiety as she waited.

Susan still had the strange sensation in her chest, and no one had found an answer for her. But given that it seemed to have an electrical feeling, the gynecologist suggested it could be a nerve issue. So, after that long wait, she visited the neurologist, who found nothing, commenting that “in freshman medical school anatomy, we learn that nerves run around the chest, not up and down.” She left without an answer to her concern.

PCPs have too little time per patient

Susan’s story illustrates the problem that is so common today in primary care: insufficient time resulting in excess referrals to specialists and overuse of laboratory testing and imaging. Twenty-five years ago, about 5% of PCP visits resulted in a specialty referral. Today, it is nearly 20%. I doubt the patients are different; the doctors’ time is different. Lack of time also means most PCPs don’t help with getting specialist appointments, as happened with Susan and the neurologist.

Primary care is often thought of as being for the “simple stuff.” However, PCPs are trained and experienced to deal with most problems that cause a person to need medical care. When they do have time, PCPs can treat the vast majority of issues brought to them by their patients without the need for specialist referrals or excessive testing.

They can — and do — give superb preventive care. This care will reduce serious chronic illnesses in the future, especially for the diseases that account for 75–85 percent of all medical costs today. When PCPs have time, they can handle 90 percent (or more) of the care needs of those with chronic illnesses without a specialist referral. They can coordinate the care of patients who need to be referred, ensuring high levels of quality in a reasonable time and at a reasonable cost. By doing this, they can develop a trusting relationship and be true healers.

The primary care physician should be the backbone of the American healthcare system. But primary care is in crisis — a severe crisis. In this story, the PCP did not truly listen to his patient. He did not stop and think the issue out carefully. He had no time to delve into what might be causing Susan’s discomfort since there was a waiting room full of patients, and he needed to see about 24 that day. So, instead, he took the easier path and referred the patient to a cardiologist since this seemed like a logical choice given her stated concern.

Had he followed the other side of the fork in the road, listened long enough, and then thought about it, he would have concluded that Susan was hypersensitive to minor — albeit real — sensations. He would have offered reassurance that it did not represent a life-threatening ailment, that it was real but of no concern. He might have provided a few weeks of a low-dose anti-anxiety medication such as alprazolam (Xanax), offered further reassurance, and told her to return soon for a follow-up.

At the follow-up, he might have explored the issues producing anxiety or stress in her life — finances, marital relationship, a disruptive child, or an overbearing in-law. If he had done so, he would have learned that she was overcome with guilt that her grown son had become addicted to alcohol and narcotics. What Susan really needed was assistance to overcome her stress, not months of specialist hopping, which was unnecessary, expensive, and only increased her stress.

Specialists are too focused on their “organ,” not the whole patient

Susan was shipped from doctor to doctor, test to test, and even had an operation with no one listening enough to figure out her problem. All each specialist could do was say it was not in their “organ system” and leave her without a sense of closure. Each said it was not the heart, the stomach, or the nerves. The surgery “went fine,” but she still had the unpleasant sensation. This resulted in far less than adequate medical care and cost a king’s ransom — nearly $18,000, which, fortunately, was mostly paid by insurance.

That is what happens today. All that was needed was for the PCP to spend some more time — time to listen, time to think, and then time to counsel. That is not expensive at all, maybe a few hundred bucks. But “the system” doesn’t allow that.

Susan’s story is not at all uncommon. I could give you many similar examples. Her travails with the medical system illustrate how deep the problem goes. Her journey highlights the issues that need to be addressed.

Why so little time per patient?

Why do primary care physicians have so little time? The short answer is our insurance system, which attempts to manage costs through price controls. As a result, reimbursement has grown slowly while office costs have risen dramatically to cope with insurance requirements, preauthorizations, and malpractice, to name a few.

With costs rising and income steady, PCPs are forced to make up the difference through volume. This means seeing more patients per day. To see those 20–25 patients, the PCP shortens the time per visit to 20 minutes with about 10–12 minutes of actual “face time” with the patient.

In inflation-adjusted dollars, a PCP earns somewhat less today than in 1970 yet sees about twice as many patients per day. PCPs have been forced to focus on quantity when they should focus on quality.

I recently interviewed a PCP in an affluent small town in Maryland who is employed by a large primary care practice company. His employer requires that he see 24 patients daily, which he finds uncomfortable and stressful. He does not believe he is giving the level of care many of his patients require. Now, they want him to increase that number to 27. He plans to refuse and, if necessary, resign.

This crisis is the most pressing and urgent issue in healthcare delivery today. Healthcare delivery must be restructured now so that everyone, especially older adults with multiple chronic illnesses, can obtain quality, compassionate, and cost-effective care. This means having a committed primary care doctor with the time, knowledge, and experience to deliver the care needed. This will require both a change in how primary care is delivered and how it is purchased.

Among other high-income countries, Americans are the least likely to have a long-standing relationship with their PCP. Home visits are very uncommon, and Americans are the least likely to connect with their PCP after hours. On the “sort of” plus side, at 30%, American PCPs are more likely than those of other countries to screen for social needs such as housing, finances, marital discord, abuse, and food insecurity, according to an analysis by the Commonwealth Fund.

Direct primary care and concierge practices are the future

PCPs must change the paradigm and become direct primary care or concierge physicians. This means reducing the number of patients in the panel from their usual 2,000 -2,500 to around 600, even less if the practice is mostly elderly.

They give their cellphone number to patients to use 24/7, respond to texts and emails, and offer telemedicine. Appointments are the same or the next day and as long as needed. An annual evaluation is comprehensive, with a high focus on wellness preservation. The doctor does not accept insurance; the patient pays a monthly or yearly fee, usually ranging from $1000 to $2,000+ per year.

A slightly different model is used by, among others, MDVIP-affiliated doctors. Here, the PCP keeps the practice to about 500 or fewer patients. They accept insurance but also charge an annual fee for extensive wellness attention. Otherwise, the practice operates similarly to DPC or concierge practices.

A common criticism of direct primary care or concierge practices is the added out-of-pocket expense above already hefty insurance payments — “Isn’t it too expensive?” They are not. I encourage you to check out my earlier article on DPC costs versus benefits. Most DPC practices charge a reasonable fee given the attention given and often include free or wholesale costs of common generic medications and reduced-fee laboratory testing and imaging.

The results are stellar

Not only will you be on track to be healthier, which is the most essential value, but you will also save money with fewer visits and co-pays to specialists, tests, and prescriptions.

“A 2022 analysis by Hint Health found that DPC practices led to a 35% reduction in emergency room visits and a 50% decrease in hospital admissions. This shift can be attributed to the proactive nature of DPC, which emphasizes better access to care, routine screenings, and the management of chronic conditions,” as reviewed by Luis Cisneros in a wide-ranging article on DPC.

In Alaska, the Nuka Healthcare System, which uses a team approach to care with limited patients per team, has had stellar results as measured by patient and provider satisfaction, easy access to care, improved quality measures, reduced use of tests and specialists, fewer ER visits, and fewer hospitalizations.

When looked at from the totality of healthcare costs to America, the dollars spent on primary care will be more than the current approximately 5% of America’s nearly $5 trillion total health expenditures, perhaps about 7–9 percent. However, the result will be better care — by far — with greater satisfaction for patients and doctors alike. Importantly, with many fewer referrals, tests, and hospitalizations, there will be a major reduction in the total costs of care. This resolution does not add money to the system but reallocates it, ultimately reducing total expenditures.

It works. My wife and I both use DPC/concierge-style physicians. We find the care far superior and have each benefited from being able to call anytime, if necessary. We also get practical coaching to exercise, eat well, manage stress, and sleep enough. Yes, it costs money, but we believe it is worth the out-of-pocket expenditures.

I encourage you to give DPC a good look. Most DPC and concierge physicians will do a “meet and greet” at no charge. Take advantage and see for yourself.

You can read more about this crisis and its resolution in my book, Fixing The Primary Care Crisis.

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