Referral Madness

A number of people have contacted me recently hunting for a new doc, because apparently another primary care physician (PCP) in town has left. I’m also getting more requests for specialist referrals from patients I’ve never seen, especially for physical therapy.

It got me thinking about what medicine may look like if we extrapolate the PCP curve to zero. It’s not inconceivable. As PCPs close their practices, join hospitals, quit medicine, or simply retire, the workload will continue to increase for those remaining. It’s hard to imagine a Trump administration working to improve Medicare reimbursements, or to incentivize PCPs to stay in business. It’s also doubtful our country will choose to fill gaps with more foreign medical grads, though I believe we benefit immensely from their presence. So I suspect patients in the coming years will likely keep scrambling for increasingly limited appointment slots. Everyone else will be left with urgent cares, ERs, Dr. Google, concierge docs and Pre-R.

Will it be a partial or total crisis? It’s hard to predict the future, but it will certainly be uncomfortable. However, perhaps the evaporation of PCPs will get patients and communities thinking more creatively about healthcare too. One silver lining is that specialists are likely to become a little less special. If PCPs go away then so will their flow of referrals. They will no longer suffice as screeners for specialists. I suspect specialists will become more like tradesmen, and will have to choose for themselves who to see based on direct communications with patients.

Specialists will probably use telemedicine a little more as a first line of screening as well. I suspect they’ll evolve toward hiring PAs and NPs to care for the problems PCPs used to field like wrist sprains, asthma, hypertension, depression, etc. The transition over the next few years will likely be difficult, but hopefully the “I can’t see you without a referral” dynamic will vaporize as well. That would be fine by me anyways, because one of my most common calls is: “Can you write me a referral letter for Dr. XYZ. They won’t see me without one.”

While I’m happy to get paid for doing something so simple, at my core, I really hate being part of such waste. Our patient ping-pong model just feels insane.

I do realize that much of the referral madness is driven by insurers. But hopefully they will be forced to evolve too. It just baffles me what hoops patients are forced through these days though. Specifically with regards to physical therapy, if a patient wants it, why can’t they just schedule an appointment? What do I add, other than additional expense? I understand limiting access to antibiotics or narcotics, but who’s out there abusing PT?

If no PCPs, then where would you get your vaccines?… Probably pharmacies. Many offer that already. How about the mandatory yearly physical? Don’t get me started.

Regardless of where the primary care world lands, to me the most important thing is to have someone you trust in your life who is medically savvy, whether doctor, NP, PA, case manager, or nagging spouse, who you can call in a bind and who cares whether you’re alive or dead. As the primary care bottleneck tightens, unfortunately, it’s getting harder and harder for PCPs to meet those needs today.

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