Min Heo for Vox
Primary care is the foundation of American medicine — and it’s withering.
Soon after Dr. Gerard Weigel moved his family to Somerset, Kentucky, in the mid-1960s, he found himself not only the town’s only primary care doctor but the only doctor of any kind — the cardiologist, endocrinologist, and pulmonologist for each patient at his practice.
In a 1967 Mercury Monterey — ”It looked just like Steve McGarrett’s car on Hawaii Five-O,” his son, Dr. Joseph Weigel, recalls — his father would drive around the town of 10,000 to see patients at their homes.
“My father was an old-school general internist,” Joseph Weigel told me. “He was literally ‘the man’ here for all of those years.”
Four of the eight Weigel children went into medicine, and Joseph, the oldest, decided to become a generalist like his dad, who is now 96. After graduating from medical school, Joseph Weigel started practicing in Somerset in the 1980s.
At first, his career was based on relationships with patients, just like his dad’s. He felt he knew everything about them: their medical history, whether they had lost a job recently, if they had gone through a divorce. Early in his career, if one of his patients was admitted to the hospital, Weigel would follow them there. He would work in the critical care unit and sometimes even do surgical procedures, such as placing temporary pacemakers, because there was no other clinician around who could do it. Once his patients had been discharged, they would come back to his office. He would see the person through every step of their care.
But those patient-doctor relationships Weigel remembers have become a relic in the modern American health care system.
Sam, Weigel’s son, remembers going out in public as a kid with his dad and they would often run into one of his dad’s patients. The respect they would show was one of the reasons Sam wanted to go into medicine. He, too, is now a doctor, the third generation in the family. But he works at the local hospital, where he sometimes treats a patient for a few days for an acute illness and then never sees them again.
“He has a completely different lifestyle, a completely different way of practicing medicine than either my father or I ever did,” Joseph Weigel said.
Sam doesn’t envy the early mornings and late nights that Joseph would have to work back in those days to maintain his practice; his dad would come home from work and pop dinner in the microwave at 8 pm because he missed the family meal. But Sam recognizes he has missed out on something. “I haven’t had that same experience,” he said.
Today, primary care is being squeezed from all sides. Long-standing patient-doctor relationships, once the foundation of medical treatment, are becoming less common: The number of Americans who say their source of medical care is a personal physician has been steadily declining. That is especially true for younger patients: As of 2018, nearly half of adults under 30 said they did not have a primary care doctor.
Many opt instead for the convenience offered by urgent care clinics, clinics in retail stores, and even their local emergency room.
The once-dominant model of an independent practitioner who ran their own practice, an entrepreneur as much as a physician, is less and less feasible. The overhead is prohibitive. Hospital systems and other corporate entities have absorbed the majority of America’s primary care workforce. The field is becoming less attractive to aspiring doctors, who can make more money in another specialty.
Patients are paying the price for America’s failure to invest in primary care. Clinical evidence indicates that when patients have a steady primary care relationship, they tend to be healthier and live longer. But it is too hard for too many Americans to find and keep a primary care doc. By one recent estimate, 100 million Americans face some kind of barrier (physical or financial) to accessing primary care. One in four Americans doesn’t have a regular source of health care, a share that has been steadily growing since 2000.
In the face of those headwinds, some primary care practices are trying to recapture what has been lost, to re-engage their patients and communities so that they might enjoy the benefits of having a long-term relationship with one physician. Some of these experiments rely on new technologies (such as for virtual visits) and on new business models (such as direct primary care practices and concierge-style clinics).
In one sense, primary care is trying to find a modern version of the kind of more personal medicine the elder Drs. Weigel practiced. Doctors say they are doing more home visits, holding later office hours, and setting up clinics in schools and workplaces. They are trying anything to meet their patients where they are, to salvage that core tenet of medical care Weigel and others fear is disappearing.
Why fewer and fewer Americans have a primary care doctor
Primary care doctors are intended to be patients’ first contact point with the health care system, the practice where people receive regular physicals, basic medical tests and treatment for mild illnesses, and are referred out to other doctors if their problems are serious.
These long-term relationships of mutual trust between doctors and patients are part of the foundation of American medicine. In the 1800s, the profession was in competition with home-based care and unscientific healers. It distinguished itself over time through professionalization, but also because doctors established their authority by settling down in a community, caring for patients’ medical needs for years. Paul Starr, in his acclaimed history The Social Transformation of American Medicine, quoted contemporary reports of patients in the 1840s and 1850s who would wait for hours at their doctor’s home until he returned from another call.
That image of the do-it-all primary care physician persisted for generations, well into living memory. Dr. Dominic Mack, a doctor for more than 30 years and the director of the National Center for Primary Care at the Morehouse School of Medicine, described growing up in Augusta, Georgia, where a handful of primary care doctors cared for most of the Black population. They admitted patients to the hospital and called in prescriptions. They would even deliver babies and perform general surgery.
“That one doctor retained the knowledge of your health throughout the system,” Mack told me.
In the early 1980s, three-quarters of US doctors still owned their own practice. But over the ensuing decades, that share would steadily drop. The push to control costs in the ’80s and ’90s led hospitals to start buying up more independent practices. Managed care — the idea that a single patient’s needs across the health system should be overseen in a more comprehensive way — made integrating physicians into a larger health system the logical move. Even as the craze for HMOs faded, doctors found it increasingly difficult to operate their own practices in competition with the growing hospital systems. Joining a larger system became more attractive, and hospitals were willing to put a lot of money down to get their foot in the primary care field.
Today, for the first time, fewer than half of doctors own their own practices. Doctors under 40 are much more likely to work for somebody else than their older counterparts.
It’s not just the business side of primary care that is changing. Patients’ expectations are evolving, too. Even in the 1990s, Americans would often face much longer wait times than they do now. But today’s patients no longer have the patience to wait for the doctor to see them.
A survey of physician staffing firms observed that wait times for primary care have actually dropped from a high of more than four weeks in 2017 to about three weeks in 2022. But that improvement was not really a sign that it was easier for patients to get an appointment. Instead, analysts at Merritt Hawkins wrote that “a growing number of patients are accessing primary care through urgent care centers, retail clinics, and telemedicine.”
“What is unique about current times is the changes in patients’ expectations with immediacy of access to doctors. I don’t want to be on hold for 10 to 15 minutes. I don’t want to wait months for an appointment,” Ishani Ganguli, assistant professor of medicine at Harvard Medical School and Brigham and Women’s Hospital, said. “It makes sense we as consumers and patients want that from our primary care.”
So patients have sought out alternative options, prioritizing their convenience over the continuity that is increasingly hard to find.
Urgent care clinics have been around since the 1970s, but they have enjoyed a boom in the past decade. In 2014, there were about 6,400 urgent care clinics in the US; that number had grown to more than 11,000 as of early 2023. CVS and Walgreens have established in-store clinics built on a similar premise: You may not see the same doctor every time, but you can see a doctor quickly. Walmart began to adopt the same model in 2019, and the company plans to double its health care footprint by the end of 2024. Dollar General, which recently hired a chief medical officer, appears to be on the same path.
“We’re living in an era when people don’t have a relationship with a bank teller or hardware store,” said Dr. Yul Ejnes, who practices in Rhode Island and is the former chair of the American Board of Internal Medicine’s board of directors. Consumers expect service “24/7/365 … Health care has evolved in that way. People want what they want when they want it.”
But something may be lost under the new model. Research has consistently found that a long-term relationship with a doctor leads to better health results. One recent analysis, published in April of this year, found that when patients lose their longtime primary care doctor, the number of emergency department visits and hospital admissions increases, as does their mortality rate.
“These effects were magnified if that relationship was longer in the first place. That really does align well with prior studies and clinical experience,” Ganguli told me. “A patient you meet for the first time may not believe you for good reason: They don’t know you. But over time, you build that relationship, that same advice carries a lot more weight.”
How primary care doctors are trying to reinvigorate their practices
In some ways, the problems facing primary care are not new. Ejnes remembers being at a policy meeting in the mid-1990s when one of the agenda items was about a troublesome demographic: young adult men who had health insurance but who were not establishing relationships with primary care docs. The Washington Post reported on the same trend earlier this year.
But the problems are going to get worse as fewer doctors in training elect to practice primary care and more family physicians reach retirement age. Right now, according to a report from the Milbank Memorial Fund, 1 in 3 US doctors practices primary care, but among young doctors two years into their career, the share is only one in five. The Association of American Medical Colleges projects the country will be short as many as 48,000 primary care doctors by 2034.
The traditional fee-for-service model for financing medical care — in which doctors are paid based on how many appointments they have and how many tests they order — also contributed to primary care’s deterioration. Doctors have been rewarded for seeing as many patients as possible in a given day, not taking more time to establish closer relationships with them. Insurers and health systems have been slow to adopt so-called “value-based payments,” which could reward primary care’s contribution to patients’ long-term health.
Doctors characterize the new mode of health care as “industrial” or, as Ejnes put it, “transactional.” Thirty years ago, Ejnes told me, “it was just you and the patient in the exam room.” But today, “a dozen other people are there in spirit” — a performance evaluation team monitoring how the patient is faring with managing their diabetes, a billing team that decides how to code every service, an insurer that wants all this documentation in order to cover drugs or tests.
As they feel intimacy with patients slipping away, doctors are turning to technology that promises to provide convenience: telemedicine, widely adopted during and after the pandemic, and new business models, particularly direct primary care and concierge-like clinics, that could eliminate some of the perverse incentives created by volume-based payments.
For both primary and concierge care, patients pay a flat fee — a retainer of sorts — to establish a relationship with a doctor. In direct primary care, the doctor will typically make house calls for both check-ups and sick visits. That model has been growing quickly, with an estimated 1,600 practices across the United States, but still serves a small percentage of the population, about 300,000 patients. With concierge clinics, the best known of which is probably Amazon-owned One Medical (though it sometimes disavows the “concierge” label), patients can not only access their personal doctor on demand, they may also be enrolled in wellness programs and other perks the clinic offers.
Both models mean doctors are no longer dependent entirely on the number of services they provide. They have a steady source of income from patients’ membership fees. Ejnes noted that direct primary care was not as financially affected during the first few months of the pandemic, whereas regular independent practices saw a huge drop in patient visits and some were threatened with closure as a result.
Based on his conversations with colleagues, doctors at a regular clinic might have as many as 1,500 patients on their rolls; those in direct primary care or concierge care may carry only 500. The model gives physicians the leeway to give their patients the more personal touch without jeopardizing their livelihood.
“We have to understand, patients don’t necessarily want what we’ve been selling,” Ejnes said. “We can still offer the same good we would have offered 30 or 40 years ago, but in a contemporary way.”
These ventures aren’t a cure-all. If every primary care doctor suddenly cut their patient roster in half, the shortages already in existence would get worse. And these clinics have often catered to upper-middle-class professionals living in cities, not marginalized communities where medical access is most constrained.
Even at more conventional practices, though, doctors are experimenting. What unites these disparate efforts to reinvigorate the field is, ironically, a return to the basics.
Dr. Oswaldo Bacani and Dr. Jennifer Bacani McKenney, father and daughter, are part of a practice in Fredonia, Kansas, that is taking an all-of-the-above approach to connecting with their patients.
Bacani came to the US from the Philippines and settled down in Fredonia for what was supposed to be a one-year trial after his medical residency. But he and his wife liked the town so they stayed; they’ve now lived there for 45 years. At first, he was one of the do-it-all doctors, performing surgeries at the local hospital in the morning and seeing his primary care patients in the afternoon. But over time, he focused more on the latter. McKenney says she remembers watching cartoons in the back office of his primary care practice, watching the patients come and go.
“The thing I always remembered is watching Dad interact with his patients. You could see it was personal,” she told me. “They would hug. They would laugh.”
He would come home with pies his patients had made him. One time, a patient paid for surgery with a goat. The kids named it Peaches, after its favorite food.
“I’d see the way his patients loved him, the way they came up to him,” McKenney, who works with her father now at the hospital where she was born, said. “I never remember not wanting to be a doctor.”
Even in their small town, where interpersonal relationships may come more naturally, they have noticed some disengagement from patients. Some people in Fredonia became more skeptical of medical experts after the Covid-19 pandemic.
So their practice is reaching out to the community. They have started setting up flu shot clinics on-site at local businesses. They have considered contracting with local companies to act as a direct primary care provider for their employees. The practice has also set up a clinic at a local school so that students and teachers wouldn’t have to leave and come sit in their waiting room if they need care for something minor.
Those attempts to bridge the patient’s desire for convenience while maintaining a long-term relationship with one practice could help arrest primary care’s decline. Ganguli told me she has begun holding office hours until 7 pm at least once a week, so it’s easier for people to come in after work, and she has seen employer-driven efforts to provide primary care up close after one Boston-area hospital set up an on-site clinic for its employees.
Ejnes, whose practice was recently acquired by a larger health system, said he and his colleagues have set up an after-hours co-op of sorts: They take turns being on call after regular business hours. Maybe the patient won’t see their own doctor, but they’ll at least see someone who knows their doctor. (It is a similar concept to the co-ops that are prevalent in the Netherlands, which Vox profiled a few years ago.)
This is what the new MO in primary care looks like. Meet the patients where they are. Lure them back with the kind of convenience that had prompted them to seek other options in the first place.
“We’re not waiting for them to show up,” McKenney said.