Lisa Farren (Host): Hello everyone and welcome to Crushing Healthcare, where we explore diverse perspectives regarding the state of healthcare today. Gutsy visions for a more affordable, accessible, equitable, and sustainable healthcare model.

So welcome everyone. I'm your host, Lisa Farren. Today, we're going to dive into what I consider to be a very important topic in healthcare today, the status and the future of primary care physicians. We're going to explore the truth around media reports claiming primary care physicians are a dying breed and that primary care medicine is fading away. Are these news reports accurate or is the situation not nearly as dire as the media would have us believe?

Let's explore the drive behind the editorials, how primary care physicians are pushing back and what's fueling a restoration of primary care. It's an important topic. Our healthcare system needs primary care providers. So joining us today, we have two great guests to speak about the topic. We have Sudeep Bansal, MD. Dr. Bansal is a physician at Avanta Clinic, a family-owned, independent Internal Medicine and Primary Care practice located in Connecticut. Dr. Bansal's career has included practicing medicine as a hospitalist physician, a primary care physician, as well as serving as a Chief Medical Information Officer and Chief Quality Officer at St. Francis Healthcare Partners, the precursor organization of Southern New England Healthcare Organization, which is commonly known as SoNe Health.

Dr. Bansal is board-certified in both Internal Medicine and Clinical Informatics. He is helping to shape the future generation of medical professionals. He's an Assistant professor at Quinnipiac University and teaches medical students at his medical practice. Dr. Bansal also writes and podcasts about healthcare on his personal website, pcplens.com.

Also joining us today, we have a returning guest, James Uberti, MD. Dr. Uberti is Medical Director at SoNe Health, where he works closely with providers to support them in maximizing performance improvement and clinical outcomes. Dr. Uberti is a recognized leader and advocate for value-based care. His career as a primary care internist spans more than 30 years in the greater Waterbury Connecticut Market with experience practicing medicine as both a physician employed by a hospital system, as well as an independent physician and a partner in a primary care medical practice.

So, who better to walk us through today's discussion than these two physicians who can speak firsthand on the topic and give us a truthful perspective. So if you pay any attention to healthcare news, these days the reports I'm going to say paint a pretty dismal picture, particularly for the future of primary care physicians. Are the reports accurate? Let's hear from them. So, Dr. Bansal and Dr. Uberti, welcome and welcome back. Let's dive in. Are you ready?

Dr. Jim Uberti: Sure, Lisa.

Dr. Sundeep Bansal: Yes, we are. Thank you, Lisa.

Host: Okay, good. All right. I'm going to start with you Dr. Bansal, if that's okay. What is your take on the recurring narrative in media reports touting the death of primary care? As a PCP, would you say this is accurate or exaggerated reporting?

Dr. Sundeep Bansal: First of all, thank you for the introduction. Media will always exaggerate. The death of primary care headline, you know, it grabs attention. Media thrives on some kind of a dramatic statement. And, you know, based on that, we are also here talking about it. But reality is often much more nuanced. It's absolutely true that the entire medical profession is under strain, not just primary care, but we are far from extinct. Like, there is still a lot of good stuff going on in primary care. Yes, there's been a lot of challenges since 2001. Medicare reimbursement has declined anywhere between 33-50% depending on how you calculate that.

We've had a lot of regulatory things thrown at us, including HIPAA in early 2000, then MIPS, MACRA quality measures to the point where most practices are spending almost like $50,000 per provider per year, documenting quality measures and submitting them to insurance companies. So, there are tons of challenges.

But there are also tons of bright spots. We've also had an entirely new class of advanced practice providers join the workforce, nurse practitioners, physician assistants who are taking up the mantle of primary care and really serving patients' needs. We have geographic variation where, you know, there are some places where there's fewer providers. But in other places, there are providers thriving, like in Connecticut, with the help of SoNe Health.

And yes, we are deeply impacted, but there's a lot of good things happening. There are other business models like direct primary care, telehealth companies are popping up to provide primary care services. So, business models are changing, but we're evolving, and we're still here taking care of patients.

Host: That's good to hear. Thank you. So, all right, let's dive in a little more. Dr. Uberti, what do you think are the biggest challenges or threats to primary care? And what are some of the examples?

Dr. Jim Uberti: Yeah, good morning, Lisa. So even though that the speaking of the death of primary care may be premature, we have to acknowledge the significant pressures on primary care. Certainly, one of them is burnout. And that's actually become a recognized syndrome, including exhaustion, cynicism, and/or decreased effectiveness at work. And depending on the surveys that you read, as many as 50% of U.S.-practicing physicians have at least one symptom of burnout, and it's especially skewed toward frontline physicians. Those in the ED, for example, and especially PCPs. And burnout affects virtually every aspect of healthcare from the number of physicians leaving or retiring early to patient satisfaction and the care patients receive. A burned out physician tends not to provide good care.

Primary care physicians are working in a payment system that seems to value procedures over cognitive work and treatment over prevention. So, PCPs are marginalizing the system that value specialists and high tech services, but not necessarily their time spent with the patients and their knowledge.

There's also been a lot of consolidation in the market, healthcare systems and private equity acquiring practices. And so, the PCPs in these models become cogs in a machine. Offices become profit centers. And so the models are based on how many patients can be seen in a clinic day. It results in decreased workload and less time for the PCPs. With that consolidation, there's loss of autonomy and decreased control over one's work and the erosion of meaning of one's work. There's increased clerical burdens, especially EMRs, which distracts from meaningful interactions with patients and really adds to the clerical work, sometimes at night, sometimes on weekends, even on vacation, causing difficulties with work-life balance for PCPs.

I think we're all aware of the administrative and regulatory burdens too that have mounted over years and decades. What this has resulted in is a decreased pipeline of PCPs. Medical students and residents seem to be turning away from that specialty. Perhaps they're observing burnout, they're observing the stress, they're observing the financial strain, or even the disrespect that PCPs may be receiving. And so, they see primary care as less prestigious than it used to be. So, all those pieces are really impacting primary care, and at least has gotten it now into the national discussion about whether primary care is at risk.

Host: You're right. So, that's a good number of obstacles and challenges they're facing every day. As you said, I'm sure that distracts them, forcing them to spend time on other things rather than patient care and feeling unfulfilled. So, that's really hard. What are some of the ways to address these challenges? Are there better or more effective solutions to address sort of the root causes?

Dr. Sundeep Bansal: So, I think we do need to get back to what makes primary care great again. And the number one thing is getting back to the patient-physician relationship. With everything that Jim just said, you're looking more at the computer than looking at the patient. We are typing more, documenting more, collecting data more than listening to people. And that has to change, and the business model needs to change to support, allowing us to talk to patients. And, you know, we're seeing some things improve on that end.

The first one is the emergence of what's called the direct primary care or the concierge model. You know, you might be hearing a lot about it as an alternative to primary care. And this is just an outgrowth, because a lot of physicians who burnt out and they do not want to deal with insurance companies. They just go out and say that, "Okay. Yep, we'll just charge $50, $100, $150 per month for patients. And that we are not going to deal with insurance companies, and we can concentrate on just taking care of people." So, that's one way to do it.

The other way to do it is to partner with organizations like SoNe Health, which can help take away a lot of those burdens and allow us to see more more patients. There are other people who are doing it as telehealth models. There are technology companies who are now thinking about direct primary care in a box where they can create the entire infrastructure and the primary care physician can just go in, see patients. And a company behind the scenes can take care of all the backend regulatory compliance, documentation work for these primary care physicians. So, there are lots of strategies emerging, and business models are going to continue to change, but I think we'll always find a way to survive.

Host: Thanks, Dr. Bansal. I just really want to say I appreciate how you mentioned the return to the patient-patient relationship. That's something we've talked about multiple times in these podcasts. So, I just want to thank you for that, because I think that's something that not only are the physicians craving that, but patients are absolutely craving that as well.

Dr. Uberti, do you see anything that indicates a spark in the resurgence of primary care based on what Dr. Bansal said?

Dr. Jim Uberti: I think so. So, a few minutes ago, I spoke about burnout. And intuitively, I would've thought that with all the stress and pressures on a small independent practice like Dr. Bansal's, for example, that there would be the risk of greater burnout. In fact, the opposite is true. A 2018 study showed that smaller independent practices had less burnout; in fact, dramatically less burnout than providers who were working within a private equity or hospital system.

So essentially, being small, being independent, being autonomous, protects against burnout because autonomy provides the care that allows PCPs to practice the way they envision when they enter the profession. They have time to spend with patients, they have time to listen, they get freedom and control over clinical decisions and the practice settings they are in, their professional activities, and they can ensure the best possible care based on their expertise and judgment. So essentially, this is the opposite of burnout.

From the patient perspective, I think it's much more satisfying too. Patients don't want to feel rushed. They want to feel heard, respected, and cared for with a focus on clear communication and a sense of partnership with their healthcare providers. So, a strong physician relationship is based on trust, respect, empathy, and compassion partnership. That's all predicated on listening.

And so, the physicians need the time to listen. Because as every medical student learned early on, the vast majority of diagnoses are made from taking a good history. You have to listen to take a good history. Even back in the 19th Century, Sir William Osler, a physician and the founder of Johns Hopkins Hospital in Baltimore stated, "Listen to your patient. He's telling you his diagnosis." So, centuries later, that is still true.

I also want to add, so Dr. Bansal mentioned SoNE Health, Southern New England Healthcare Organization. Our organization is focused on the sustainability of physician independence and autonomy, and I just described the benefits of that. We always look to honor the sanctity of the patient-patient relationship, which is really the most important relationship in all of healthcare. And we do that through a number of ways.

One is supporting our physicians, independent physicians through population health, helping care for their patients across the continuum of care, especially their sickest, most complex and most at-risk patients. We support and reward preventive medicine. We contract for optimal rates. And, you know, rather than a solo practice trying to obtain decent rates from an insurance company, we are stronger together as a network. We do credentialing with payers, which often can be time-consuming and even costly for a practice. And we provide any other services that are required by a practice that allow PCPs to focus on patient care. So, I think through networks like SoNe Health and others, there is the ability to allow primary care physicians to practice the way they once envisioned.

Dr. Sundeep Bansal: If I can just jump in on what Jim said, just echoing what SoNE and other companies like SoNe allow us to do is really take care of our patients. And as you also mentioned before, right, like it's the patient-physician relationship. As Jim mentioned, we are so much happier in a small practice because we can control our time, we can dedicate time to our patients. And that is missing.

I have so many patients who switch from large organizations and who come to us and like, "Oh my God, you actually sit down and listen to me. I can finally talk to somebody instead of somebody just going in and out." So, it's better for the patient. And it's also better for us as providers because if I want to keep 30 minutes with the patient, I can do that. I don't have to go to a large organization who's only giving me five-minute slots 15-minute slots per patient. So, I can control my time much better. And in return, because I can control my time much better, I can give more time to people.

Host: That's very well stated. Thank you, Dr. Bansal and Dr. Uberti. It's true. As I said, I really think, patients are craving that time. They're tired of feeling rushed, and spoken at rather than a conversation. So, it's all really great. And so far, everything I've heard indicates that there is hope in primary care.

It's not nearly as catastrophic as the editorials are touting. but now that we've examined the challenges and some potential solutions and remedies to the issues that PCPs are facing, I kind of want to know just personally what you're both thinking. So the question sort of for both of you from a personal standpoint, what are your thoughts on the status of primary care in our healthcare system today? What keeps you professionally motivated and energized when you face some of the challenges that we've heard discussed today?

Dr. Sundeep Bansal: There's no question, primary care is at a crossroads, right? There's an old saying, the only constant thing in life is change. And healthcare is changing, primary care is changing. And change is coming faster, and more change is coming, but we are adapting. The things that's still keep us going, again, going back to the relationship, right? There is joy in medicine when you get somebody to quit smoking, when you control somebody's diabetes, when you get them to lose weight. Like, you know, we give high fives in the office when somebody does that. And there is real joy when you know that you've changed somebody's risk of downstream heart attack, stroke, and they're now living much better because of you.

So, there is a lot of things that are still good in medicine. There's this whole new paradigm shift coming down the road and actually already here, artificial intelligence. We hear a lot online that, "Oh, artificial intelligence is going to replace doctors." I look at it completely different. Artificial intelligence has the potential to give us time back by taking care of all the drudgery that Jim talked about, the documentation, the synthesizing of the notes by doing all the backend work for us and give us more time so that we can talk to patients. And I think that's something to look forward to and to be celebrated. Because if we can use artificial intelligence and other like this, we can go back to the basics of what we do, which is to take care of patients.

Host: That's great. Thank you. So, Dr. Uberti, how about you?

Dr. Jim Uberti: So, I would go back to the essence of primary care, which keeps me optimistic. And I'll go back, you described various editorials, and even podcasts across the country, talking about the death of primary care or the future death of primary care. And there was an editorial in the Journal of Graduate Medical Education that really inspired me to be interested in doing a pod like this. And it was called a Eulogy for the Primary Care Physician. And I'll quote from it: the role of the PCP was born from a simple, noble idea that every patient deserves a trusted doctor who knows their health inside and out, who guides them through the complexities of the medical system and fosters relationships, not with charts, but with people care that transcends physical ailments to address the whole person."

The role of the PCP at one time was prestigious and it was sought by medical students, driven by the close bonds they could form with patients, the potential to influence health at a fundamental level. And for many, including myself, and I'm sure Dr. Bansal, being a primary care physician, represented not a career, but a calling. So in this editorial, they describe some sort of infection virus or whatever that is ripped through the primary care community and is going to lead to its demise. But I want to be optimistic.

I'm going to suggest that because of an immunity of some sort, there are many, many primary care physicians who have survived these apocalyptic events who still have a calling and whose pilot lights still glow bright. They and the patients they care for must truly continue to be our focus. We need to partner with them, support them, and again, make the physician-patient relationship the essence of healthcare, and that'll be to the satisfaction of both those who deliver the care and the patients who receive that care. So, I'm bullish that there are people out there, there are physicians out there, who view primary care as a calling and who just need our support to fulfill that calling.

Host: Both of you, so well articulated. I love, Dr. Bansal, there is joy in medicine that really resonates with me. And Dr. Uberti, the analogy of the pilot light still burns brightly. Fantastic. Thanks for sharing that optimistic and encouraging analogy to kind of wrap us up. Dr. Uberti's been on the podcast with me several times, and he knows I'd like to end on a positive note when I can. So, I appreciate that.

Primary care providers do face some very real challenges as we've heard today. But they're not only surviving, you're thriving. It's really just finding a way to navigate the changing landscape of healthcare today. And it really does come down to protecting, nourishing, and elevating that patient-provider relationship, which is good news for all of us because PCPs are critical to our healthcare system and to patient outcomes. We know that effectively coordinating and guiding patients along their healthcare journeys. So, thank you very much, Dr. Bansal and Dr. Uberti, for chatting with us today, sharing your time and your thoughts. And I especially just want to thank you both for the important work that you do touching lives. So, thank you.

Dr. Jim Uberti: Thanks for having us, Lisa.

Host: So as we end, as always, I like to remind everyone that we all have a role to play in healthcare transformation. So, join us in Crushing Healthcare.