Today, Explained - The Dollar General will see you now

Episode Date: October 27, 2023

The primary care physician shortage is ruining health care in America. Dollar General, Best Buy, and Walmart are trying to fill the void. Vox’s Dylan Scott explains. This episode was produced by Jon... Ehrens, edited by Amina Al-Sadi, fact-checked by Laura Bullard, engineered by Patrick Boyd, and hosted by Sean Rameswaram. Transcript at vox.com/todayexplained Support Today, Explained by making a financial contribution to Vox! bit.ly/givepodcasts Learn more about your ad choices. Visit podcastchoices.com/adchoices

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Starting point is 00:02:07 Today explained Sean Rahm's firm. I mostly try to avoid doctors, had a bad experience, but I recently tried to get my once-a-decade checkup, and getting an appointment with a new physician was tough. It was like trying to get into New York's hottest club tough. Dylan Scott covers healthcare at Vox, and he's been having a tough time too. Yeah. I mean, your story is not unique, I am sad to say. My family has gone through the exact same thing. My wife in particular has been trying to find a new primary care doctor for like the last
Starting point is 00:02:37 year. And first of all, there just weren't that many who were accepting new patients. And second of all, once a couple of times when she did actually have an appointment scheduled, it ended up getting canceled and she had to kind of start from scratch. And it's not just Dylan and me in and around DC. We asked you about your experiences and they reflected ours. Yeah, my name is Mindy and I'm from Arvada, Colorado. Both my wife and I, we just really can't find a primary care at all. My name is Macy. I live in Columbus, Ohio. I knew I was turning 26 and was going to lose health insurance from my parents. So six months in advance, I started to make all of my preventative and annual appointments. A lot of offices in the Columbus area were full up to 9 to 12 months.
Starting point is 00:03:31 So I was not able to get into a lot of my appointments prior to losing insurance. And, you know, that's just preventative and annual stuff. And if we take a look at the data, like, those kinds of experiences are not that unusual. The number of Americans who say that their primary source of medical care is actually a personal physician, one person that they go back to again and again, those numbers have been declining. And especially for younger patients, about half of people under 30 say they do not have a primary care doctor. About one in four people say they don't have any regular source of healthcare in the United States, and that number has been growing.
Starting point is 00:04:10 Primary care, what was once kind of the foundation of American medicine and of people's relationship to the healthcare system, has really been getting squeezed for decades now, and I think patients especially are starting to feel that squeeze. We asked Dylan what primary care looked like back when it was the foundation of American medicine. If you lived in a small town, there was a primary care doctor, and they ran their own practice,
Starting point is 00:04:36 they were in charge, they employed themselves, you'd go see them for your checkups, for sick visits. If you went to the hospital, they'd probably go to the hospital with you and admit you and oversee your care there. That's when the family doctor, the primary care doctor, had this place of primacy in the American health care system. And when does it start to go south? In the early 80s. Hell yeah, it's the fucking 80s. Some important things started to change with the overall healthcare system around that time. Some of the big ones are hospital systems were growing. They were looking for new revenue opportunities.
Starting point is 00:05:19 And so they identified, like, all right, we're providing all this inpatient care, performing surgery, delivering babies, fixing broken bones, whatever. But like, you know, there's this whole other swath of the health care industry, primary care, you know, outpatient visits where there's even more money to be made. Like back, you know, 30, 40 years ago, most doctors were self-employed, like something like three-fourths of doctors were running their own business. They were entrepreneurs as much as physicians. But these days, and just in the last couple years, we've reached a milestone where like, actually, most doctors and most primary care doctors are now employed by somebody else. They work for a hospital or, you know, maybe a larger system of clinics, what have you. But that's been a real change. We've gone from the sort of like, you know, the independent doctor to primary care doctors
Starting point is 00:06:08 who are now just kind of cogs in the system. And I think that has led to, you know, less of a personal relationship between patients and their doctors. And I know that doctors in the field are really concerned about that. Hi, this is Pamela Root, and I'm calling from Vermont. And I work with a lot of elderly people who have had unbelievable problems with trying to get things resolved with doctors and appointments.
Starting point is 00:06:36 And it just seems that privatized, these big investment companies that own all these hospitals and medical facilities, they would rather not deal with doctors. Why does this consolidation, though, lead to the shortage that you're describing? It's a combination of a few different things. It is partly a consolidation, like health systems absorb these primary care practices. And, you know, their directive to the doctors is like, you need to see as many patients as possible. And so that gives, you know, their directive to the doctors is like, you need to see as many patients as possible. And so that gives, you know, because the way primary care doctors are paid or their health systems are paid for their services is largely fee for service. Like you have an appointment, you order a test, volume is king. You need to be doing as many different services as possible.
Starting point is 00:07:22 Hello, my name is Debbie Kennedy, calling you from Salem, Oregon, which is a medical wasteland. It's become universal throughout the city here to just give people 15 minutes of your time if they have an appointment with you. And that's not their fault, that's the fault of whoever's running the clinic. Obviously, from a hospital's perspective,
Starting point is 00:07:45 they want to bring in money, but they also want to minimize their overhead. So they're going to only hire as many primary care doctors as they think is worth their while, but not more. And because hospital systems are often so dominant in their local healthcare markets, that can make it a lot harder for another doctor to set up an independent practice. Hello, my name is Soraya. I'm from Houston, Texas. We also are suffering the healthcare shortage. Essentially, we have hospitals where people are jumping from hospital to hospital depending on who is offering the bonus. But we just don't have enough providers to fill all of the positions.
Starting point is 00:08:22 The other part of it that I think is really important is from a medical training perspective and from an economic perspective, you can make a lot more money if you train to be an orthopedic surgeon or do some kind of other medical specialization. You potentially could make twice as much money. We have this system of medical training where Medicare is responsible for setting up residency programs so that doctors in training can actually practice in the field for a few years after medical school. And the number of slots that are devoted to primary care has not been sufficient for a long time, according to people who look at these workforce issues. So we're both not creating enough primary care doctors in our medical training pipeline. We're not giving aspiring doctors much of a financial incentive to practice primary care. And we've just made the prospect of entering primary care, in terms of your work experience,
Starting point is 00:09:19 less appealing. Because now you're just going to be, like I said before, a cog in a larger hospital's machine. Like that's why we're seeing these dwindling number of people who are entering the primary care space. Yeah, this is Daniel Blakely. And I was hospitalized randomly for a hiking incident. And when I got out of the hospital, it was directed by the emergency room doctors to contact my primary to figure out my recovery. When I got home, things did not get better. They actually got worse. And I kept trying to call my primary. He never called me back, not once. And it's kind of indicative of the healthcare in San Luis Obispo, which is considered a rural area. So it
Starting point is 00:09:56 doesn't attract doctors. I had to wait almost a year to get my first visit with this doctor. And now I'm having to wait almost the same time to switch doctors because I just can't trust this original doctor anymore. Where is this doctor shortage felt most profoundly? Rural areas in particular experience the worst shortages. And that's, you know, it does go back right there to the economics.
Starting point is 00:10:21 On top of that, you know, there are like other considerations when people are trying to decide where to work, right? It's not just about where's there a job, it's like, what kind of community do I want to live in? Where might there be a job for my partner? That kind of thing. And that continues to tug more and more doctors towards large population areas. But if you kind of take a big step back, it's not totally clear whether we don't have enough doctors, like, overall. Oh? The issue is less that, like, we have an overall doctor shortage and more that the doctors we have are not very well distributed.
Starting point is 00:10:57 We might, in theory, have enough doctors. What about the patients, Dylan? We've been talking about doctors, hospitals, the industry, but what about patient behavior? Has that changed in a way that affects this shortage or affects the ability for patients to find doctors in any meaningful way? It does seem that what has changed is patients' expectations about how quickly they should be able to access a doctor. Hi, this is Jessica Starr. I'm calling from Springfield, Massachusetts. Finding a doctor has been insane. I couldn't find anybody who could take me in less than six months. Now, I was able to resolve this by moving to a telemedicine doctor's office. So now I have an app on my phone and a doctor that I can just send a message to at any point, which is really great, but it also is kind of missing that in-person touch. And so there's this, you know, kind of industry of alternative
Starting point is 00:12:01 options that has started to proliferate. Like we've seen an explosion in the number of urgent care clinics in the United States. You've seen pharmacies like CVS and Walgreens start to set up clinics in their stores where people can get at least like very basic healthcare services and even get, you know, a physical, get some of their vitals checked, that kind of thing. And we're seeing other companies start to explore this space. Like, you know, Walmart has pledged to double its healthcare footprint. It's become clear that sort of the traditional model of primary care is broken, in part because of issues on the supply side that we've already talked about, but also because of, you know, the demand side and consumers' expectations about being able to see their doctor whenever they want to see their doctor.
Starting point is 00:12:45 And so we're seeing these competitors pop up, and it's led to this kind of inflection point for primary care going forward. Whether big box entering big medicine is a good thing for little patient when we're back on Today Explained. Support for Today Explained comes from Aura. Aura believes that sharing pictures is a great way to keep up with family. And Aura says it's never been easier thanks to their digital picture frames. They were named
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Starting point is 00:14:42 with real-time notifications. Or how about more ways to customize your casino page with our new favorite and recently played games tabs. And to top it all off, quick and secure withdrawals. Get more everything with FanDuel Sportsbook and Casino. Gambling problem? Call 1-866-531-2600. Visit connectsontario.ca. Doctor, doctor, give me the news. Doctor. okay today explain is back with dylan scott from vox dylan you said that big pharmacy the the walgreens the cvs's were part of the reason that patients are losing their patients but also maybe part of the reason that it's getting hard to find a doctor. But I just recently read that Rite Aid,
Starting point is 00:15:25 one of these big pharmacy outfits, is in financial straits. One of the country's largest pharmacy chains, Rite Aid, has filed for bankruptcy protection. What gives? Well, I think the Rite Aid situation, it's unique. The reasons that Rite Aid is citing for preparing for bankruptcy is that it has some longstanding debt. It also has some financial obligations as a result of some of the opioid epidemic settlements that have been made with state and federal governments over the years here in recent years. Fair. So I do think that it's not necessarily a sign that this business model is going under. I think it's still important for the subject that
Starting point is 00:16:05 we've been discussing because these clinics, these minute clinics that are largely run out of these big pharmacy chains, for some people, especially for people who generally speaking, don't have a lot of healthcare access, that might be the most obvious place for you to go to get basic medical checkups, to get your vaccines. Even if these kinds of medic clinics aren't a perfect replacement for like a personal physician, they do provide health care for a lot of people, particularly people who might not have access to other kinds of health care. If a Rite Aid goes under, which is happening, who steps in? Is it just CVS or Walgreens? Because I've heard like at least CVS is shutting down
Starting point is 00:16:45 stores all over the place too. Yeah, you're right. The nation's largest pharmacy chain is now planning to close as many as 900 stores over the next three years. That's about one-tenth of its locations. Walgreens has said the same thing. It comes after they failed to meet earnings expectations and lost about 59% this year in reported net income. I think some of that is linked more to just like the general struggle of brick and mortar retail right now. And part of the reason I think that is that we do see other chains still interested in getting into the healthcare game. I think, you know, the most striking example has been Dollar General. Dollar General, the known dollar store?
Starting point is 00:17:25 The dollar store where you're supposed to be able to, you know, go pick up like your household cleaning supplies for a couple bucks or whatever, you know, yeah. Hi, besties. We are sitting outside of the Dollar General and I'm about to take you in store and show you some deals that you can do utilizing this coupon right here,
Starting point is 00:17:43 the 5 off 25 Saturday only coupon. They've become kind of omnipresent across the country, again, particularly in neighborhoods and communities where there might not be a lot of other just shopping retail options. And so they have identified, you know, healthcare as a potential opportunity for expanding their business. So can you get like a colonoscopy for like a couple bucks? We're not there yet. You know, they've been taking baby steps. So like first, they hired a chief medical officer a couple of years ago and announced they were creating like a healthcare advisory board to kind of figure out like what would a dollar general but for healthcare look like? And so they've been slowly ramping up over the last couple of years.
Starting point is 00:18:27 Like for one, they've just started to stock healthcare products in their stores. And then earlier this year, they started piloting like mobile clinics that would be held, you know, at the locations of their retail stores. So they've set up these like trailers. They've partnered with a group called DocGo, which is like, you know, its whole business is providing mobile health and transportation services.
Starting point is 00:18:52 And so in Tennessee, they set up a handful of these mobile clinics to do a lot of the same stuff that Walgreens and CVS have been doing at their minute clinics. You know, physicals, routine checkups, vaccinations, lab testing, evens, routine checkups, vaccinations, lab testing, even diagnostics like an EKG.
Starting point is 00:19:13 If somebody comes in complaining about their heart, they can do certain urgent care services like, you know, treating wounds and even help, you know, people who have like high blood pressure, diabetes, you know, get their vitals checked and potentially get prescribed any medication that they might need. So I do think that that suggests that, yes, while those marquee pharmacy chains have had some business struggles here of late, there are still other franchises that see a real opportunity in providing this basic kind of medical care to people, particularly people who might not have a personal physician and who are just looking for some kind of option to get their basic medical needs met.
Starting point is 00:19:50 I've seen a pharmacy at the Walmart. Dollar General is getting in the mix. How long is it until Best Buy and TJ Maxx are getting in on the action? Well, it's funny you should say that because Best Buy has begun talking about offering telemedicine services. I mean, that's funny you should say that because Best Buy has begun talking about offering telemedicine services. I mean, that's another potential opportunity here.
Starting point is 00:20:08 That's another way in which primary care may begin to evolve. Maybe you don't have a doctor's office or even a pharmacy nearby, but most people can hop on their phone or hop on a computer and talk to people that way. Then this is happening across different practices, not just in terms of what Best Buy is trying to do. Like, I'll make a confession here, Sean. Okay. I got my physical... At Best Buy?
Starting point is 00:20:31 Not at Best Buy. At a normal doctor at a big hospital system, you know, totally part of all the trends that we were talking about in our earlier segment. But like, my blood pressure was a little high. And so like, they wanted me to start monitoring it. And I, you know, I was able to get this blood pressure monitor for my house that puts all the information onto my phone. And then I can just
Starting point is 00:20:51 send that as a digital message to my doctor without ever going in to see him. And this is another way that physicians are trying to make everything more convenient for their patients, because like we said, patients don't have the patience to wait to be seen by a doctor like they used to. And that's where I think these other companies like Best Buy, they're like, we have the entire infrastructure to do this kind of stuff. So maybe this is a way that we can get a piece of the big healthcare pie that's an enormous part of our economy. So at least they're having some kind of contact with the healthcare system rather than being cut out entirely. Is there like a 1% equivalent to what's going on on the more middle class end of the spectrum here? With like, if Best Buy's getting in and Dollar General's getting in, is like Louis V gonna get in or something to provide healthcare services?
Starting point is 00:21:41 What's the 1% doing? Well, I do think some of these concierge clinics, like One Medical, which Amazon acquired a couple of years ago, I think those are a good example of what kind of the high-class version of this looks like. You have this clinic that's your home base. You pay a monthly or annual retainer to be on their patient roster. Basically, what that retainer is supposed to give you is pretty much direct access to your doctor whenever you want it. And that can either be like you come in for checkups or maybe for an acute medical visit. You know, it should be really quick, really easy to get an appointment. Or you might like have your doctor's phone number and you can like text them
Starting point is 00:22:20 if you've got a question or you've got, you know, you've got one of these messaging portals. And there's sort of an understanding that because you pay basically to be a member of this clinic, that you're going to get really, really quick access. That's, I think, what kind of the higher class version of this looks like. A similar but distinct model is known as direct primary care. And it works on a similar business model where it's like you pay a monthly or annual fee to be a part of this practice. And what that fee is supposed to get you is that direct access to your doctor whenever you want it. That kind of convenience that patients, I think, feel like they've been losing from their more conventional primary care physician. How should we feel about it, Dylan?
Starting point is 00:23:02 I mean, it's easy to scoff at, dollar store getting involved in healthcare, or maybe it's a bit of a head-scratcher to hear that Best Buy wants to provide you with blood pressure checkups or whatever it might be. But is this ultimately a good thing that these big box stores and chains want to step in and provide healthcare in a country that apparently has a bit of a shortage? This is an all-hands-on-deck situation. Fewer and fewer Americans have our usual source of healthcare, go and see a doctor on an annual basis. That's how we catch things early. That's how we get ahead of things. And if we get ahead of things, that tends to lead to better healthcare outcomes down the road.
Starting point is 00:23:42 And so while I do think something is lost when you don't have that personal relationship with an individual doctor, I still think it's better for people to have a clinic at their local pharmacy or to be able to go to Dollar General. And it's clearly a net good for healthcare access in a general way
Starting point is 00:24:01 that people now have these options available to them. I think the question right now is do these sort of alternative models for providing primary care for people, can they do at least a good enough job of approximating what people would get from a more conventional primary care doctor that were at least, you know, addressing their healthcare needs and help preventing worse outcomes down the road? But I think if we want to look at the long term, how do we kind of create a primary care workforce that's big enough, that's robust enough for our country that is able to engage with people as they want to be engaged with, we got to look at
Starting point is 00:24:39 training, we got to look at how we pay doctors, and we got to look at how we finance the hospital systems that increasingly employ our primary care doctors. Dylan Scott, senior healthcare correspondent at Vox. His one about all this is called What Happened to the Family Doctor? Find it at Vox.com. Our program today was produced by John Ahrens. We were edited by Amina Alsadi, fact-checked by Laura Bullard, and mixed by Patty Boyd. The rest of the team includes Victoria Chamberlain, Siona Petros, Halima Shah, Avishai, Artsy, Hadi, Mawagdi, Amanda, Llewellyn, Isabel, Angel, Rob Byers,
Starting point is 00:25:24 our managing editor, Matthew Collette, our executive producer, Miranda Kennedy, and our Thank you. Explained is distributed by WNYC. The show is a part of Vox, which is totally free. Thanks in part to contributions from our listeners. Join us at vox.com slash give. Thank you.

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