I think many solutions exist but the simplest would be to divorce primary care from the entanglements of insurance companies and simply do what every other professional does. See a patient, charge a fee to the customer/patient, and get paid by the patient. 85%-90% of primary care is routine office based visits, so the charges are the same or lower than that of what electricians, plumbers, lawyers charge.

The expensive stuff (high end diganostics, hospital stays, non generic meds, could still be payed for by insurance companies).

The other thing to do is to make primary care training easier to acheive..and allow those doc’s whose inclinations are to focus on prevention..to do just that. If the doc’s wan’t more training and management in management of acute or severe chronic illness, then they could do added trainnig in areas of interest. Either way, the fact that ER’s are swamped by routine primary care issues , coupled with the lack of interest of med students to choose primary care, couple with a endless beuracracy of business and legal dictates means that the end of primary care is already here.

what do I know? Well its been about one year since I closed my primary care practice (11 years in beuracratic hell) and I have retooled as a hospitalist. I am very glad that I made this move.

You suggested that any additional money put into primary care would have to come out of the funding for specialist care. Why?
Physician and clinical services amount to only about one-fifth the (approximately $1.9 trillion a year) cost of health care. (See this data from CMS: http://www.cms.hhs.gov/NationalHealthExpendData/downloads/PieChartSourcesExpenditures2004.pdf)
Why should the other four-fifths of funding remain sacred?

Defiinitely agree with DB’s comments. Practiced rural FP with my wife for 5 years & got fed up with being extremely busy & poorly paid (I think I made quite a bit less than our local optometrists, dentists, & vets who were cash up front, which is part of the problem with medicine). I now teach at an FP residency program. Same income, but fewer hassles. I love what I do, but the system is killing us.

I think there are 2 possible solutions:

1. Govt controls a lot of the reimbursement, just shift part of the payment pie back to primary care & decrease the amount of paperwork. But, the pie won’t shift because of subspecialist’s/AMA preventing that and the government just adds another layer of hassles & paperwork every 2-3 years (HIPAA, EMTALA, OSHA, etc.).
2. Go back to cash up front & get out of the insurance business. That’s why dentists, optometrists, vets, etc. make more than primary care docs. Patients won’t like it because they seem to think health insurance should pay for absolutely everything. It should work more like other insurance & only pay for the catastrophic things. E.g., you expect car insurance to pay for your accidents, but not your oil changes.

NP’s aren’t the solution because primary care and chronic care are not near as easy as you think. Many FP’s & internists will tell you that they still wish they had more training for what they do even after 3 years of residency. Like the saying goes, you can’t diagnose it if you don’t know what it is. Patients & diseases don’t always follow the textbook and there are always lots of complicating variables.

I suspect one of 2 things will happen in the next 5 years. Either govt will wake up & start a universal health care system with basic primary care coverage, or primary care will abandon the current system & go back to the cash up front practice of the old days.

Unfortunatley for doctors, the government has at least 2 trump cards that will prevent primary care doctors from getting paid more:

1) Allow foreign doctors to flood the country. There are literally millions of them waiting and the govt can just let them all in if the american docs start dropping out of primary care

2) Continue to allow NPs to do primary care medical jobs. NPs already have full autonomy in many states and can script meds, order lab tests, and do exactly the same diagnosis/treatment that primary care doctors do. The government will use this and expand their scope of practice even further.

Just a minor point on the insurance. Medical insurance is often the second largest payment a family makes per month after housing. Families want insurance to take care of everything because they have already invested so much of the family income in a system that does not even recognize their contribution.

Steve Lucas

true enough health care is expensive as is the electric bill, taxes, phone/cable bill, gas bill, food bill, etc….that’s why I think primary care would be better as a cash only enterprise where fee were posted up front and the consumer can decide if they wan’t to spend their dollars on a primary care visit or some other need. It works in all other aspects of the market economy so why not with office based primary care ?

Steve’s point is well taken. I pay $975/mo. for an individual PPO plan (I’m self-employed), but my money does little talking for me in this screwed-up third-party payer system.

In shopping for a PCP recently, I found that even getting an appointment was a struggle. One practice told me they could see me in a couple of weeks, UNLESS I WANTED TO SEE THE MD, in which case it would be five months. (The two weeks entailed seeing a PA.) I eventually booked with a practice that offered me a real MD, but still required a month lead time. At that appointment, after briefly seeing the internist, they took blood–it required a FULL MONTH to get the results back. They also scheduled a physical exam, which required five months lead time. So, obviously, the PCP shortage has hit us hard here.

I would go for retainer medicine in an instant, were it to be made available in this area. Alas, its acceptance has been slow in this state, where “social engineers” claim that it unfairly skews good health care toward those who can afford it. (Cadillacs for all; buses are discriminatory.)

Short of retainer medicine, from a disenfranchised consumer’s perspective, it would be wonderful if primary care practices could return to the fee-for-service system that seemed to work quite well when I was a lad. I hope that the optimism expressed here in this thread about the potential return of primary care to that type of payment system is not misplaced.

–TNT