Shortage of primary care threatens health care system
Kevin does a good job of explaining the difficulties of primary care in our system. As a critic I suggest these modest additions:
1. I like the Dinosaur’s insistence that we use payment rather than reimbursement in our discussions.
2. Kevin does not explain that “fee for service” does not provide fees for all services. We only get paid for the visit, not for chart review, lab review, telephone calls or emails. We do not get paid for discussing the problem with a subspecialists (curbside consult.)
With those modest critiques, I commend this article for your perusal.
How did we let primary care slip so far? The key is how doctors are paid. Known as “fee for service,” most physicians are paid whenever they perform a medical service. The more a physician does, regardless of quality or outcome, the better he’s reimbursed. Moreover, the amount a physician receives is heavily skewed toward medical or surgical procedures. A specialist who performs a procedure in a 30-minute visit can be paid three times more than a primary care physician using that same 30 minutes to discuss a patient’s hypertension, diabetes or heart disease. Combine this fact with annual government threats to indiscriminately cut reimbursements despite rising office and malpractice costs, physicians are faced with no choice but to increase quantity to maintain financial viability.
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It starts with reforming the physician reimbursement system. Remove the pressure for primary care physicians to squeeze in more patients per hour, and reward them for spending time with patients, optimally managing their diseases and practicing evidence-based medicine. Make primary care more attractive to medical students by forgiving student loans for those who choose primary care as a career and reconciling the marked disparity between specialist and primary care physician salaries.
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2 Responses to Kevin on primary care
Dan Smith
March 13th, 2008 at 6:56 am
The problem began when we physicians did nothing while our customers (patients)were removed from the loop and we accepted payments from the government and insurance companies. Under the system we have now it is economically rational for the payors to reduce their payments as much as possible. If the quality of service drops (and it does) the patients, formerly the customers, get hurt. The third party payor walks away with the profits. No amount of tinkering with payment reform, EMRs, quality indicators, etc is going to change the facts. We will be stuck with a bad system until either the patients or the doctors have had enough and wak away from the game.
bing
March 13th, 2008 at 9:26 am
DB:
I would add one more small edit to your list of two. When one speaks of a remedy for the disparity between primary care and specialist salaries, EVERYONE except the specialist assumes that the only way to accomplish this is to reduce the specialists income, hopeful that a zero-sum game is in effect and this money will then flow to the primary care physician. This was, of course, the canard used to sell the RBRVS system to organized medicine (and we’ve seen how THAT worked).
Who doesn’t feel that their contribution is under-appreciated. I am an ophthalmologist. My core procedures have been ravaged by our third-party payer system, going from an unsupportably high price, through a reasonable market “trading zone”, and now far below what is a realistic representation of the expense, skill, and risk acceptance involved in these procedures. This phenomenon is due simply to the frequency and success of this particular part of my world. Must we continue to de-value and demonize specialty medicine and specialists? Must we continue to allow people outside of medicine to use a divide and conquer strategy, moving like so many sheep dirrected by wolves? Why can we not simply work to enhance the prestige and income of the primary care physician AND the specialist, or better yet leave that up to the individual physician and patient?
The primary care physician is indeed under-paid and under-appreciated, but she is neither of these because the specialist is over-paid.