A Primary Problem

As our readers are probably tired of hearing, our enormous investment in so-called "health care" in the U.S. -- now 16% of the economy and growing -- isn't paying off. One reason is that our non-system, a patchwork of perverse market incentives and regulated sectors designed more to satisfy political constraints than to keep the population healthy, ends up allocating disproportionate resources to specialty care and high technology interventions for already sick people, than to primary care intended to catch problems early and keep people healthy.

Robert L. Phillips discusses the present and future of primary care in the U.S. in, where else, the British Medical Journal. (Sometimes you need your friends to tell you what you can't see about yourself, it seems.) Primary care docs in the U.S. -- internists, pediatricians, and family medicine practitioners (familiatricians?) -- are paid less than half as much as radiologists. They have far too little time to spend with patients -- from their own point of view, as well as from the patients' point of view. Relatively lucrative diagnostic and surgical procedures, as well as care for their patients when they are hospitalized, are increasingly being taken away from them and given to various categories of specialists. Patients' lack of continuity of insurance coverage means that primary care physicians often have only short-term or episodic relationships with patients.

Given the patchwork of financing for health care in the U.S., the scope for government policy to fix this problem is somewhat limited, but certainly Medicare can do a lot. Medicare can increase reimbursement rates for primary care, and assure that more primary care preventive services are reimbursable. State Medicaid programs can do the same. In addition, although Phillips does not say it, we need to find ways to redirect the investments being made in medical services and research in the U.S. Capital is flowing to lucrative, high technology equipment, tertiary care hospitals, and research into expensive treatments for preventable diseases, such as heart disease and Type 2 diabetes. Public policy can direct more research dollars toward such subjects as effective physician-patient communication in primary care (if I do say so myself), practice improvement techniques to enhance coordination of care (which primary care physicians were once expected to do), and enable more procedures to be performed in primary care settings, presumably at lower cost and with better integration into patients' overall treatment.

Compensation for the primary care specialties has to be made more comparable to that of other specialties, so that more young physicians will go into the field. Right now, starting primary care physicians will struggle to pay their educational debts, which are typically more than $100,000. And, if doctors are better reimbursed for each episode of patient contact, they can spend more time with patients. A basic problem is that talking and listening are the least well compensated procedures. But they are the most important ones.