The doctor will not be in . . .

The American College of Physicians, which is the appropriately general name, I suppose, for internists -- primary care doctors for adults -- foresees its own extinction. The Impending Collapse of Primary Care is the alarming title of their recent report on the state of the profession.

Sure, there's self-interest involved -- they want to get paid more, or work less, or a little bit of both -- but the fact is, fewer medical school graduates are going into primary care, and more primary care docs are getting out. The major complaints are not new -- the alarm bells have been ringing since I first studied health care policy 20 years ago, but we've just been going backwards. Medicare is extremely important in this story, but so is private insurance. Health insurance underpays for primary care physicians' time spent with patients, and the money flows toward diagnostic procedures and technical interventions.

Many of you probably are aware of the recent New York Times article that noted that diabetes management programs in New York City failed financially, even though they were successful medically, because insurers wouldn't pay for the time spent with patients to support them in taking care of themselves and preventing complications, whereas they have no problem at all with paying $30,000 for amputations.

Here are a couple of points from the ACP report:

A recently-published study of the career plans of internal medicine residents documents the steep decline in the willingness of physicians to enter training for primary care. In 2003, only 19 percent of first year internal medicine residents planned to pursue careers in general medicine. Among third-year internal medicine residents, only 27 percent planned to practice general internal medicine compared to 54 percent in 1998.

snip

The declining interest in careers in primary care is important because the collapse of primary care will result in higher health care expenses and lower health care quality:

• When compared with other developed countries, the United States ranked lowest in its primary care functions and lowest in health care outcomes, yet highest in health care spending.
• Studies have shown that primary care has the potential to reduce costs while still maintaining quality. Not only does early detection and treatment of chronic conditions play a vital role in the health and quality of life of patients, but it can also prevent many costly and often fatal complications when illnesses such as diabetes and cancer are diagnosed at a later stage. As expert diagnosticians, providing patient-focused, long-range, coordinated care, general internists play a significant role in the diagnosis, treatment and management of chronic conditions. It has been reported that states with higher ratios of primary care physicians to population had better health outcomes, including mortality from cancer, heart disease or stroke.
• States with more specialists have higher per capita Medicare spending. An increase in primary care physicians is associated with a significant increase in quality of health services, as well as a reduction in costs.

. . . If they do say so themselves. But they're right. Medicine ought to be about taking care of people, and doctors who do that need to be valued, and paid for it.