The Doctor is Out

Okay, now that we're all done baking our punctuation marks, it's time to get back to Medicare. In my view, the biggest flaw in Medicare is that it underpays for primary care and overpays for specialty care. An excellent overview of the history behind our current crisis in primary care is offered by Lewis Sandy and colleagues, but as usual, you can't read it because you are nothing but common scum.

In a nutshell, when health insurance first appeared on a substantial scale during the Depression, it paid for hospital care and surgeons; as it broadened to include Blue Shield plans that paid more broadly for physician services, it mostly covered specialty services; the availability of insurance, combined with the very narrow, biological view of medicine that was in vogue in those days, meant that fees for specialists grew to be much higher than fees for primary care. This discrepancy essentially got fossilized into the insurance system - at first the private system, and then, when Medicare came along, into the public system, through what are called Relative Value Units which set the reimbursement rates for various procedures, based essentially on historic norms.

Nowadays a bio-psycho-social view of medicine is widely accepted. It is neither effective nor cost-effective to treat people as piles of unconnected organ systems, ignore them until the kidneys or liver or metabolic regulation or whatever stops working and then send them to a kidney or liver or endocrine doctor for high tech biological tinkering. People need an ongoing relationship with an accessible primary care doctor who understands their full medical picture and also has some understanding of their life, circumstances and personality so they can work together to promote wellness, catch disease processes early, and if need be coordinate the various biological interventions that ultimately may be needed. But doctors who do this are paid much less than doctors who zap you with radiation or remodel your internal organs. They are also overworked and underappreciated. Hence there are not enough of them because who wants that when you can make millions working 9 to 5 and you don't even have to be on call?

Medicare also pays for a good chunk of graduate medical education -- residencies and fellowships -- and it also skews that funding toward the narrower specialties.

Lots of people know this is wrong and are trying to change it, but the medical specialty societies up until now have proven to be too powerful. As a result, we face a crisis. Specialists today typically make 2 1/2 times as much as primary care physicians, whose real income has actually fallen by 10% from 1995 to 2003. If Medicare fixes this ridiculous situation, private insurers will follow. American College of Radiology, get out of the way. You already have your yachts and horse farms. ¡Basta! Okay, I'm dreaming. But it has to be done. Sandy et al want 50% of the clinician work force to be in primary care. That will require redirecting training funds and drastically revising reimbursement policies, among other steps. We can crank up the primary care clinician workforce relatively quickly by training more nurse practitioners and physicians' assistants, who are much easier and cheaper to create than new doctors, but we need physicians too.

We can also reorganize primary care to make it work better for patients and be more rewarding for clinicians. That's another story, for another day.