Universal Health Care and the Crisis in Primary Care

I am moderating a Town Hall Meeting on Healthcare on June 14, 2009.  Lots of opinions, lots of controversy.   We all know the health care system is broken, and too costly.  We just don’t have the perfect solution.

Many studies show that improving access to primary care will prevent many serious illnesses such as heart disese and cancer.  Primary care physicians are also on the front lines to coordinate care among specialists, to make sure that duplicate studies are being done, and that the patient is collaborating in his or her plan of care.  

Pediatricians and other primary care physicians promote vaccinations, which prevent many serious illnesses.  Do you want to depend on your heart doctor to advise you about colon cancer screening or your stomach doctor to discuss the shingles vaccine? 

Specialists play a valuable role in the health care system.  They just can’t substitute for primary care physicians.  Primary care is critical to prevent serious illnesses and contain health care costs.

But most primary care physicians face decreasing reimbursements from Medicare and Medicaid, and increasing regulations from commercial insurances.   So why does the insurance company try to limit what it calls “unnecessary” medical care by requiring administrative forms and phone calls to be completed by physicians to obtain CAT scans and brand name medicines?  Who benefits, the patient or the insurance company? Did you know that the CEOs of Aetna, UnitedHealthcare and Blue Cross Blue Shield get paid over 20 million dollars per year? And I am guessing that the CEOs get as many CAT scans, MRIs and brand name medications they want. 

Many experts argue that universal health care will result in a two tiered medical system like in Europe and Canada.  Patients (e.g. CEOs of big companies and politicians) who have the resources get top-of-the-line-cost-is-of no-issue medical care, while many other patients have long waits for access to basic medical services that we do routinely daily here in America. 

There is a serious lack of morale among primary care physicians.  Many of them have had to retire early or close their doors because they cannot make ends meet doing primary care.  Sure some of them adapt and inject restylane or do laser hair removal, but there is only so much hair in the world.  Once all the hair and spider veins have been zapped, primary care physicians will be hard pressed to find procedures that yield adequate compensation.  Certainly counseling patients during office and hospital visits about diabetes, lifestyle changes and smoking cessation, which prevent so many illnesses, is poorly reimbursed compared to high dollar procedures such as heart surgery and stomach bypass surgery.  Wouldn’t it be better to live in a culture in the country where health and wellness is promoted to PREVENT costly procedures that are required when patients become ill?

The current model of health care pays for treatment of illnesses over the prevention of illnesses.  Procedures are compensated at a significantly higher rate than health counseling and the treatment of chronic illnesses such as asthma, high blood pressure and diabetes.  I am NOT arguing that we should do away with lifesaving procedures.  But we cannot sustain our current health care model where 10 % of patients make up 90% of health care expenditures.  And most of that money is spent in the last year of life.  Many times, patients are kept on ventilators despite clear evidence that they have terminal illnesses that are not reversible.  When a patient has a massive heart attack or stroke and cannot tell you that the last thing he wants is to die on a ventilator in an ICU of a hospital, the health care system must continue to do expensive, futile treatment.

The average American is not sympathetic to the concerns of primary care physicians, because it is believed that primary care doctors earn too much anyway.  So that is why only 2% of medical school graduates go into primary care.   They prefer to enter higher paying specialties, especially in light of the fact that the average medical student graduates with $140, 000 of debt. 

If America wants to maintain a high intellectual level to it’s primary care  work force, then primary care physicians must be fairly compensated for their time (including coordination of care) and intellectual care such as counseling patients on health maintenance.  There is no way around it.  Medical students and residents will not go into primary care, and primary care physicians will continue to go out of business if reimbursements are not increased.  

Of course, the trend currently is to have primary care be carried out by nurse practitioners and physicians assistants.  Just remember, there is a HUGE difference in the time and depth a physician trains vs. a nurse practitioner or physicians assistant’s training.  I am afraid for America if primary care is taken out of the hands of doctors, due to expense, and put in the hand of unsupervised allied health practitioners.  Certainly physicians assisstants and nurse practitioners play a vital role in health care.  But they do not SUBSTITUTE for a physician.

We all believe that universal health care will ultimately decrease health care expenditures.  But the question is who will pay for universal health care?  Raise taxes?  Or pay for the uninsured in hidden ways such as increased hospital charges and health insurance charges for patients who do have insurance.  We all pay for the uninsured, and we pay for it in the most costly way:  emergency room care and hospitalizations.

One of the lessons learned from Massachusetts is that if everyone has health care insurance, there aren’t enough primary care doctors to meet the demand!  I know there will be dissenting views from nurse practitioners, patients and politicians.  Let me know what you think. 

And if you appreciate your primary care physician, tell him or her!  A kind word goes along way to improve the morale of primary care physicians, and reminds them that they went into primary care to make a difference in the lives of their patients, not to learn how to fill out insurance forms!

Dr. Vee

Last updated June 8, 2009 by Dr. Vee