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

3 thoughts on “Universal Health Care and the Crisis in Primary Care

  1. It is heartening to see that some patients do recognize that at heart, most primary care physicians went into the profession because they truly care about patients, their lives and their health.

    I am convinced that tort reform would help physicians not feel so compelled to order multiple tests to cover the rare possibility of a missed tumor, disease, etc.

    If doctors had more time to collaborate with patients on a plan of care, listen to patients and their symptoms, everyone (doctors and patients) would feel more fulfilled. It is hard to live on a every fifteen minute appt. schedule, and so unfair to the patient.

    You are right that tort reform is never discussed, because trial attorneys and insurance companies have too much leverage and money to allow a meaningful look at how fear of malpractice suits (most doctors fear this more than anything else in their professional careers) drives prescribing and ordering practices.

    I had high hopes that President Obama would see the wisdom of enhancing primary care and preventive medicine to save health care costs. I was disappointed that he believes that physicians do procedures that bring more money to them rather than what is right for the patient. I have never seen this type of behavior in physicians. I have never heard a physician plan a surgery or other procedure simply because he would benefit financially from it.

    In fact, all of the tests I order cause more work for me, and I do not benefit financially at all.

    We as physicians should be silent no longer. We must advocate for a fair system for patients and doctors alike.

    Thanks so much for your comment.

    Dr. Vee

  2. Dr. Vee,
    Your perspective and truth from one dealing with the realities of our health care system on a daily basis is so valuable. America’s Doctors are one our country’s greatest resources. Where would we be if the best of the best were gone tomorrow and we were all left with the ones the person commenting on this article had to endure?

    I do believe that Medicine is a calling and those who are called enter the field with the highest motives and strength of character that guide them through the practice of their craft.

    By nature most physicians are not prone to activism and protest. Generally they want to be left alone to do the work of their calling. While their energies are more than spent taking care of their patients there are those out there doing all they can to take advantage of where they have dropped their guard. The powerful trial lawyers are out of control and no longer really on the side of protecting the public from dangerous incompetence. Instead, empowered by the protection of a faction of our lawmakers, they are gleaning wealth from the pockets and hearts of our nation’s doctors. It is an unopposed feeding frenzy that needs to be addressed in any and all health care reform legislation. Yet none of the proposed health care reform bills contain any provision for tort reform. When it is proposed it is defeated and voted against by those providing the blackmailed protectionism of the trial lawyers. No one is asking for the removal of this important work of protecting the public just reform and correction.

    The will and enthusiasm of our physicians is being eroded layer by layer by the lack of tort reform and by the bureaucratic paper work required by the government programs and insurance companies.

    Doctors are the heart of our health care yet where is their voice and who is in there presenting their perspective? It isn’t the AMA which has caved to political pressure. Looks like it is up to us the ordinary citizen to tell our congressmen and women how necessary tort reform is to us and health care reform.

  3. Dr. Vee,

    You asked, so here is my unflattering opinion of primary care physicians. I have to say that my opinion is biased because I became disabled at 50 at the hand of primary care physicians, who (I guess) were not paid enough to read or even tell me, the patient, about positive test results time and again. All symptoms were deemed to be curable with Prozac, which caused considerable physical damage to my body. I didn’t realize the extent of their incompetence until I assembled my medical records and discovered mistake after mistake. I’ve chronicled my experiences with physicians from 2003 on my blog at http://doctorblue.wordpress.com.

    I could go on and on about comments from my primary care doctors, the so-called coordinators of my care like “I thought Dr. Yoho was treating you” or “I wash my hands of it” (it being my care because a referred specialist didn’t perform a biopsy she felt was needed). I thought once a physician accepts money from a patient for years, there is some kind of obligation to diagnose and treat the patient when the patient needs medical care.

    Maybe there are caring physicians out there. I haven’t found one. I am in desperate need of gastrointestinal surgery and have to figure out how to find a surgeon who has worked on someone with a redundant cecum and severe sigmoid colon stricture. The radiologist’s CT scan report which also speculates about the possibility of a cancerous mass in my colon didn’t phase my primary care physician, who told me I just had colitis. Colitis doesn’t disable you. More serious illness does.

    When my money ran out after years of not working and being on my own, I applied for Social Security Disability. I was awarded disability within three months for severe degeneration of my spine caused by untreated infections. I qualify for Medicare this August — about the same time I’ll be evicted from my home.

    I agree primary care physicians should be paid more, but only if they start actually caring for their patients. Under the present system, they are nothing but a roadblock to patient care. I’d change my mind if even one primary doctor did anything to help me now get the care I needed years ago.

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