With all the plans to reform health care now careening around Washington, it's surprising that none addresses a remedy that is key to any genuine overhaul: the resuscitation of primary care medicine. Primary care today is in a state of profound disarray, with physicians leaving the profession in droves and virtually no students coming along to take their place.
At this rate, many Americans will soon no longer have a doctor to turn to - just the emergency room and, if they're very sick, a bevy of expensive specialists. To address health care reform without tackling the crisis in primary care is to waste our words and endanger our health.
Under our current reimbursement system, sickness is a lucrative business. Third-party payers, which include public programs (such as Medicare and Medicaid) and private insurance companies, are often required to pay large sums to companies and institutions after a person gets sick. The incentive, therefore, has been for the health care system to develop products and services to take care of sick people. There is little or no financial incentive to keep people well or to catch diseases before they require expensive medications or hospitalizations. But this is the very terrain of primary care physicians. Their holistic focus saves untold lives - and saves the reimbursement system a great deal of money.
Given the lack of incentives to go into primary care medicine (a field that includes pediatrics, general internal medicine and family practice) and the high cost of medical training, it is not surprising that students are choosing more lucrative specialties. In 1997, graduating medical school students filled 71.7 percent of available family medicine slots nationwide. That number fell to 42.2 percent in 2009, according to the American Academy of Family Physicians.
If this trend continues, life will be much more frustrating for patients. If you're lucky enough to have one of the remaining primary care physicians, you shouldn't be surprised if you can't get in touch with him or her when you need to. With continued reductions in reimbursement for office visits, physicians' only recourse to cover costs will be to further increase patient volume. Although the problem of reduced reimbursements is common among all physicians, it especially affects primary care physicians, who rely solely on offices visits for income and are the first responders to upward of 3,000 patients each.
The problem is worse than just low reimbursements for office visits, however. A substantial portion of what primary care physicians are asked to do is often not reimbursed at all. This includes discussing complicated situations and coordinating care with specialists; rendering advice over the phone; discussing preventive medicine issues such as smoking cessation, weight loss and exercise; conducting or ordering screening tests to detect diseases before they become symptomatic; and having intelligent and compassionate discussions with patients and their families regarding end-of-life care. Ironically, it is precisely these uncompensated services that save third-party payers - and the health care system as a whole - enormous amounts of money.
With this type of reimbursement system in place, it's no wonder that primary care is a dying profession. Forty-nine percent of primary care doctors said that over the next three years they planned to reduce the number of patients they see or stop practicing entirely, according to an October 2008 survey.
So what would the end of primary care as we know it mean for you? It would mean spending long, miserable hours in emergency departments or walk-in clinics when you feel your absolute worst. Unless health care reform genuinely addresses the collapse of primary care in this country, emergency rooms and hospitals will become even more crowded, visits to specialists will become more fragmented, costs will continue to skyrocket and, ultimately, care for sick people will have to be rationed by third-party payers, public or private. Perhaps it is about time these payers recognized that it is in their financial best interest to have a fleet of intelligent, well-trained primary care physicians keeping their clients healthy.
Real health care reform should promote a reimbursement system that invests in patients' health through payments for preventive medicine services, management of chronic diseases and coordination of care among specialists. The return on this investment could be huge. If primary care once again becomes an attractive way to make a living, the exodus of physicians would turn around naturally, access to primary care would increase and the health care system would start to focus on health as much as it does disease.
Dr. William S. Queale is an internist in private practice at Johns Hopkins at Greenspring Station. His e-mail is firstname.lastname@example.org. Hope Keller is a freelance journalist in Baltimore and a patient of Dr. Queale's. Her e-mail is email@example.com.