… or, If We Beg, Will You Go Into Primary Care?

What if tomorrow 30% of the nation’s plumbers disappeared?  Perhaps they vanish due some fantastic science fiction experiment gone horribly wrong.  What would happen?  Would a national plumber group call for making plumbing a more attractive profession?  Would there be a cry for greater federal plumbing subsidies to draw more people from other fields into plumbing?

No.  (Or at least, I hope not.)  In the short term, there would be a terrible shortage of plumbers.  The plumbers available would have more work available then they could possibly complete.  They would have to raise their rates to match demand to supply.  This would have two important benefits.  First, it would force customers to conserve on plumbing services.  As plumbers got more expensive, less important or less urgent jobs would be deferred, since only those with a need that justified the expense would want to pay the higher fees.  Second, plumbers would make much more money than they used to, attracting more people to the field.  People who previously were having a hard time deciding between plumbing and some other field would be more likely to go into plumbing.

Within a very short period of time the number of plumbers would be very close to what it had been before the Horrible Plumber Vanishing of 2010, and their fees would be almost back down to what they were before the HPV.  Things would quickly be more or less back to normal.

Well, a similar but much slower vanishing is happening to primary care doctors.  Yesterday was Match Day, the day on which all graduating US medical students find out the residency to which they have been accepted.  The numbers for primary care continue to look bleak.  The number of medical students that matched to an internal residency was 2,772, up 3% from last year, but 30% lower than in 1985.  Despite this year’s small increase, the overall trend is one of medical students fleeing from primary care into higher-paying specialties.

This is occurring at the same time as our population ages, the baby boomers reach Medicare eligibility, and health care reform promises to add thousands more to the rolls of the newly-insured.  National groups have been warning of a looming primary care shortage for years, and this year’s Match Day numbers only reinforce that concern.

The American College of Physicians (ACP), the national organization of internal medicine doctors (of which I am a member) issued a press release expressing concern about this trend.  Dr. Steven Weinberger, an executive in the ACP, said “it is critical to begin making careers in internal medicine attractive to young physicians”.  Is it?  But why isn’t the problem fixing itself, like the imaginary plumber problem?

The reason is that most doctors can’t increase their fees.  Their fees are set by insurance companies.  The normal market response to a shortage — higher fees followed by more people entering the field — isn’t happening.  So Dr. Weinberger is left urging that Medicaid and Medicare payments should be increased to primary care physicians, a bitter prescription when the costs of these programs are already skyrocketing.

Dr. Weinberger would serve ACP members and our patients more effectively if he realized that pressuring insurers to increase payments to doctors is a tactic that has run its course.  Bankrupting the nation with ever-increasing costs is not a sustainable way to promote primary care.  The surest way to attract more physicians to primary care is to have patients decide for themselves with their own dollars how much primary care they need and how much they are willing to spend for it.  Dr. Weinberger should be encouraging doctors to work directly for their patients.

After all, that’s how we ensure that we have enough accountants and lawyers and plumbers.

Learn more:

American College of Physicians press release:  Residency Match Results Not Encouraging for Adults Needing Primary Care

Los Angeles Times Booster Shots:  Primary care still isn’t an attractive choice for new doctors

For the last few years the future of primary care has been looking bleak.  Fewer and fewer medical students are choosing primary care careers, just as baby-boomers retire and will need more care.  Primary care physicians meanwhile are retiring early or cutting back their practices at record numbers, worsening the coming shortage.

The current issue of the Annals of Internal Medicine publishes a perspective article by Dr. David Norenberg that heaps on the gloom.  Describing himself as closer to the end of his career than the beginning, he mourns the end of the golden age of primary care.  While he was attracted to the close and prolonged relationship with patients that only primary care can provide, he sees young students turned off by the recent trends in medicine – insurance companies dictating care, reimbursement set by arcane algorithms, and a focus on quantity, not quality.

A recent Medical Economics article (link below) lends credence to Dr. Norenberg’s pessimism.  It details the filling of next year’s residency positions by medical school graduates.  Yet again, primary care positions have declined as students stampede into subspecialties.

Dr. Norenberg’s observations are right on the mark.  Then he proceeds to offer a solution that is sure to fail: a single-payer medical system based on Medicare that pays primary care doctors more.  Versions of this general scheme – giving everyone Medicare either as a sole insurer or as a “public option” to private insurance – are being considered as possible overhauls to our healthcare system.  Meanwhile, just this month the General Accounting Office announced that Medicare will run out of money by 2017.

The hull of the ship is leaking.  Time to board more passengers.

Demanding that insurers (either private or government) pay primary care doctors more will only lead to an internecine fight with specialists over who gets a bigger slice of the pie.  We miss the bigger picture that the whole pie will be gone in a decade.  We’re fighting over crumbs.

The case that primary care is valuable must be made to patients, not policy makers.  Patients will vote with their own dollars and decide for themselves the kind of healthcare they prefer.  The insurance model in which we all pay for each other’s care is failing catastrophically, but because of entrenched interests we will stay on that sinking ship until the water is up to our necks.

Eventually, out of the wreckage, patients will build a new system in which they each largely pay for their own care, using insurance only for unforeseen disasters.  How long that takes depends on when we notice the water rising.  Some of us are already heading for the lifeboats.

Learn more:

Annals of Internal Medicine article:  The Demise of Primary Care: A Diatribe From the Trenches

Medical Economics article:  “Match Day” delivers another blow to primary care

Financial Times article:  Medicare forecast to run out of money in 2017

Previous related posts:

Will Primary Care Survive?

On Being Doc and Being Happy

Pay for Performance: Peril for Patients

As summer approaches, researchers at Auburn University have performed a study demonstrating the dangers of that ubiquitous summer accessory, the flip-flop.  They recruited volunteers and recorded their gait in both sneakers and flip-flops.  In flip-flops the subjects took shorter steps and didn’t raise their toes as far as they did in sneakers.

This makes sense, if you think about it.  When we wear flip-flops we curl our toes down to keep the sandals from flying off our feet.  This keeps us from taking a long step and also has our heel hit the ground at the wrong angle for optimal walking.

The investigators warn that this abnormal gait could contribute to foot and knee pain in people who walk long distances in flip-flops.  I’m sure this news ruins your day, if not your summer, but don’t despair.  The authors reassure us that wearing them for short distances like around the pool should be fine.

So when you see me at the beach in my wingtips, now you’ll know why.

Learn More:

ABC News article: Flip-Flops Can Cause Long-Term Health Problems

New York Times Health blog: Summer Flip-Flops May Lead to Foot Pain

Tangential Miscellany:

This week, I’d like to leave you with the eloquent rant of my patient Stephen J. who emailed me to vent about the problems with medical insurance.  I couldn’t have said it better.

Reason 4,327,602 to be critical of health insurance: “The Ticket Punch.”

Here is how it works.  Medical insurance companies pay by the visit.  Doctors need volume.  When a patient visits a doctor with a new complaint the doctor may need to “waste time” errr “spend time” diagnosing the problem.  The flat payment doesn’t cover the time.  So when the doctor sends the patient for an MRI, reviews the MRI and concludes that the patient should see a surgeon, he makes the patient come in before telling him that.  The patient would be better off to hear that in a phone call.  The other patients in the crowded waiting room would be better off too but the doctor can’t bill for the call and needs to “punch his ticket” in order to be paid.

Doctor’s used to validate parking; now patients punch billing chits for doctors.

I like the idea that a doctor can value a patient’s time and be paid to do so.  And I like parking validations.

Patients paying doctors directly for their care is best for patients, best for doctors, and best for the country.  Most of my patients know that this simple idea has been my obsession for the last few years.  Initially, I thought this idea was just a good way to reorganize my practice.  But now, with Medicare within a decade of insolvency, with decreasing numbers of medical students choosing primary care as a career, with increasing numbers of patients finding good primary care either unavailable or unaffordable, it is an idea that deserves broader attention.

Coincidentally two op-ed articles this week made the point that insurance for routine care is a big part of what’s wrong with American healthcare.

Tuesday, Jonathan Kellerman, a psychologist and a renowned author of mystery novels, wrote an op-ed in the Wall Street Journal comparing health insurance companies to the Mafia.

Today, the LA Times published an op-ed (by me!) asserting that customer service is better in most doughnut shops than in most doctors’ offices, and insurance interference is partly to blame.  In it, I try to convince doctors to give up the insurance business model for simple retail medicine – the doughnut shop model.

I urge you to read both articles and pass them around to friends and colleagues, especially to physicians.  Thank you for spreading my obsession.

Learn more:

“Dollars to Doughnuts Diagnosis” by Albert Fuchs

“The Health Insurance Mafia” by Jonathan Kellerman

Tangential Miscellany:

Happy Passover to all my Jewish readers!

The scientific evidence for treatment of obesity is trending in a very interesting direction.  For years a safe and effective medication for weight loss has been sought, with only modest results.  (I wrote about orlistat, the medication in Xenical and Alli, a year ago.)  Surprisingly, for obese patients evidence is increasingly mounting in favor of surgery for weight loss, rather than medications or even diet and exercise.

In 2006 a randomized study demonstrated that patients with mild to moderate obesity lost more weight and had a better quality of life than patients randomized to diet, exercise and weight loss medications.  Last week, the evidence got even better.  A study published in the Journal of the American Medical Association examined the effect of laparoscopic gastric banding on obese patients with diabetes.  The study randomized patients with recently diagnosed type II diabetes with body mass indexes between 30 and 40 (20 to 25 is normal) into two groups.  Both groups received conventional diabetes care with medications, but only one group underwent laparoscopic gastric banding.  The difference between the groups was very impressive.  73% of the surgical group had their diabetes entirely resolve, compared to 13% in the conventional therapy group.  The surgical group lost an average of 20% of their body weight, compared to 1.7% in the conventional therapy group.  Importantly, there were no serious complications in either group.  The study generated a lot of media coverage, including this article in the LA Times.

So if you have diabetes and are very overweight, surgery is no longer the most radical option.  It’s becoming the most conservative evidence-based option.  If this trend continues, diet and exercise for obesity will be considered the radical fringe option.

(I’m grateful to Jay F. for pointing me to the LA Times article.)

Tangential Miscellany:

My 15 minutes of fame is extended slightly by this article on concierge medicine.

This week’s New England Journal of Medicine publishes a health policy report about electronic health records (EHRs).  The article reviews the potential benefits of EHRs to patients and to physicians and laments that as of 2005 only about 23% of physicians used them.

The reasons for the slow adoption of EHRs provide an instructive illustration of deep problems in our healthcare marketplace.  EHRs are expensive, but they hold the promise of allowing better patient care, fewer medical errors, and eventual cost savings.  In the delivery of any other good or service a new technology that offers these benefits is adopted quickly and becomes ubiquitous.  That’s why pay phones and LP records have nearly vanished; they were replaced by cell phones and CDs.  Why then the stubborn persistence of paper charts?  The reason is the dysfunctional way in which most healthcare is bought.  The cost of the vast majority of care is paid not by patients, but by third parties, either private insurance companies or government entities.  These payers also set the price that can be charged for services.  Unfortunately, this applies not just for major unforeseen expenses, like catastrophic illnesses or hospitalizations, but also for routine and preventive care.  The effect is that there is no financial incentive for most physicians to increase the quality of the care they deliver, just the quantity.  If the price for the service is fixed, doctors can’t make more by taking better care of each patient; they can only make more by seeing more patients.  So why would doctors invest the time and the capital in an EHR that provides better care?  Any cost savings resulting from better health would benefit the insurance company, not the doctors.  Paper charts after all, are worse for patients, but don’t slow the doctor down.

It’s only when patients pay for their own care that the competition and balance present in all other marketplaces returns to healthcare.  When patients and physicians set the price, patients have a strong incentive to ensure that the care they pay for is excellent, and physicians have a strong incentive to invest in whatever technology will deliver quality care.  That’s why our office had an EHR from the day we opened in 2003.  While national physician groups were lobbying for government or insurance subsidies for EHR purchases, my partner and I simply bought one, confident that what was best for our patients would eventually be best for our practice.

It’s you, our patients, who make possible our EHR and our dedication to old-fashioned attentiveness powered by twenty-first century technology.  Thank you.

Tangential Miscellany:

A happy Father’s Day to all us dads!

Last weekend U.S. News & World Report had a fascinating article called “The 18-second Doctor”.  The article is an interview with Dr. Jerome Groopman, author of How Doctors Think, a book that examines how physicians analyze information and make (occasionally wrong) decisions.

The article gives some examples of how taking the time to listen to the patient can be critical for arriving at the correct diagnosis.  I encourage all of you to read it.  I just added the book to my Amazon list.

I’m grateful to my patient Andy Raymond for pointing me to the story.

Tangential Miscellany:

My wife and I wish a happy Easter and a happy Passover to all of you who are celebrating.

Yesterday’s L.A. Daily News business section featured an interesting story about concierge medicine.  I was delighted to be one of the physicians interviewed for the story.  I’m grateful to Barbara Correa for shining some light on a practice model that has received very little attention – a model that I’m convinced is better for patients, better for doctors, and better for the healthcare system.  I’m also grateful to my patient Deborah Bradley for taking the time to talk to her.

The story is called “Ca$h Care”, which is a cute headline, but highlights what a strange marketplace healthcare has become.  We expect customers to pay for their own food, housing and transportation, but we’re still not used to patients paying for their own routine healthcare.  We would never let our employer decide for us who can sell us a car, or where we can shop for clothes, but we’ve become used to the idea that our employers should determine our healthcare options.  The only solution that will work nationally is the solution that has worked in the distribution of every other good and service.  Routine care should be paid by patients who should be free to seek care from any physician they choose.  The price for that care should be set by the patients and physicians.  Health insurance should only cover unaffordable catastrophes, and like life insurance or car insurance, should be removed entirely from the responsibility of employers.

So please help me spread the word.  Otherwise, when patient-sponsored medicine makes quality affordable healthcare widely available, the L.A. Daily News will get all the credit.

Garlic is frequently touted as a natural treatment for high cholesterol, and many garlic extracts are sold with the suggestion that they improve cholesterol levels.  The current issue of the Archives of Internal Medicine has an article reporting the most definitive study yet looking at the effects of garlic on cholesterol.  Volunteers were randomized into four groups:  raw garlic, powdered garlic supplement, aged garlic extract supplement, or placebo.  None of the groups had a significant change in their cholesterol, though the raw garlic group reported much more bad breath and body odor.

The results are also reported in this Los Angeles Times article.  This statement from the study’s principal author summarized it well.

“It just doesn’t work,” said Christopher Gardner, a Stanford professor of medicine who led the study. “If garlic was going to work, in one form or another, then it would have worked in our study. The lack of effect was compelling and clear.”

Nevertheless, I still think it’s yummy.

Tangential Miscellany:

I wrote last summer about my involvement with the Society for Innovative Medical Practice Design (SIMPD), a national organization of physicians who work for their patients, not for insurance companies.  Because of my long-standing interest in medical ethics, I had the honor to serve with Dr. Robert Briskin and Dr. Garrison Bliss on the SIMPD ethics committee.  We were charged with the task of crafting a statement of ethical principles that would guide us and future physicians in our new practice models.  I’m very happy with the product of our work.  Our statement of ethical principles demonstrate that concierge physicians take ethics seriously, and that practices that align physician interest with patient interest can avoid many of the ethical pitfalls of traditional practices.  If you have an interest in medical or business ethics, I’d love to hear your feedback.

Last week’s New England Journal of Medicine features an important article by Dr. Thomas Bodenheimer, Primary Care – Will it Survive?  I encourage all of you to read it.

Dr. Bodenheimer starkly presents the looming crisis in primary care.  Patients are waiting increasingly long for shorter appointments, frequently do not understand their doctor’s instructions, and are increasingly dissatisfied.  Primary care doctors are seeing more patients then ever before, for flat or declining reimbursement.  Ironically, this is happening at a time that the number of preventive tests and services that primary care doctors are expected to deliver is increasing.  Not surprisingly, primary care physicians are increasingly dissatisfied, and fewer medical students are choosing primary care.  Just as the baby boomer generation ages and requires more care, there will be even fewer trained primary care doctors.  This is clearly a recipe for a national disaster.

While Dr. Bodenheimer perfectly details the symptoms and the severity of the impending disaster, he never attempts to diagnose the cause, and therefore recommends therapy that is sure to fail.

Why is it that for all other services, from transportation, to housing, to even leisure, Americans are generally satisfied?  Why is it that even those below the median income can typically afford the basics in other services, while the middle class increasingly can not access quality medical care?  The reason is that other services are generally purchased directly while healthcare is usually purchased through a third party.  When we shop for a service ourselves, we find providers who give us great quality at reasonable prices; when we allow middlemen to shop for us we pay them to tell us what services we need and to set the price we’re willing to pay.  Price inflation and decreasing quality is an inevitable consequence of delivering care through third-party payers.  That is why for all other services, insurance is purchased only to cover catastrophes.  You want home-owners insurance in case your house burns down.  You would never want home-owners insurance to cover mowing your lawn.  That would immediately lead to lawn mowers becoming unaffordable, and lawns being neglected.

In any other marketplace customer dissatisfaction would create an irresistible opportunity for a provider to give the customers what they want.  So when Dr. Bodenheimer prescribes

A covenant is needed between those who pay for health care and those who deliver primary care: primary care must promise to improve itself, and in return, payers must invest in primary care.

he misses the point entirely.  Payers investing in healthcare is what brought us to this calamity.  It is patients who must invest.

Like in every other marketplace, informed patients who demand quality and bear the cost of their care will lead us to affordable care for everyone, not just the rich.  You will bear the burden of the coming crisis, and you, not government, not insurance companies, will deliver the solution.