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.