May 26, 2009
Torpedoing Primary Care
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.
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
Important legal mumbo jumbo: