How Medicare Killed the Family Physician

 

I work for a health-insurance firm, and my brother is a primary-care physician. As he tells it, my industry is accountable for the death of his. Insurance companies, he argues, have killed primary care by grinding down reimbursement and compelling doctors to see more and more patients just to earn a living.

I empathize with my brother, since I realize that doctors' business with insurers is not always straightforward. I'm also conscious of the market's price sensitivity-and reimbursement paid to medical professionals comes from costs paid by customers. Insurers will have to keep prices down.

Remember Marcus Welby, M.D.? He defined the family health practitioner on television in the 1970s, exemplifying the four Cs: caring, competent, confidant and counselor. In the mid-'60s, I remember that my spouse's father, a real-life Dr. Welby, telling me the thrilling news that the federal government was going to begin paying him to see seniors-patients who before he had seen for the proverbial chicken (or nothing at all). That fabulous deal was Medicare.

Medicare presented a whole new dynamic in the delivery of health care. Gone were the days when physicians were paid dependent on the value of their offerings. With settlement coming directly from Medicare and the federal government, patients who used to pay the tab themselves no longer cared about the asking price of services.

Eventually, that disconnect (and subsequent program expansions) resulted in significant strain on the federal budget. In 1966, the House Ways and Means Committee estimated that before 1990 the Medicare budget could quadruple to $12 billion from $3 billion. In fact, before 1990 it became $107 billion.

To fix the cost issue , Medicare in 1992 started employing the "resource based relative value system" (RBRVS), a way of comparing doctors based on factors such as education, effort and specialized training. But the system failed to consider aspects such as outcomes, quality of service, severity or demand.

Nowadays most insurance companies employ the Medicare RBRVS for the reason that it is perceived as objective. As a consequence of RBRVS, specialists-in particular those who carry out a lot of operations-do extremely well. Primary-care doctors do not.

The primary-care physician has become a piece-rate employee focused on the volume of patients seen each day. As Medicare and insurers focused on trimming the prices of the most commonplace types of treatments, the income and career satisfaction of primary-care medical professionals eroded.

Therefore those physicians left, sold or changed their practices. Novel health-care service models, such as the concierge practice and the Patient-Targeted Medical Institution, drew doctors away from the customary service models that most patients rely on for coverage.

All of those elements have contributed to a fragmented, expensive health scheme with most of the residual physicians centred on reactive instead of preventive treatment.

The solution to the problem is making primary-care physicians the captains of the ship. They should control the time and monetary wherewithal necessary to take care of their patients, tailoring care to patients' express circumstances and needs. And they need the information to monitor their patients' results, so they can lead patient development. They will then be able to slow (and on occasion reverse) their patients' illnesses, keeping them out of hospital emergency rooms and specialists' offices. The end result: diminished premiums and improved quality of care.

So who really killed primary care? The concept that a centrally designed structure with the appropriate formulas and enormous quantities of statistics could replace the art of practicing medicine; that the human dynamics of market demand and the patient-physician relationship can be disregarded. Politicians and mathematicians in ivory towers have placed primary care last in line for esteem, assets and prestige-and we all paid an astounding cost.

 

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