put your money where your mouth is

Most people recognize that the cornerstone of a functional health system is widespread availability of primary care. This makes sense. A primary care doctor manages all the different parts of your health care, coordinating your goals and wishes, recommending preventive and wellness measures, attending to new illness, and eliciting specialty input when needed. But the dirty secret is that many people just can’t access good primary care, and President Obama acknowledged as much last week. There simply aren’t enough primary care doctors in practice, so wait times for an appointment can go weeks or months.

And that’s if a primary care physician lets you in the door. When I practiced inpatient medicine at the county hospital, I assumed my patients couldn’t get primary care because they were uninsured, or because they were too disorganized to get to appointments. I thought there would be no problem when I went to work in the ‘burbs. Not so. Now I get an earful from elderly patients, who tell me they can’t find a primary care doctor within thirty miles who will accept their Medicare card. Sometimes they end up in the hospital just because no one’s continuously managing their chronic medical conditions and numerous meds.

Neither Obama nor his administration have described a serious solution to the primary care deficit, other than to say that medical schools need to train more primary care doctors. Well, the University of Washington here in Seattle has been doing just that for thirty-five years, and my first book, What Patients Taught Me, was about the amazing experiences I had in their rural training program.

But I don’t practice primary care, and neither do many other graduates of this program. Many folks including myself see the problem as one of pure economics. Primary care physicians earn the lowest of all doctor salaries, which drives the vast majority of young physicians into the more lucrative specialties. And the trend is towards increasing reimbursement rates for specialists, while pay for primary care has largely stagnated.

The bottom line is that if price really does equate with value, then payments to primary care doctors must increase significantly. Can it happen without triggering a global rise in health care costs? Maybe, if payments to specialists are redistributed to primary care doctors. But there’s been tremendous pushback from the various specialty groups, who’d like to maintain their current income streams, thank you very much. Look for epic struggles on this issue in the months and years to come.

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