Primary Care Physicians: An Endangered Species

A recent Health Care Blog Post explains the looming crisis in primary care. Some background: great health care systems are anchored by primary care physicians (PCPs), the generalist doctor whom your family depends upon for standard medical care. The PCP must have a workable basic knowledge of nearly all medical specialties and be able to diagnose and treat most illnesses. It is the PCPs job to refer patients with more complex medical issues to specialists. Specialists are experts on specific areas of medicine.

Data shows that higher percentages of PCPs are associated with healthier, lower-cost populations. In most developed countries with healthier populations than ours, PCPs (generalists) represent 70-80% of total doctors – while the remaining 20-30% are specialists. In the U.S., not only are the numbers reversed, the trend is getting worse. As PCPs dwindle in this country, wait times for medical attention will increase, quality of talent will drop, and quality of care will continue to drop. What’s causing the change? Well, in a word….money.

I’m not accusing doctors of being greedy – I’m accusing them of being human. Compensation drives behavior. If you don’t believe me, read Freakonomics. Specialists earn, on average, well over twice as much as PCPs. And with the increased risk of socialized medical systems, I don’t know a single medical student or resident who isn’t going to be a specialist of some kind (and I know a lot of them). Many of them simply cannot afford to be a PCP – with hundreds of thousands of dollars of loans to pay off, they stand little chance of ever building any real wealth if they become a PCP. To quote the blog post: “Between 2000 and 2005, the percentage of medical school graduates choosing Family Medicine dropped from a low 14% to an abysmal 8%. Among Internal Medicine residents, an astonishing 75% now end up as hospitalists or sub-specialists rather than office-based general internists.”

So if primary care is so critical to our nation’s health care (outcomes and costs), why doesn’t the market respond by paying PCPs more? The answer is simple: we don’t have a free market in American health care. What we have is Medicare’s Resource-based Relative Value Scale (RBRVS). Originally conceived in the 1980’s by Harvard Economist William Hsiao, the system was originally designed to calculate an accurate way to reimburse physicians for their time spent on medical procedures — and to reduce disparities in the medical specialities. The problem is the reimbursement formularies reward complex medical procedures over pro-active health care management (preventative care), and after 20 years of budget problems, Medicare continues across-the-board cuts to its doctor and hospital reimbursement levels…which penalizes PCPs more than specialists because of lower reimbursement levels to being with. In fact, in January of 2008, an inefficient Medicare will enact a 10.1% cut in physician reimbursement rates. (Medicare’s costs are skyrocketing – at current trend levels they will account for 20% of our nation’s GDP by 2050).

So why a reimbursement system that favors specialists to generalists? Well, apparently Congress approves 90% of the legislation recommended by the American Medical Association(AMA). The AMA represents a surprisingly small percentage of American physicians. This is reflected in its 30-member committee (called the RUC), comprised mostly of specialists, whose job it is to lobby Congress. “In other words – and it is important to be clear about this – the premeditated actions of the specialist-dominated RUC, operating under the auspices of the AMA and in alliance with [Medicare], appear to have played a direct role in the current primary care crisis by driving policy that financially favored specialty care at the expense of primary care. Equally important, this relationship has been key in establishing drivers of our health systems relentlessly explosive cost growth with its attendant impacts on the larger US economy.”

Two things will help solve the problem. Better representation of primary care physicians on the RUC, and a transparent, non-Medicare-dependent free market for health care.

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Another Shot at the Government

Two posts ago, I attacked Medicare. In my last post, I pointed out how budget cuts have all but destroyed the effectiveness of the U.S. Food & Drug Administration. In this post, I’m going to talk about the U.S. Department of Agriculture, in another chapter about what happens when citizens entrust their health & wellness to the government.

There’s a great article from Men’s Health magazine posted on MSNBC health by Nina Teicholz entitled: “What if Bad Fat isn’t so Bad?” The thesis of the article is that there has never been a consensus in the medical community that high-fat diets shorten life-span and low-fat diets extend it. Much like the scientific “consensus” that humans are contributing to irreversible climate change proselytized in Al Gore’s “An Inconvenient Truth,” (I urge you to read MIT Professor Richard Lindzen‘s Editorial (excerpt) in the Wall Street Journal), the “consensus” surrounding the American diet is a myth. More alarming is the fact that there has never been a causal connection established between saturated fat and heart disease…and there is countless correlational evidence to the contrary.

Still more alarming: these studies have been around for over three decades and the American Medical Association disagreed with Congress’ decision to make it government policy to support the supposed “diet-heart hypothesis” in 1977. Translation: Congress chose to make official diet recommendations, for the past 28 years (a revised food pyramid finally replaced the old one), based upon dubious science. And they did it knowing full well that many, many doctors, epidemiologists, and public health experts disagreed with the decision – which would (and did) affect American diets and American health. Why did the government choose to publish an official recommended diet to Americans when they didn’t have valid scientific conclusions? One likely possibility is that they had a competing interest: American farmers.

Remember the “four food groups” and the old Food Pyramid that recommended 6-11 servings of carbohydrates each day? It’s nearly undisputed now that lots of refined starches trick the body into producing extra insulin which tells the body to store energy as fat – and eating a high calorie diet dominated by carbs , rather than fat, has likely contributed to America’s staggering obesity problem. That’s right, the official recommended American diet changed the way we ate for the past thirty years, and 2/3 of Americans are now medically overweight. Why would the government recommend a diet that, in the beginning it knew wasn’t proven and along the way knew it was just plain wrong?

Well, I didn’t know this, and I suspect few other people did: the food pyramid was published by the USDA, not the FDA. The USDA’s role is to promote American agriculture, not the American diet. Dr. Walter Willett, a renowned medical doctor, public health expert, and tenured professor at Harvard, published a book in 2001 called “Eat, Drink and Be Healthy,” that pointed out this very fact. Dr. Willett attacks the USDA Food Pyramid. “At best, the USDA Pyramid offers wishy -washy, scientifically unfounded advice on an absolutely vital topic- what to eat. At worst, the misinformation contributes to overweight, poor health, and unnecessary early deaths. The thing to keep in mind about the USDA Pyramid is that it comes from the Department of Agriculture, the agency responsible for promoting American agriculture, not from agencies established to protect our health…And there’s the root of the problem- what’s good for some agricultural interests isn’t necessarily good for the people who eat their products.”

So it’s not a stretch to say that American agricultural lobby probably influenced Congress, in the way that lobbyists are known to influence, to ignore the American Medical Association’s dissent, and promote their products to Americans for thirty years. When a government sells out, someone wins and someone must lose. American agriculture scored a bid win, and the American waistline lost big.

What point could I possibly be trying to make, besides “the government can’t be everybody’s friend?” Here’s my point: government-run universal health care would be like giving someone with Dissociative Identity Disorder a white coat and declaring that he is your family’s doctor for life. He would suffer from multiple personalities, each with different fetishes, and he would have a lifetime tenure, regardless of his level of competence. The kicker is that you would never know which personality was present when he was diagnosing your child.

Any universal health care plan by the government is forever for sale, just like every other interest at Congress’ door.  And unlike standard health insurance, the government is prone to vote the deepest pocket, regardless of whether that deep pocket represents health care, or whether it represents the National Potato Council.

Chew on that…

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