Unrealistic public expectation of absolute precision and perfection from health care providers,
We do not expect this even in NASA space missions but this is expected of health care providers
Primary medical care yields no such scar. We trade in an intangible: a relationship between doctor and patient. We educate and advise, comfort and communicate, diagnose and anticipate, while surgeons do.
Why do invasive procedures intuitively carry more weight, and consequently higher remuneration, than do careful consideration, diagnostic acumen, patience, communication, and management of chronic conditions? Surgery has intensity (Bodenheimer 2007, 301). It has drama. As seen on TV, the surgeon brings to the operating table a refined skill set, tire-less effort, stubborn determination—”often wrong, but never in doubt”— and, of course, liability as a cost of doing business. Talk, by comparison, is cheap.
The relatively low reimbursement,
You Get What You Pay For 193
when compared to that of specialists, is further demoralizing,2 leading long-established, productive practitioners of primary care to abandon ship either by “upgrading” to a specialty or by prematurely leaving the practice of medicine altogether (Sox 2006, 57). From a policy perspective, health care strategists pay lip service to primary care, but, in reality, it re-mains the Rodney Dangerfield of medicine: They don’t get no respect.
The extraordinary expectation of superhuman immediacy in the information age, coupled with the demand that such service be provided gratis, may hasten the demise of primary care. Ours is not a business that lends itself well to modern concepts like “outsourcing” and 24/7 free “customer support.”
The practice of primary care medicine is under siege. Its practitioners are beleaguered by ever-increasing patient volume and the relentless demand for physician access. They feel squeezed by decades of steeply rising overhead and stagnant Medicare reimbursement. Young physicians, fresh out of medical school, avoid residency training in primary care as they observe its older practitioners burning out, demoralized, and disillusioned. The final nail in the coffin for primary care is a pay-scale structure that relegates it a distant second choice to specialty care. Geriatricians and primary care providers to the elderly, in particular, are a breed in jeopardy.
The fast-food model of service meets its nemesis when it greets its first customer who is eighty-nine, has a litany of medical com-plaints, lacks adequate social support, and has more than a touch of forgetfulness. Walmart will be quick to tell that customer, “You really need to see a doctor.” Treating a patient for a sore throat is not comprehensive primary care, and medicine, arguably, is not fast food (Schell 2006).
While luxury medicine, delivered by an attentive concierge physician to the well heeled, is hardly egalitarian, it does adhere to the tenets of good primary care: communication, compassion, continuity, and care that is comprehensive and coordinated. This is good doctoring, albeit only for the fortunate few.10 Walmartization of medicine, on the other hand, is insidious. A big-box retail clinic is a corporate liquidator, teasing out profitable health-provider services like treatment of a sore throat or administration of a vac-cine. Such “clinics” strip primary care of its viable component assets and discard those services that are not profitable, such as the care of complex patients with multiple chronic illnesses. Their business plan maximizes re-turn on shareholders’ equity but is highly detrimental to the survival of primary care and to the prospect of any reorganized overall national health care plan. No physician endures the rigors and costs of prolonged medical education with the goal of one day becoming a loss leader.
the demented, slow, hearing impaired, inadequate, lonely, anxious, neurotic or obsessive-compulsive, and the depressed or disconsolate. All require and indeed demand extra time with the doctor. However, the primary care physician, like any other service provider, is the proprietor of a business. Even the most altruistic, compassionate, and understanding doctor has an office to run and bills to pay. Time is money.
However, our rudimentary methodology of measurement, focused strictly on the technical, is not sufficiently sensitive to detect those subtle nuances of sentient and sustained doctoring. How do we pay for that under P4P?
The supply of current and future primary physicians is dwindling. An ill-conceived payment reform, the wrong medicine at the wrong time, will make matters worse, hastening the demise of the practice of primary care. A look at the experience with P4P contracts in Massachusetts is instructive.
As with the little Vietnamese village Ben Tre, in a war long ago, for some reason we felt we had to destroy primary care “in order to save it.”
There is a limit. How much care can a doctor ever hope to pack into an office visit? A primary care physician cannot be all things to all people, day in and day out. How many patients can he stuff into the waiting room, where there already is no space to add any more folding chairs? Insuring 40 million more Americans, while noble, is meaningless if those newly insured will be hanging from the rafters in the waiting room. We need to recruit, even draft, primary care doctors and create proper incentives that will promote the growth of primary care medicine. If primary care truly is the backbone of U.S. health care, then we need to support it. We must put our money where our mouth is.
Finally, we need to appreciate what primary care is not. It is not, and can never be, a surrogate for a warm and caring, functional family. It is not an anchor for modern, mobile family members who are isolated and adrift, emotionally and geographically. Attachment and family connection are essential to human health.
The primary care doctor cannot raise your
Epilogue 217
child, re-establish your ruined relationship with your mother, or cure the loneliness of later life within a dysfunctional family. Like charity, primary care really begins at home.
We do not expect this even in NASA space missions but this is expected of health care providers
Primary medical care yields no such scar. We trade in an intangible: a relationship between doctor and patient. We educate and advise, comfort and communicate, diagnose and anticipate, while surgeons do.
Why do invasive procedures intuitively carry more weight, and consequently higher remuneration, than do careful consideration, diagnostic acumen, patience, communication, and management of chronic conditions? Surgery has intensity (Bodenheimer 2007, 301). It has drama. As seen on TV, the surgeon brings to the operating table a refined skill set, tire-less effort, stubborn determination—”often wrong, but never in doubt”— and, of course, liability as a cost of doing business. Talk, by comparison, is cheap.
The relatively low reimbursement,
You Get What You Pay For 193
when compared to that of specialists, is further demoralizing,2 leading long-established, productive practitioners of primary care to abandon ship either by “upgrading” to a specialty or by prematurely leaving the practice of medicine altogether (Sox 2006, 57). From a policy perspective, health care strategists pay lip service to primary care, but, in reality, it re-mains the Rodney Dangerfield of medicine: They don’t get no respect.
The extraordinary expectation of superhuman immediacy in the information age, coupled with the demand that such service be provided gratis, may hasten the demise of primary care. Ours is not a business that lends itself well to modern concepts like “outsourcing” and 24/7 free “customer support.”
The practice of primary care medicine is under siege. Its practitioners are beleaguered by ever-increasing patient volume and the relentless demand for physician access. They feel squeezed by decades of steeply rising overhead and stagnant Medicare reimbursement. Young physicians, fresh out of medical school, avoid residency training in primary care as they observe its older practitioners burning out, demoralized, and disillusioned. The final nail in the coffin for primary care is a pay-scale structure that relegates it a distant second choice to specialty care. Geriatricians and primary care providers to the elderly, in particular, are a breed in jeopardy.
The fast-food model of service meets its nemesis when it greets its first customer who is eighty-nine, has a litany of medical com-plaints, lacks adequate social support, and has more than a touch of forgetfulness. Walmart will be quick to tell that customer, “You really need to see a doctor.” Treating a patient for a sore throat is not comprehensive primary care, and medicine, arguably, is not fast food (Schell 2006).
While luxury medicine, delivered by an attentive concierge physician to the well heeled, is hardly egalitarian, it does adhere to the tenets of good primary care: communication, compassion, continuity, and care that is comprehensive and coordinated. This is good doctoring, albeit only for the fortunate few.10 Walmartization of medicine, on the other hand, is insidious. A big-box retail clinic is a corporate liquidator, teasing out profitable health-provider services like treatment of a sore throat or administration of a vac-cine. Such “clinics” strip primary care of its viable component assets and discard those services that are not profitable, such as the care of complex patients with multiple chronic illnesses. Their business plan maximizes re-turn on shareholders’ equity but is highly detrimental to the survival of primary care and to the prospect of any reorganized overall national health care plan. No physician endures the rigors and costs of prolonged medical education with the goal of one day becoming a loss leader.
the demented, slow, hearing impaired, inadequate, lonely, anxious, neurotic or obsessive-compulsive, and the depressed or disconsolate. All require and indeed demand extra time with the doctor. However, the primary care physician, like any other service provider, is the proprietor of a business. Even the most altruistic, compassionate, and understanding doctor has an office to run and bills to pay. Time is money.
However, our rudimentary methodology of measurement, focused strictly on the technical, is not sufficiently sensitive to detect those subtle nuances of sentient and sustained doctoring. How do we pay for that under P4P?
The supply of current and future primary physicians is dwindling. An ill-conceived payment reform, the wrong medicine at the wrong time, will make matters worse, hastening the demise of the practice of primary care. A look at the experience with P4P contracts in Massachusetts is instructive.
As with the little Vietnamese village Ben Tre, in a war long ago, for some reason we felt we had to destroy primary care “in order to save it.”
There is a limit. How much care can a doctor ever hope to pack into an office visit? A primary care physician cannot be all things to all people, day in and day out. How many patients can he stuff into the waiting room, where there already is no space to add any more folding chairs? Insuring 40 million more Americans, while noble, is meaningless if those newly insured will be hanging from the rafters in the waiting room. We need to recruit, even draft, primary care doctors and create proper incentives that will promote the growth of primary care medicine. If primary care truly is the backbone of U.S. health care, then we need to support it. We must put our money where our mouth is.
Finally, we need to appreciate what primary care is not. It is not, and can never be, a surrogate for a warm and caring, functional family. It is not an anchor for modern, mobile family members who are isolated and adrift, emotionally and geographically. Attachment and family connection are essential to human health.
The primary care doctor cannot raise your
Epilogue 217
child, re-establish your ruined relationship with your mother, or cure the loneliness of later life within a dysfunctional family. Like charity, primary care really begins at home.
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