RIP primary care? Regular readers of this blog already know this:

Primary care — the basic medical care that people get when they visit their doctors for routine physicals and minor problems — could fall apart in the United States without immediate reforms, the American College of Physicians said on Monday.

“Primary care is on the verge of collapse,” said the organization, a professional group which certifies internists, in a statement. “Very few young physicians are going into primary care and those already in practice are under such stress that they are looking for an exit strategy.”

Dropping incomes coupled with difficulties in juggling patients, soaring bills and policies from insurers that encourage rushed office visits all mean that more primary care doctors are retiring than are graduating from medical school, the ACP said in its report.

The group has proposed a solution — calling on federal policymakers to approve new ways of paying doctors that would put primary care doctors in charge of organizing a patient’s care and giving patients more responsibility for monitoring their own health and scheduling regular visits.

U.S. doctors have long complained that reimbursement policies of both Medicare and private insurers reward a “just-in-time” approach, instead of preventive care that would save money and keep patients healthier.

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  • Grumpy

    I got out before I went crazy, retiring at age 59. No more worries about lawsuits, Medicare audits, productivity numbers, office politics, etc., etc. I actually have time for medical and other reading, travel, hobbies, and my family! I even have time to read blogs…

  • Anonymous

    I do more primary care in my ER during a day shift then any type of emergency medicine. And I personally cannot get in to see my PCP. They tell me to go to the ER! Wasn’t like that 5-10 years ago. Goodbye Primary Care.

  • Anonymous

    Maybe the market doesn’t WANT primary care. Maybe people prefer instant service, like in drive-up readi-care, for more urgent issues and not have to wait interminably and demeaningly simply to get a prescription for antibiotics or see if their sprained ankle is anything to worry about. Maybe they would prefer to see specialists–who really know something–for chronic matters.

  • Anonymous

    That may be true but this is a very expensive model and the society does not have enough money for it. Plus, it is a risky model because if nobody actually knows you and nobody is in charge of the whole picture, errors are more likely to happen. About the knowledge… I found myself thinking sometimes “I could really treat this” but the defensive medicine and the idea of not being paid properly for the risk I’m taking made me refer the patient to a specialist. If that is what society wants, that is what they will get : 5 minutes of their cardiologist’s life every three months, one angiogram yearly and a pacemaker in the nursing home.

  • Anonymous

    Anon 9:10 says “maybe the market doesn’t WANT primary care.”

    Really??? Then why do I have 7 new patients every day, and am booked out for new patients for a month? This has nothing to do with insurance requirements to have a PCP. People want someone to look at the whole picture and listen to them. Trust me, a subspecialist will not do that. People need primary care doctors to be a first line of defense. I treat everything, and when absolutely necessary, I refer to specialists. I resent your comment that specialists “actually know something.” Trust me, after 12 years of higher education and many years of practice, I know more than just a bit about treating diabetes, hypertension, heart failure, depression, AIDS, IBS, rheumatoid arthritis, osteoarthritis, etc. I challenge you to find the subspecialist who can do all of that, in addition to just letting someone cry on their shoulder because their husband left them, their wife is dying, or they lost their job (all of which patients of mine dealt with last Friday).

    The vast majority of my patients do not want to see subspecialists for every little chronic illness. They don’t have the time or money, and they would prefer one person to treat everything and keep track of everything. It’s also much better care- trust me, important info gets lost when patients are shipped from doctor to doctor. For example, take a typical patient of mine with morbid obesity, type 2 diabetes, hypertension, coronary artery disease, hyperlipidemia, hypothyroidism, peripheral vascular disease, osteoarthritis and depression. Keep in mind, this is a TYPICAL patient. In your method, they would be taken care of by an endocrinologist, a diabetologist, cardiologist, nephrologist, vascular surgeon, orthopaedist and a psychiatrist. Or they can see me and get the same level of care with one person prescribing everything, checking for drug interactions and monitoring compliance. So, seven subspecialists versus one absolutely qualified primary care doctor. What seems like the better method for both patients and the health care system? You tell me. I think the answer is clear.

    A level 4 visit for such a patient with me will net me about $50 for about an hour’s work. THAT’s why no one is going into primary care.

    Sorry for the long post.

    NH Doc

  • Anonymous

    Well, NH doc does seem to froth when someone states the obvious that specialists know more about a given condition that he does. I think that’s obvious–only an ego-driven doctor lunatic would question that.

    As for his “typical” patient with the parade of horrible diseases that supposedly wants one person to track his/her decline to death, that’s not typical at all. Most people are healthy, even most people who see doctors. There may be a place for doctor-coordinators for very sick people, but for most people it may not be necessary.

    Again, we must return to market principles. I think most healthy people would prefer instant care for their little illnesses and resent having to wait to see a primary care. I also suspect that for most chronic diseases specialists are better. Given those preferences, there should be a MUCH smaller role for primary physicians.

  • Anonymous

    Anon 11:15- Are you a physician? I’m not being sarcastic- I just want to know what you are basing your statements that most people who visit the doctor are healthy on. I really don’t think my practice is out of the ordinary.

    Also, I’m a she, not a he.

    NH Doc

  • Anonymous

    NH Doctor:

    It is a statistical question whether the average patient is as sick as you describe–any particular doctor’s view is quite irrelevant. I’m surprised that as someone presumably trained in science you should confuse the anecdotal with the empirically demonstratble (Not being sarcastic).

    You didn’t respond to my points. You just condescended. How typical from a doctor.

  • Grumpy

    Certainly, any patient who would prefer to see a specialist rather than see me as a primary care internist should be welcomed to do so. I certainly don’t want to confront a patient who doesn’t want to see me and is forced into the situation by the “HMO Model” of care. Yes, let the market control patients’ behavior and hope they have enough knowledge to make the right choices for their (and their family’s) health. And let them bear the cost: headache, off to the neurologist–cachinck; cough, off to the pulmonologist–cachinck; funny bowels, off to the gastroenterologist–cachink; paplitations, off to the cardiologist–cachinck; sore shoulder, off to the orthopedist–cachinck; stuffy nose, off to the ENT–cachinck. I have had many patients who went this route and then returned to me for anothher opinion when they didn’t like what the specialist told them. I would tell them to go to another specialist (cachinck, cachinck), since the specialist obviously knew more and had more valid opinions than mine. Then I had more time for the patients who were beating down the doors to try to see me.

  • Anonymous

    “It is a statistical question whether the average patient is as sick as you describe”
    Sir, you have no clue !

  • Anonymous

    Anon 12:22:

    Please check out the acutual ACP position paper at the following website: http://www.acponline.org/hpp/statehc06_1.pdf. Look at page 3 especially, as there you will find the answers to your “statistical questions.”

    You still haven’t told me why you think that most people who go to the doctor are healthy.

    NH Doc

  • Anonymous

    Hate to say it Ms. NH Doc, but you ain’t too smart. The website you list is simply a plea by primary docs for more money from medicare, along with dire predictions of gloom and doom about the impending disaster of too few docs.

    There are no answers to my statistical questions–ahh–but observe your approach to argument, Ms. NH Doc. You intimidate; you do not respond. It points to a noxious insecurity in yr character–perhaps you could be helped by therapy.

    As for the paper’s assertions:

    First, there is no clear relationship between medical outcomes and the number of docs. Japan has fewer docs per capita, yet the Japanese live longer. Show me data that fewer primary doc wil mean worse outcome, then I’ll listen. Otherwise, it’s just primary docs whining for as menay lexuses as their opthamologist friends.

    second, are you REALLY worried about the supply of doctors? If so, there’s a simple answer–eliminate licensure requirements. They’ll be more docs, and I bet the market will do a better job than the self-serving, oldboy networks of peer review to keep quality high. Oh . . . but that would cut into yr income, and we can’t have that.

  • Anonymous

    Sigh.

    I guess I’ll stop feeding the troll.

    BTW, that’s DR. NH Doc to you.

  • Anonymous

    as I said, you’re a very insecure woman.

  • Anonymous

    “You didn’t respond to my points. You just condescended. How typical from a doctor.”

    You always troll like this? Typical of a Doctor? All doctors are the same? Do you write “typical of a Jew? Spic? Negro? Queer?

    By the way, nothing to do with your argument, but there’s a great shortage of specialists in this country. Every other country in the world uses “family doctors” to cover most illnesses, here we have so many specialists, and it’s not even enough because we need every headache to see a neurologist, to satisfy the lawyers. Meanwhile, our healthcare system is not even in the top ten in the world. I’m disagreeing with you, yes. Now i’m sure your comeback will be an insult, so shoot away.

  • Anonymous

    1. To generalize over a group, say doctor, does not make you racist or antisemitic or anti-italian.

    2. OK–so now you’re saying we don’t have enough specialists or primary doctors–and we have really bad healthcare.

    3. As I said earlier, if we have too few doctors, eliminate licensure requires, lower barriers to entry–and we’ll have more doctors.

    4. problem solved, dear frother

  • Anonymous

    “To generalize over a group, say doctor, does not make you racist or antisemitic or anti-italian.”

    No. It just makes you sound stupid. No 2 doctors are the same, not 2 lawyers, electricians, breadmakers are the same.

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