Universal coverage without primary care access is useless

Bravo to the NY Times for exposing what I’ve been saying repeatedly:

Now in Massachusetts, in an unintended consequence of universal coverage, the imbalance is being exacerbated by the state’s new law requiring residents to have health insurance.
Since last year, when the landmark law took effect, about 340,000 of Massachusetts’ estimated 600,000 uninsured have gained coverage. Many are now searching for doctors and scheduling appointments for long-deferred care.

Barack and Hillary want to bring a similar system nationwide. Are they paying attention to what’s happening in Massachusetts?

Comments

Anonymous
I do not know where the average salary of 160-175 comes from. I here this quoted all the time and feel it is inflated. It sounds like Dr. Atkinson works very hard and makes only 110,000. That’s more accurate.
The public will never see things from our perspective as long as they all think we are making 160-175,000.
I personally, made 120,000 last year, a salary that has not budged in 6 years.
When she states that she never planned on getting rich in medicine, but never felt she would feel so disrespected, it is as if the words were leaving my mouth.
More cynically, the shortage of primary care will lead to more mid-level providers and further marginalization of family physicians and general internists.
The future is bleak.
Comrade Underpaid in Upstate New York
Anonymous
The only way to increase access is to raise payments which will attract new practitioners. Economics 101. Insurance coverage is NOT the answer, as Dr. Atkinson’s comments regarding Medicare payments indicate. The only way to increase payments is to raise taxes, diminish payments for nonphysician services, or balance bill/concierge medicine. As the first two options are unpopular for a variety of reasons, option three is the only plausible solution. A practice with a waiting list indicates a fundamental mismatch of supply and demand and that your services are underpriced relative to demand.
Anonymous
I have termed this the “Ontario-ization” of Massachussetts. I think we are up to, what? … several million Canadians without a family physician.
Next will come breath-taking waiting lists for treatment in Massachusetts. I would give this two years to develop for the sub-Medicaid below the cost of doing business plans.
Following this, we will see immediate access to care (what they call in Ontario “jumping queue”) only via political connections. Otherwise you wait endlessly on what Canadians darkly call “Euthanasia by Queue.”
Ian Furst http://www.waittimes.blogspot.com
So what is the solution? Eliminate coverage so people go without care again? The last “Anonymous” comment is illogical. Just because you don’t seek care doesn’t mean you’re not in a queue. You’re just so far to the back that no-one is counting you. In Ontario, because we have universal coverage the entire population is accounted for when we create the queue lists. Whereas, until recently, you did not. People that waited until they were critically ill, finally came forward and were quickly treated. The illusion, is that they still received timely care. The reality is far different; just because they didn’t come forward doesn’t mean they don’t exist.
That being said, you’re still going to have to deal with a crisis of resources because the underinsured are now coming forward. Since the government is unlikely to pony-up more money you can either rationalize care or increase efficiency (the latter is my personal goal).
By the way, I’ve never heard the term “euthanasia by queue” in Ontario and could only find 2 Google references to it by someone named “FormerACLUMember”. I have a list of wait times references
that give very specific indicators of how long people actually wait (check out the ICES ones for Ontario). The reality of waiting in Ontario is not great, but it’s well documented and we’re all working to make it better. As far as salaries go in Ontario, our GP’s earn an average of
$183,448 which will make it difficult to recruit new family doctors since it’s on par with other parts of North America. Our specialists, on the other had do much better earning substantially more than $183,448
Most of my blog is about wait times and in particular wait times in Ontario, should anyone need more info.
Ian.
http://www.waittimes.blogspot.com
Anonymous
Hi,
As one who was denied regular health insurance and who can’t afford Hippa coverage at $1,000 per month, what is your proposal Kevin for coverage for someone like me?
Than you Ian for speaking up for people like me.
AA
Anonymous
Dear AA,
You are the person all of us are worried about, not just Ian (who seems to have an unspoken agenda??)
I graduated with an Economics degee and after going to med school spent 5 years doing general internal medicine, so I think I have something intelligent to say about this problem in general and your situation in particular.
When you say you were denied coverage, did you mean that was because you had a pre-existing condition? Another option is to get catastrophic hospital coverage with a high deductible to protect yourself from huge medical bills and pay out of pocket for the outpatient stuff.
Another alternative is to talk to a social worker about medicaid if $1000 is too steep (and it is certainly too steep for me!)
What alot of people advocate is putting the consumer in the position of cost-controller. Currently, if you have insurance, you demand for additional medical services is infinite as you don’t pay anymore. If you pay all (or a portion), you view each test and visit very carefully. What you might do is pay (out of pocket) a general internist to give you some straight talk about what your medical problem is and what is the minimal level of care you can get by on.
I know it might seem discouraging listening to what happens on this page about declining availability of doctors, but the availability is declining for the same reason that you don’t have insurance–the numbers just don’t add up right.
b
Ian Furst http://www.waittimes.blogspot.com
No one denies the long waiting lists (as you’re google search proves). But who’s living the illusion? If Mass. included everyone who has to wait until they have enough money to go to the doctor before the seek care in the waiting lists do you think the queue length would change? There is no way I’d say our system is better because I think it’s broken, but I’d like to be able to compare apples to apples.
John
Throughout the years the source of income statistics has only been an annual survey of subscribers by Medical Economics. The survey is voluntary; the group surveyed is self selected. Most answers are given off the top of the head of the responder, and no effort is made to verify the responses. Personally, I not only doubt the accuracy of questions like “How many hours do you work a week?”, “What is your practice overhead?”, and even “How many patients do you see in a week?”, but I really question the accuracy of the derived salary statistics since (1) It is unlikely high earners are going to admit it and (2) there is reason to believe that people will “low ball” their income to skew statistics.
But consider the disparity between Dr. Atkinson’s $110,000 annual income vs. the presumed average of upwards of $170,000. The real issue is not the reimbursement itself, but the context in which you consider it. Presuming that she has an overhead in the lower range at 50%, her practice’s annual per patient revenue is $73. If a practice paying the higher supposed average income had even a worse overhead at 65%, their annual patient revenue would have been a much higher $162.
In either case, the revenue generated by primary care is a very small percentage of the annual cost of care that exceeds $6000/person in the US today. Put in that context, the problem in my opinion is that primary care is essentially irrelevant to the rest of the health care industry. For a brief period in the 1980s when it appeared that FPs would be empowered to control far more than their own revenue by being designated as “gatekeepers”, hospitals took an interest in primary care because of the potential revenue that it controlled. When it turned out that this control was illusory and hospitals lost all interest in primary care in favor of contracting directly as a “preferred provider”.
Yet the problem today is even worse than one of irrelevance. I believe that hospitals today view primary care as actually harmful to their revenue. In short, what has always been criticized as “bad utilization” has always been “good revenue” to a hospital. Using as an example a patient with a migraine, treatment in my office is going to be generally considerably less than $100 even if it involves a visit in the middle of the night and even a treatment plan for future avoidance of such urgent care, which is an inconvenience to both of us, while care in an ER will likely include an imaging study, a bill of several thousand dollars, and an invitation to come back any time for more of the same.
Given that context, it’s fairly easy to see who gets the free use of a state of the art facility, a paid staff, more limited work hours, better benefits, and better income. That’s how you spell respect on a professional level.
Anonymous
I don’t know why some Canadians are so quick to deny the reality of waiting for care. It’s a natural consequence of their system, and the main rationing tool used. Clearly, the tax rates required to give timely MRIs/CTs/knee replacements/hip replacements, etc. are more than even our northern neighbors can stomach. So they ration by limiting supply. Wait lists ensue.
Now, that may be a decent way to control costs. It may be the best way. It may not. But let’s not pretend it’s not happening.
Anonymous
There always seem to a few hyper-defensive boosters of Canadian/British socialized medicine. You simply can’t have a rational discussion with them. They are utterly immune to an honest appraisal of the problems. And forget any appeals to civil liberties or human rights.
Anonymous
Agreed. Read any Canadian newspaper on any given day and there is likely to be a story about a patient traveling to the States for treatment due to a queue or facilities unavailable. The US is Canada’s safety net. Who will be ours?
Anonymous
Take back your ancillaries from the radiologists! When I was in primary care, I never made less than 300k! Why is it that most PCPs just give away imaging, labs, basic procedures that used to be done by GPs? PCPs only have themselves to blame for the demise of income over the last 20 years. Remember, the PATIENT is the currency and the control over the specialists.
Ian Furst http://www.waittimes.blogspot.com
Just came back to the posts — I’m taking a bit of a s** kicking so time to defend myself.
1. I do have an agenda – I want to lower wait times. Our practice does it with efficiency so I figured I could add something to the discussion with my blog/comments. No financial interests to declare. My name is attached to all the my posts.
2. I don’t think it’s me that’s denying the wait lists. It’s all I blog about and it’s all published in nauseating detail across Canada (see http://www.ices.on.ca for stats in Ontario). We have a problem, we’re trying to improve the situation. What I’ve taken issue with is that when people in the US talk about wait times they rarely mention what happens in County and VA hospitals. I do not have stats on this – it’s a completely anecdotal observation from the small amount of training I’ve had down there and talking with friends.
3. Free market care is our safety net, not just the US. You’re just the biggest & closest supplier of it. We have some practices up here but they are not common.
3.As far as being a “hyper-defensive booster” — I liked that line. Deep down I prefer our system but I only claim to make a study of wait times. I’ll leave it to the politicians and economists to determine the most economical model. My preference is for universal coverage but not at any cost.
Good debate/ Good posts. Thanks Ian.
Anonymous
>>We have some [free market] practices up here but they are not common.
From what Canadian physicians here south of the border tell me, the deal is you are 100% in or 100% out. Sort of like the “opted-out” status with Medicare here. So to be a private doc you’d have to be in an area where you could get enough patients willing to pay out-of-pocket.
And from what I hear, the provincial governments still try to find reasons to shut down such practices, even though legal. I’m going by what the Canadian docs here tell me. Does that sound accurate?
For example, implied in this article (links to Canada.com)
http://tinyurl.com/4ot4u5
the authorities seem to be looking for ways to find a private emergency clinic to be in some violation of the law.

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