Dear Senators McCain and Obama:
I am a physician in Nashua, New Hampshire, and as an independent, swing voter, will be important to your Presidential fortunes in this battleground state.
As a primary care doctor, it comes as no surprise that I have focused on your proposals to reform our healthcare system. I applaud both of your efforts, and they could not be more different. The election will truly be a referendum on whether the country will endorse the left’s focus on universal coverage, or the market-based solutions of the right.
The United States boasts the world’s most expensive health care system, and has close to 50 million citizens without health insurance. After scouring your websites and listening to your rhetoric, it is discouraging that you propose very few solutions that address the root of today’s healthcare problems: the primary care physician shortage.
Senator Obama, your plan is strikingly similar to the reform underway in Massachusetts. You keep the current system intact, and strongly encourage (versus mandating) citizens to obtain health insurance from a private or public insurer.
However, you assume that there will be enough primary care doctors to care for this sudden influx of newly insured patients. As Massachusetts is finding out, that is far from the case. Dr. Bruce Auerbach, president-elect of the Massachusetts Medical Society, sums up the problem:
“It is a fundamental truth “” which we are learning the hard way in Massachusetts “” that comprehensive health care reform cannot work without appropriate access to primary care physicians and providers.”
And this is a state that ranks far above average in the per capita supply of primary care doctors.
Newly insured patients who cannot access timely primary care will flood the already crowded emergency rooms, further driving up the cost of care.
Implementing your plan without a solid primary care foundation will doom your proposal to failure. Universal coverage is useless without appropriate access to care.
Senator McCain, first let me say that your absence in July’s vote on the Medicare bill to repeal physician payment cuts was disappointing. Choosing not to support physicians will certainly linger in my mind on November 4th.
That said, I am encouraged with select aspects of your health plan. You prioritize cost containment, propose divorcing health insurance from employers, and invoke the idea of tort reform.
Your plan takes a traditionally conservative, market-based approach to health insurance, emphasizing the use of tax credits and health savings accounts.
However like your Democratic counterpart, you do not address the primary care crisis. If your plan comes to fruition, patients will be more responsible for their health spending. Forget the fact that there currently is not enough transparency nor cost information available for many patient-consumers to make an informed decision.
Without adequate access to primary care, patients will be forced to choose care at more expensive venues and sacrifice preventive care. Health savings accounts will not be adequate for emergency room bills or prolonged hospital stays.
Senators, at a time where Baby Boomers are approaching age 65, the outlook on who will care for these new Medicare beneficiaries is dismal. A survey from the Journal of the American Medical Association found that two percent of graduating medical students say they plan to work in primary care internal medicine. Let me repeat that. Two percent:
The results of a new survey . . . suggest more medical students, many of them saddled with debt, are opting for more lucrative specialties.The survey of nearly 1,200 fourth-year students found just 2 percent planned to work in primary care internal medicine. In a similar survey in 1990, the figure was 9 percent.
Paperwork, the demands of the chronically sick and the need to bring work home are among the factors pushing young doctors away from careers in primary care, the survey found.
“I didn’t want to fight the insurance companies,” said Dr. Jason Shipman, 36, a radiology resident at Vanderbilt University Medical Center in Nashville, Tenn., who is carrying $150,000 in student debt.
Primary care doctors he met as a student had to “speed to see enough patients to make a reasonable living,” Shipman said.
I do not hear any solutions addressing this issue on the campaign trail. No suggestions to, i) reform the dysfunctional physician payment system which rewards expensive procedures at the expense of office visits for preventive and chronic care; ii) encourage medical students to enter primary care fields by forgiving their medical school debt; and, iii) fairly reconciling the wide chasm between specialist and generalist salaries.
The simple fact is that unless you solve the primary care issue, neither of your plans will be successful.
I look forward to listening to any proposals you may have to address the primary care crisis. I also wish both of you the best of luck as we come down the home stretch of a grueling campaign season. You don’t need me to tell you that every vote counts.
Mine’s up for grabs.
Sincerely,
Kevin Pho, M.D.
Nashua, New Hampshire
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- A young physician writes to Barack Obama
- Coverage does not equal health care
- "Obama, wake up"
- ER visits and health care costs rise in Massachusetts due to lack of primary care access
- John McCain so gets it
{ 16 comments }
You prioritize cost containment, propose divorcing health insurance from employers, and invoke the idea of tort reform.
How is divorcing health insurance from employers a good idea? This is breaking what exists, without allowing any kind of group plans in return. Individual plans are OK – when you are young and healthy. At the same time, those with chronic conditions, as well as those over 50 or 60 will not be able to buy anything at all.
Additionally, employer-sponsored plans don’t have to hide costs from patients. High-deductible/HSA plans are being offered by employers as well. Many employers stop offering HMOs and offer instead PPOs that require employees to pay percentage of cost rather than fix co-payment, and that after a deductible. Type of plan offered and who offers it (individual or group) are two different subjects, but for some reason people keep confusing them.
I found it very interesting your take on healthcare. I personally am leaning toward McCain’s proposed plan, as I don’t want the govt telling me who I can see.
It appears to me it is a vicious circle with the healthcare. You go to school, get in debt up to your yingyang, then are forced to go into a specialty where the pay is a lot more so you can pay off your debt from school.
I think both candidates should put a working team together consisting of a student or two, some major insurance companies to include Medicaid/care persons, a govt budget person, a couple nurses and doctors and see what they all think.
They also could come up with some incentives for the regular student who wants to become a primary doctor but can’t afford it (I’m sure money incentives would work).
The problem is, there is so much red tape involved and then you get those insurance company and drug companies involved and you’ve really got a bunch of red tape. I can see why Hillary failed the first time around on this issue.
It was very nice to actually hear remarks from a doctor out in the real world. My question is, how does McCain or OBama get to you.
The validity of your primary care shortage points I wonder to phase 2? Having mandated coverage, not reimbursement, but coverage we now must mandate specialty choices?
As a primary care internist in private practice, I have always felt compelled to vote Republican even though I do not always agree with the Republican platform. The primary reason for this is my perception that Democratic candidates are hugely supported by donations from Trial lawyers associations and so could be expected to vote against physician friendly legislation such as tort reform. (http://www.campaignmoney.com/Trial_Lawyer.asp)
I feel if I were to vote against the Republican candidate, I’d be voting for the party that is “in the pocket” of the Trial lawyers. (I’m aware that the Republicans may be “in the pockets” of other special interests such as big business or organized religion, etc.) I wonder if physicians who vote democratic are in private practice, or would they be more likely to be in an educational or salaried job, where getting sued wouldnt be as much of a worry?
I am in private family practice, and have been for 10 years. Although I have concerns regarding the ability of democrats to fix healthcare, I have always voted democratic and never republican.
George Bush has been in office since January 2001. For most of that time until January 2007, the republicans controlled both houses of congress. A doctor, Bill Frist, was even the republican head of the senate.
During that time, they did NOTHING, repeat NOTHING, to help doctors with tort reform. Reason: they did not care. Doctors fell for lip service only and did not hold them accountable.
The Bush administration recently vetoed (which was overridden) attempts to stop medicare cuts. The Bush administrations supervision of CMS is also behind recent reforms such as “never events”. After all, this is a “business” concept: why should doctors and hospitals be paid if the results were not good?
Don’t be foolish again.
Abandon the notion that somehow the republican party supports doctors more than democrats. It is a lie.
Actually, it was that the Democratic minority in Congress could simply filibuster any attempt at tort reform. Believe me, for their business interests if nothing else the Republicans would LIKE to get tort reform through. But it’s completely dead as a federal issue for as long as Democrats have 40 senators (i.e. forever).
If you want to increase your income, without regard to the impact on your patients, you should definitely vote Republican.
Once health insurance is divorced from employers, only a select few will be able to afford unsubsidized coverage. That means you can cherry-pick from the healthier and younger members of the dwindling upper- and upper-middle classes, who will be the only ones able to afford your services.
You already have the right to deny access to Medicaid and Medicare recipients, which you should do as soon as economically feasible. Not only will you free yourselves from obscenely low reimbursement rates, but from the onerous paperwork and regulations, as well. This will allow you more time for better paying patients, more time with family, and perhaps a vacation here and there.
Also, you’ll no longer need to worry about the dearth of medical students interested in primary care. You see, once McCain’s brilliant plan is in place, there will already be a sufficient number of you for the patients who can afford primary care.
And what of the middle- and lower-class masses? Well, screw them. If they can’t earn enough to afford decent healthcare, they deserve to rot anyway.
Heaven forbid someone should propose or endorse a plan that benefits both doctors and regular citizens. That just wouldn’t be American.
And we definitely need tort reform.
Paperwork, the demands of the chronically sick and the need to bring work home are among the factors pushing young doctors away from careers in primary care, the survey found.
* Paperwork and demands of dealing with the chronically sick are the reasons no one should go into the education field, either. Paperwork is everywhere; I work under the wonderful NCLB, and the paperwork can be crazy at times. I have never found a job, when dealing with human lives, that is without paperwork. And, there are quite a few classrooms equivalent of a ped. psych ward!
Let’s see, in the next decade, our bright kids, will be work at less stress occupations – Starbucks – and our dumb students cannot rise to any expectations – education, nursing or medicine. Our country is in the dumps!
Really great letter , I agree most of its points and thinks that much more has to be done on health care facilities in USA.
Thanks
Are you guys listening to yourselves? Once again you’re asking the government to do what you should be doing for yourselves. It’s not going to happen. The government is going to demand the most work for the least money for as long as you allow it.
Stop waiting on a politician or political party to save you. Save yourselves.
P.S. The feds can do little about tort reform that affects you (putting aside that it really doesn’t help you anyway). It’s a state law issue.
From Someone Who Knows:
No one wants to go into primary care because it is not a challenging occupation. It is a job for nurses. That’s what PCP’s in Canada (and other nationalized and partly-nationlized systems like the U.S.) are: glorified nurses.You don’t need an IQ of 120 and 10 years of training to take vital signs, evaluate primary complaints, prescribe outpatient solutions and triage complex or sick patients to better-armed sources.
You, sir, are a dinosaur who made bad choices and you resent it — don’t blame the political party platforms for that.
Why are you blaming the government because students don’t WANT to go into primary care? Did you anywhere list WHY they don’t? I’ll tell you:
It’s a dumbed down job that refuses to shed its doctor-glory rep from 30 years ago.
Truth is, now students want to go into other specialties because that’s what smart people like: more complex problems with more complex technology and better pay.
Sorry.
Next patient.
Sadly, Anonymous is right when he says primary care has become a “dumbed down job…” It shouldn’t be, but it now is thanks to the cost-savings pressures of our medical environment. As an internist perpetually referred to as a “primary care physician”, I work in an environment that rewards mediocrity. (And I’m in one of the “healthiest” medical groups in town).
But that’s off the point of your original comment. I agree with you that Obama does not go far enough toward universal coverage and I absolutely agree that medical insurance needs to be permanantly divorced from the workplace.
However, I think the primary care physician shortage is a symptom, not a problem in it’s own right. Paying internists more would help reduce the shortage. But it would not solve the core problem.
The real problem is our insurance structure, which Obama does not address. (I’m voting for him anyway since McCain’s ideas on the subject are simply ludicrous).
The first and foremost thing that needs to be done, is to eliminate “pre-existing conditions” all together. Everybody, sick or well, deserves to be covered. Denying coverage due to pre-existing conditions is cruel, and it’s morally and ethically wrong, finances aside.
Eliminating pre-existing conditions will force the issue; the rest will follow. The current for-profit insurance structure could not survive without it’s actuarially based business model.
What would then follow is likely a centralized universal insurance plan which will be so much more efficient than paying 25-35% overhead to insurance companies, that it will cover everyone, and maybe even have a little left over to boost primary care.
Anybody in Washington got the guts to do it?
Administrative costs are the biggest driver of health care spending. As a practicing solo internist, I see everyday the needless and repetitive bureaucratic hurdles that are placed in front of me by the large number of private, profit guided insurance companies and the numerous satellite industries created to support them (e.g. radiology precertification companies and third party prescription drug companies). To truly arrive at a system that will work the best for all, we need to create a basic single payer system, one that allows uniform and efficient interaction between the physician and the payer and eliminates the for profit health insurance industry. We can call it a not for profit system, that guarantees basic coverage for all and reduces the administrative expenses created by the for profit health insurance industry, currently eating up over 40% of the healthcare dollar.
In fact, there is an example of such an approach currently and it is called Medicare. Expanding the role of Medicare to cover the health of all Americans would be a step in the right direction. Of course, the cost of such an expansion of Medicare would be enormous, but would be more than offset by the cost reductions realized through the elimination of inefficiencies in the for profit system. It might be argued that this is anathema to the capitalist objectives of our free market system. The fallacy there is that the healthcare of our people is not and should never become a profit driven commodity. (Besides, a single payer system doesn’t mean there cannot be a separately existing for profit health insurance industry for those willing to pay more for added services). The same holds true for our national defense, where there is a single payer system, the defense department. If we value our nation’s health as we do our nation’s defense, it makes sense that there should be a single payer here as well. Another argument that may be made is that such systems have been tried elsewhere like Canada and the U.K. with mediocre outcomes. It would be the job of any administration to bring together the right team to create a system that works for the majority of the people and that learns from the experiences of others. It would be necessary to provide sound, physician and patient (not trial lawyer) sensitive tort reform as we have seen in states like California and Texas as well as liability reform based on the prevention and acknowledgement of medical errors as has been proposed by both Barack Obama and Hillary Clinton (http://content.nejm.org/cgi/content/full/354/21/2205).
No system will satisfy everyone. The mark of a good system would be to provide basic quality healthcare to the most number of people in an efficient and cost conscious manner.
I do not believe that your solution to medical problems are in any way logical. First, how is the government supposed to encourage students to enter primary care? The government cannot under ANY circumstances force ANYONE into ANY career, it would be dangerously immoral, and at the expense of liberty. Individuals should always choose which field they want to go into, and the government should not play ‘favorites’ when it comes to primary care. The government does not owe any incentives to medical students who do choose primary care as a specialty. Second, the government has absolutely NOTHING to do with the financial aspects of medical education. The government should not be allowed to deal with medical colleges on behalf of medical students. The financial goings on between a medical student and a medical school must stay just that. The government cannot just ‘forgive’ loans, this isn’t a gift. The government is not benefactor for any citizen of the country. It is immoral for the government to direct people into certain professions by offering free education, that is the decision of the medical school, and the achievements of the medical students. I fully support scholarships and all, but the government does NOT owe anything to anybody for free. This isn’t Soviet Russia, the government will NOT simply prioritize one single specialty or profession just because there will not be enough of those professionals. This is up the individuals providing health care, the doctors. If there isn’t enough plumbers in the country, should the government subsidize plumbing courses and tool kits for for anyone who wants it? No! The individual should bare the burden of the cost, and other taxpayer. Medical professionals, or any other professional should not get their education funded by the public at large- no matter how much the government can afford it- it’s simply IMMORAL! Furthermore, it’s completely ridiculous that you suggest the government does something about the differences in salaries between different specialties. Primary care physicians earn less than neurosurgeons not because the government orchestrates some kind of conspiracy to keep primary care physicians down. The government shouldn’t have to pay for someones CHOICE of going into a particular specialty. It was a choice based on the will of the medical student, you, as a primary care doctor should know this. Why should taxpayers pay for the career you chose? If you’re not happy with your salary then YOU do something about it, you chose this specialty- you were never forced into it- you knew the salary that you were most likely to have. The possible shortage of physicians will eventually be filled. I support the idea that medicine should be operated on a purely capabilities basis. If physicians do not like to do business with insurance companies, then they simply shouldn’t! Doctors should be able to compete with one another based on their competence and services they offer, and prices they ask for! That way, dealing with cash, and not the third party insurance companies, doctors set the price- patients pay directly. That will ultimately lower the cost of health care, and increase the quality of it via competition. Patients will choose which doctors to go to, and doctors will choose the prices.
V.B.
New York
I certainly hope that ‘One Who Knows’ doesn’t come into our busy inner city busy ER with a critical issue. You will be quite dismayed to realize that we -the nurses- will have saved your ass before the doctor can even get into the room.
Our Docs are great. They are quite overextended. Most of us in healthcare are practicing compromised care. The paperwork/EHR does indeed take priority because it’s all about the revenue for the hospital/hospital corporation. Even we nurses are harassed by management about charting/billing. (Yes, I do know the bills have to be paid)
There should be no room for profit in healthcare.
We are taking care of each other. We should make a good living. It should be that simple.
YES. If people had access to healthcare we wouldn’t be overcrowded on a continuous basis. The little old lady with HTN wouldn’t be in crisis because she couldn’t afford to fill all her medicines. If there were alternatives for the patients whose pain clinic, drug treatment center, homeless center etc etc closed for economic reasons- they wouldn’t be adding to our wait times of 6-18 hrs or more. We see the Pts that are to supposed to ‘follow-up with PMD or specialist’ in our ER routinely as there just are few specialists/PMD’s who can afford yet another Medicaid/ Medicare or Insurance-poor patient. Or maybe their PMD just doesn’t have an extra minute for yet another Pt. Frequently they can’t FIND a PMD and many of the same reasons apply
I won’t even touch on the millions of dollars that are spent on the abuse of the system. (And the sense of entitlement some of our most obnoxious and abusive Pts have shown)
Thank you for this chance to speak,
ER RN for decades.
We are still there because we still care.
Unfortunately the government does already play favorites by having Medicare/Medicaid set reimbursement rates for the nation favoring different specialties and a fee for service system. I think the argument is whether or not primary care physicians deserve a bigger piece of the pie. I think so, but I’m only a second year medical student. I do know that with the level of debt heaped onto me by my medical school, primary care has not become feasible (and I only have debt from medical school). My financial aid advisor has advised that I either choose a high paying specialty or do military service.
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