Congratulations to Barack Obama on his historic Presidential victory. He dominated New Hampshire, carrying my home state by over 10 points.
I voted with the nominees’ health care platforms weighing heavily. Both did not offer plans that I felt would work, as I wrote previously. While reading their competing pieces in the NEJM however, Obama made the more compelling case:
There is little incentive for young physicians to enter into primary care. And U.S. physicians practice with constant concern about malpractice lawsuits . . .Doctors should be paid fairly by private insurers and by Medicare. Payment reform should improve patient outcomes and should lower overall costs by removing incentives for unnecessary care and rewarding the right care, provided at the right time, for the right reasons. Unlike my opponent, I voted against the recent reduction in physician payments. We can’t start health reform by penalizing doctors . . .
I will invest in programs, including loan repayment, training grants, and improved provider reimbursement, to give young doctors incentives to enter primary care.
John McCain on the other hand, did not include any support for primary care. In fact, the words “primary care” were nowhere to be found in his article.
Despite the fact that Obama’s supposed tort reform stance is questionable, like McCain, he acknowledges that malpractice premiums are crippling to physicians and is willing to listen to approaches to curb lawsuits:
I will address medical malpractice with the central goal of preventing medical errors in the first place. Through substantial investment in information and decision-support technology and other patient-safety initiatives, we will reduce the types of medical errors and oversights that lead to lawsuits. And I am open to additional measures to curb malpractice suits and reduce the cost of malpractice insurance. We must make the practice of medicine rewarding again.
In the end, Obama’s NEJM piece was influential, and true to my word, McCain’s absence from July’s Medicare vote to raise physician payments was indeed a factor.
Barack Obama received my vote on November 4th. I do not agree with everything on the Democratic platform, but it was clear he understood the plight of primary care physicians better than John McCain.
Now that he’s won, let’s see some of his initiatives put to action. He must increase access to generalist physicians before expanding coverage. His plan mirrors that of Massachusetts’ reforms, minus the forced coverage, so he must be aware that without generalist physician access, the newly insured are simply going to increase the burden on emergency departments. His proposal of providing financial incentives to medical students will help long-term, while improving payment to cognitive services will prevent the current generalists from leaving primary care.
With that in mind, here are two specific solutions that will have the most immediate impact:
i) Increase Medicare’s reimbursement of the E&M codes 99211-99215 by 20 percent or more. These are the cognitive codes primary care doctors use most, and they are reimbursed at a rate substantially less than comparable procedure codes. Consider the fact that the 2 minutes it takes to freeze off a wart pays more than a 25 minute office visit. Increasing Medicare’s fees for these codes will make a bold statement that private insurers will follow. The subsequent increase in primary care revenue will prevent doctors from leaving the field or going to cash-only practices.
ii) Forgive medical student debt and subsidize tuition for every medical student who chooses primary care as a career. Only two percent of Internal Medicine residents choose primary care. Money is not the only reason, but it’s often influential. If tuition were fully subsidized and medical debt burden relieved, there would be less pressure for prospective doctors to gravitate to lucrative specialties.
The uninsured are a significant problem, and covering them is embraced by every Democratic candidate. Enacting universal health insurance is an expensive proposition, and if instituted poorly, will further cripple the system to a degree far worse than the current economic crisis.
I’m putting my faith that Obama will provide realistic solutions and ensure that our primary care system can handle the influx of newly insured patients before guaranteeing coverage for all.
Update:
Here’s how fellow internists Robert Centor, Rob Lamberts, and Matthew Mintz would advise President-elect Obama.
topics: obama, primary care
