Third-party payers and patients both drop costs onto small practices that did not exist for these practices a generation ago. Even the smallest practices have to have a business staff to file, follow and chase payments from insurers and Medicare, activities that can cost even the smallest practices many tens of thousands of dollars to do, something the earlier payment at the time of service model never had to bear.

Unless more money goes to providers, offsetting the effective cuts from rising operations costs, there isn’t going to be an “answer” to the primary care access problem. Fewer doctors will accept Medicare patients, more will choose cash-based practices and see those who are able to pay for what they want.

Expecting the generalist medical community to provide costly and valuable service without payment, something that third-party payer failure to keep pace with practice costs is inherently doing, is not a reasonable or sustainable working condition. Ultimately a system that indulges itself in this kind of behavior will fail. When it does fail, we will see even worse problems than what we presently have. Under-insured lack of access will dwarf our present problems of uninsured lack of access.

1. If it draws people into primary care who otherwise wouldn’t go, it will just mean higher levels of unhappiness in the field when they find out it does nothing to correct the problems with the field.

2. The government will then think it owns you and you will be fully subject to the whim of the mob. Note what is going on with the AIG execs. Take the King’s Schilling and you must salute and march to the King’s colors.

I don’t think it is salary, I think it is work/business conditions. I make the same as primary care in psychiatry, left one of the most lucrative fields for it, and am reasonably happy with it–at least less unhappy than the PCP’s that I know. While I sometimes have greed fits and regret not staying with the 400,000 a year field, I usually come to my senses on that point–but I wouldn’t trade with PCP’s for love or money. My compensation is reasonable for what I do but I would not find it reasonable for what they do.

There’s a chicken and egg problem in that I really do think that the key to making primary care appealing is to have role models who enjoy it and do it well. Which is not what we have right now; for every excellent and engaged primary care physician like my current doctor, there’s a handful of dead-eyed HMO docs who never would’ve gotten into medicine if they knew they’d spend their days as assembly-line prescription-writers.

I have noticed that the really good primary doctors I’ve known generally got into it because they had a mission, generally wanting to improve care for some population or perhaps wanting to improve the practice of primary care itself. Outreach to foster that sense of mission could probably help, but what happens after a couple of generations of students take the bait and end up that HMO prescription machine? Not good for credibility.

Another concern that I wonder about now is whether new doctors going into primary care can even bank on being able to practice in that field for their entire career (if desired), or if they’re in danger of being forced out long term. I would certainly be concerned about that in their place.

You should be careful in claiming that as well lest the impression be given that a certAin number of them are a “right”.

The problems with primary care are at every level. A carrot and stick approach, like a little loan forgiveness, is meaningless. Why in the world would someone choose 150,000 per year over 400,000 per year, while at the same time garnering minimal respect from the government, insurance companies, other doctors, and last but not least, patients?

A family practitioner