CNN op-ed: What good is having health insurance if you can’t find a doctor to see you?

My latest opinion piece was published on CNN this morning.

CNN op ed: What good is having health insurance if you cant find a doctor to see you? Entitled, Why the doctor won’t see you now, it should be familiar to regular readers of KevinMD. Here’s an excerpt:

Although it is a moral imperative for every American to have access to health insurance, alleviating the shortage of primary care providers is of equal importance. The prospect of suddenly adding tens of millions of patients to an overburdened primary care system has the potential to make the already dire state of American health care even worse.

Enjoy the piece.

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  • Gordon

    At the end of your opinion piece you call for primary care physicians to spend more time with each patient, but this will only exacerbate the problem of patient access – unless, of course, the number of primary care physicians increases. You have diagnosed the problem, but you provide no remedy. How about urging the A.M.A. to allow the creation of more medical schools?

  • Betsy

    I think another piece of this puzzle is that many pre-meds wishing to go into primary care have difficulty getting into med school. It is good that medicine is a competitive field, but I wonder if many bright and compassionate students are turned away. I also want to point out that many of the medical schools considered “the best” in our nation do not encourage primary care –UPenn, Johns Hopkins, and Harvard to name a few. In order to alleviate the burden on primary care docs, we need to target more programs toward them!

  • Diane Viens

    I read your commentary with interest. I have been a family nurse practitioner for 40 years working mainly with rural and underserved populations. I disagree with you that we do not need more primary care physicians, but we do need more primary care providers. I have just retired from a practice very close to a city near a major Ivy league University. Our state provides insurance (beyond Medicaid) for working people who cannot otherwise get insurance. Few physicians will take this insurance. Our practice does. Consequently, if health care reform does not have a clause that mandates that all health care providers must take a percentage of all insurances, then you are correct, access will be an issue. But reform will not work any other way. And yes, I know all the reasons that offices give why they cannot see these patients!
    The difficulty for me as an NP is that now the only referral site that does take these patients is refusing to see them because of “overload”. So they must wait in the ER. Think about what that does to the cost of health care. So before you go talking about more physicians, lets talk about why practicing physicians will not take all insured patients first and then talk about health care reform.

  • Shan

    What about some people touting “Nurse-Practitioners” and Physicians Assistants to fill the primary care gap? What’s your take on that? I’m really concerned that some patients may end up seeing somebody less qualified. Moreover I’m concerned that these new positions will encroach upon physician territory as well (ie

    • Kevin

      Before anyone attacks me for not utilizing NPs and PAs, I am on record saying that they are extremely valuable primary care providers:

      “The lesson here is that universal coverage must go hand in hand with the training of more primary care providers — not only doctors, but also nurse practitioners and physician assistants who can provide excellent primary care.”

      The point is, even accounting for NPs and PAs, there still will be a marked primary care shortage. Also, NPs and PAs are not immune to the financial incentives favoring specialty care, and we’re seeing them gravitate away from primary care as well.


  • Liza

    A very well thought out and constructive argument. Thank you.

  • Miles French MD

    Hello, I enjoyed your comments. I have a primary care clinic and work in a local ER in Southern Illinois, I also grew up and was trained in Canada. So not to blow my own horn, but I see this issue from many sides.
    I believe most patients and politicians have no clue how close to the breaking point the system is now. Many nights I babysit sick people while I patiently wait for an ICU bed, or medical bed – somewhere, any where. I could tell you some horror stories.
    My point is the system already teeters on the point of collapse. No specialists, no beds so they pile up in the ER. We don’t have time to look after them plus they take up space and then administration is is upset over patient satisfaction scores and though put times.
    There is also what someone has called, “trying out your insurance card.” Basically you have a patient who has not had insurance for a while and then has coverage. Suddenly they want all these referrals because it is covered, all the screening that is covered, rather than the generic medicine that they have been doing well on, want the latest and greatest new medications.
    I also live in fear of H1N1. It is all fine and good to suffer with the flu, but when the media start reporting that local people are dieing, shit will hit the fan. Maybe then patients and politicians will finally realize how broke the system is.
    Thanks for listening to my ranting. Take care.

  • dianeviens

    In answer to Shan, I do not agree with what “Dr” Kara is doing. I am a nurse practitioner and proud to be one. I make sure each patient I meet know that I am not an MD and the difference between the professions. I have a PhD and could use that title but I find it would be too confusing. I don’t think we need to worry about lack of patients for all of us either. Diane

  • Paul Bowling

    I’m not only concerned about the shortage but how do we get really qualified people to become Physicians, PAs & NPs?
    The cost of an education is becoming prohititive! Given a PA or NP is at least a MA / MS and cost for such programs are up to $40K per year AFTER the BA / BS and the educational expenses faced by Physicians are even worse. Many of the PA students I teach are leaving the PA programs with debts of $140K or more. I was recently talking to a newly practicing Physician and his educational expenses were just over $500K.
    Medical practice overhead is also very expensive. Mortgage, lease or rent in a decent office building or stand alone is not inexpensive add in staff salaries, EMR (Electronic Medical Record) software, medical and office equipment supplies, utilities and other necessary over head the total begins to become very high.
    And, least we forget Malpractice Insurance!
    A medical practice that accepts only Medicare / Medicaid could not last and I doubt that government funded health care program would pay more.
    So, we have high cost associated with educating the Physician, PA or NP, high cost to run a practice and outrageous malpractice cost and low reimbursement.
    If we’re EVER to have affordable health coverage we need not only health care reform but educational and medical malpractice (or just simply tort) reforms. Why would the best and brightest want to enter a profession that doesn’t pay them a sufficient salary? Attorneys in the area are making a minimum of $175 per hour (my attorney charegs $275 per hour and an attorney friend criminal defense attorney is over $500/hr!) plus billing for their paralegals and other office expenses. Engineers and computer professionals are making into the 6 figures as well as some college professors.
    I’ve spoken to citizens and health care providers from many parts of the world and I think the US Healthcare system is undoubtably the best in the world. Let’s keep it strong by attracting the most qualified Physicians and MLP (Mid Level Practitioners – PA / NP) by making education affordable, keeping malpractice premiums low with tort reform and paying a reasonable income.

  • Mike Rodgers

    Kevin, I enjoyed your article and found it to be a truthfull discussion. I only wish you would continue your thoughts with solutions. I have one, or several: 1) we must produce more doctors – all kinds – specialists and primary care – We import doctors, yet our government is willing to spend billions on health care, can’t we spend a few billion on more medical colleges. Since it’s the medial institution (AMA) that controls the medical colleges and therefore created this shortage problem then perhpas our government should graduate doctors (we have respectable military colleges that graduate some of the best engineers in the world); and 2) major tort reform – How about we give punitive damages to run medical colleges for research?; 3) insurance reform – the battle and additional paperwork that is also killing the system. We must attack all three to truly lower costs and provide better health services. Let’s help educate our citizens and give more of them the opportunity to become doctors. I’m for free higher education and even free and more medical colleges with community service in return for the education. What do you think?

  • m alexander stiffman

    Good article Kevin. I was wondering how long it would take for the medical profession (or whoever) to bring up the issues you raise. Promoters of the Obama initiative have cited Massachusettes as the exemplar of what is desired. Your article points out how that state’s program is built on a foundation of sand. Is there some way for this to run in The Washington Post and the New York Times (“reprinted with the permission of CNN”, etc.)? CNN has wide distribution, but the Post and Times are “newspapers of record” (for better or worse).

  • Will

    Kevin, I enjoyed your piece and find it to be on the target. I have had the same primary care physician for 20 years and even though we have good insurance coverage through my employer, it seems more and more difficult to get to our doctor due to the very concerns you discuss. He is genuinely dedicated but overloaded almost to the breaking point by the requirements for the system. Seems that a possible cure to the shortage of PCPs is to change the incentives by which the medical care system operates. If the percentage of reimbursemnt for costs is higher for the primary care (or preventative care) that most people seek is higher than the incentives for specialties it would potentially change the economic equation and motivate more aspiring doctors to pursue primary care. Under the current situation of constrained supply of doctors (AMA?) and highest rewards for spcialists, we should not be surprised that more health care professionals seek the more economically rewarding path. We see the same phenomena in the highly complex field of aerospace engineering which I work in.
    The other area that screams for attention is process streamling, often referred to as “Lean”. This is something we have practiced for years in aerospace both in the factory and in the office and it has been very successful in reducing non-value added effort and reducing costs. Granted I am no expert in medical processes, but my perception as a user of medical care over the years is that the process of providing medical care, at any level, is broken (scheduling, insurance, reimburesments, regulations, etc.). There are tools to help, assuming the willingness to do so.
    Just an outsiders view of potential solutions. Thanks for the chance to contribute.

  • DMS Student

    Okay, I just want to clear something up: the AMA is not some big, bad beast that wants to artificially lower the supply of physicians. The AMA has absolutely no say over med school class sizes or accreditation. The AAMC (Association of American Medical Colleges) is the accrediting body for Allopathic medical schools and the AACOM (American Association of Colleges of Osteopathic Medicine) is the accrediting body for Osteopathic medical schools. State medical boards govern the licensure of physicians. I’m not entirely sure where all the AMA bashing comes from. While I’m not a fan of all of the AMA’s positions, I do appreciate that the organization has become much more progressive lately (in part due to med student pressure) and is supporting health care reform…

    Anyway, to your point, Dr. Kim: I agree, we need more PCPs. Having other practitioners (NPs, PAs) is fine because these professionals do have an important role to play, but we definitely need more people going into family med, outpatient internal med and outpatient peds. Unfortunately, at least at my med school, very few students have any desire to do primary care. The majority of the students who go into peds or IM want to do a fellowship and specialize or become hospitalists.

    Why? Reimbursements are terrible. My SO would like to become a pediatrician, but starting salaries (post-residency and $200k of debt) are in the $90-120k range. When you get your first real job at the age of 30 and you’re staring with mortgage-sized educational debt and a salary less than the typical engineer, you’ll be forced to do a specialty which pays a little more. On top of the low reimbursements, PCPs have a challenging job (anything could walk through the door) and, as you point out, far too much paperwork.

    Part of the solution is to reimburse at much better rates for “cognitive work”. Lots of it is to minimize paperwork. Another big factor would be to have more loan repayment for PCPs. Finally, subsidizing malpractice insurance for PCPs and reforming the tort system (although the New Hampshire Medical Society has already had some success) would also help to encourage med students to do primary care.

    Anyway, I really enjoyed your column.

  • R Watkins

    Two separate but related problems:

    1. Large number of uninsured

    2. Chronic shortage of primary care MDs.

    Providing insurance to the uninsured in Massachusetts DID NOT create the shortage of primary care docs in the state with the greatest concentration of physicians; it was already a major problem, this just took the lid off it.

    The solution to problem #2 is not to remove people from the insurance rolls, and is not to open more med schools (the grads would all still sub-specialize), nor to use more NPs and PAs (they too are going into the more lucrative areas, as are FMGs).

    The only solution is to drastically increase payment for primary care services.

  • luke50

    ” Consequently, if health care reform does not have a clause that mandates that all health care providers must take a percentage of all insurances, then you are correct, access will be an issue.”

    And access will be more of an issue when I have to close my doors because I was forced to accept insurances that don’t pay to cover the cost of services rendered. And, sorry Diane, I’m not a “healthcare provider”, I’m a physician.

  • jhorstkamp

    Superb article, right on target. Keep it up, Kevin.Thank you for getting the word out, for primary care’s sake.

  • Alisa Bowman

    This goes to show that the entire system is broken (big surprise, I’m sure). You’re right: universal health care won’t create more docs, esp primary care docs. But it will allow upper middle class people like me (yes, I am not a member of the working poor that we keep hearing about) to actually afford to stay healthy. I am self employed, which means I have to buy my own insurance. I’m a mother. Do you know what premiums cost for a family of three? Do you wonder why your patients refuse treatment? Why they ask you NOT to test them? It’s because we can’t afford to find out what’s wrong with us. Fixing insurance and offering an affordable option addresses one part of this huge problem. Hopefully other aspects of it will get addressed too, before the entire system fails.

  • andrew cook

    I have spent the past 5 years living in Costa Rica, where there is a mix of private and public healthcare. Most Costa Ricans use their neighborhood pharmacist as a primary care physician. The pharmacist can diagnose most ailments and even write a prescription for the patient. One of the most surprising things is that if you have a nasty cold, the pharmacist can give you an injection that will allow the patient to be functional for a 2-3 days. Should the symptoms persist he will recommend that the patient go to the hospital. Compare this to the US where a pharmacist is nothing more than an overpaid pill counter. I think that US congressmen and senators should acutally spend some time looking at the universal healthcare system in other countries rather than spitting out kneejerk criticism.

  • Marjorie Lynch, FNP

    Luke, you are indeed a “healthcare provider.” You are also an MD. I, on the other hand, am an experienced Family Practice NP and like you, see complicated patients with multiple medical problems every day. Teamwork is essential, not optional, to carry our work forward. Comments like yours, which underscore an unnecessary arrogance, only seek to divide us and sully the wonderful working relationships all providers should strive for with each other. Take off your crown and get to work!

  • jhorstkamp

    Thank you DMS student. Others give us theory, but medical students give us fact. Why are you all avoiding primary care? Please ask your classmates to chime in–at this website. You are the most important people in the primary care shortage debate, and we need to hear your voices.

  • Linda

    Thank you for opening this discussion. Hopefully CNN will understand the importance of your article. We have all seen the commentators, legislators and ads by lobbyist that all have insurance and don’t have a clue of the questions to ask much less open discussions of resolutions.

    Obama could combine a couple of his campaign promises. Healthcare reform and community service. Starting with this year’s graduating class of any and all med students offer them full payment of their student loan cost in return for paid employment as a PCP for a determined number of years. Or is this too simplistic? Would this not serve multiple purposes? Bridge the current gap of PCP’s, entice more med students while still exposing the grad to building a patient base for their upcoming private practice?

    The importance of your article can’t be emphasized enough.

    Those with insurnace feel such a false sense of security.

    Those with cash but no insurance just don’t understand there is NO amount of cash to get you help for a life threatening illness. Yes you can go to the Doc in the Box but if it is beyond their capacity they must refer you to a specialist and/or labs whose first question is what kind of insurance do you have.

    Some how the uninsureds faces have been lost. They are not the people qualified for Medicaid or old enough for Medicare. They are the working poor. Those that make too much to qualify for any assistance or have multiple working family members for the ‘combined household’ income to exceed any assistance level. Or the Temporary Permanent worker. Those that go to work everyday for years but are not insured since their employer can classify them as Temp worker by allowing them only 36 hours a week.

    Again your article is timely and your efforts to open discussion are admirable…..but will it go anywhere? Will CNN and Wolf, Campbell or Anderson understand they just don’t know the questions to ask and ARE the problem in perpetuating the stagnation of any reform?

  • CC

    I’m a medical student too, and I crossed primary care off of my list already. And loan forgiveness will not sway me. Even though med school will cost me ~$500k after all the interest on loans, over a 30 yr career earning >$100k less annually makes loan forgiveness chump change. Besides, I could have joined the military or other govt programs already and gone to school for free.

    While I understand why we need more primary care docs, the lifestyle, paperwork and huge patient panels are not attractive. The culture of medicine, which at times looks down on primary care, puts up another barrier for students. It would take a substantial increase in pay for me to consider primary care. Before you think I’m just another greedy soon-to-be doctor, put yourself in my place. We’re all rational actors, why should I choose a career for a fraction of the money than other doctors?

    Instead, I am leaning towards EM. Still get to see a huge variety of pts and disease, no call, better pay than primary care, and it’s parts of medicine I am interested in. Plus, I still get to feel good for helping the less fortunate and being in the trenches of the US health care system, and have the possibility of getting a schedule with built-in time off to use my skills in a charity/relief manner (yay shift work!)

  • jhorstkamp

    CC, Thanks for your input. ER is a noble profession. What kind of a pay increase might make you reconsider primary care? And please encourage your classmates to add their opinions.

  • Conan

    I had been interested in doing an early post college career change to become a doctor. I was told by medical schools that (and it is the case now in PA and NP schools) that if I didn’t take my premedical courses within the last 4 years I’d have to take them all over again. That’s pretty wasteful and expensive, I can see perhaps doing a few but as you know, Newton’s law of F=MA hasn’t changed in 300+ years. The current system discourages many good people from becoming doctors – no doubt because in the past there was a forecast for a surplus of healthcare providers.

    There is alot of unnecessary expense in creating doctors in my opinion. All those expenditures have to be paid for somehow. For example, if you can do a 6 or 7 year dual Bachelor +MD program instead of the standard 4 and 4 you can save 35-40000 dollars per year. If there is less cost in the education then the new doctors do not have to require as high incomes to recoup their investment.

  • luke50


    I object to everyone -MDs, PAs and NPs – being lumped together by the insurance companies and by our benevolent government as “healthcare providers”. Sorry, but I did alot of training and sacrificed alot of my life to get where I am, and I bristle when I hear a phrase that demeans myself and my profession. I’m tired of being devalued by a Federal Government and insurance companies that want nothing more than to pay me as little as possible for the work I do, and drown me in a bureaucracy that doesn’t work. To be called a “healthcare provider” by Uncle Sam lumps us together as equals in training and experience. You have a valuable role, I’m sure, and I have mine. But, sorry, we’re not equal. We’re team players, and need each other, but we’re not equal in training. This is why that damnable nametag just pisses me off. Outside forces have destroyed the reputation of physicians, and this idea of “equality” is part of the problem.

    BTW, though you’re not in a position to know this, I have successfully fought for the ability of APNs to practice in my hospital, despite the rebukes of fellow physicians, because they helped the Medical Staff keep the various subspecialists who hired them to keep coming to the hospital to see patients. So calling me arrogant and telling me to take off my “crown” doesn’t help your argument. I’m just trying to help salvage something of my profession before it goes into the toilet.

  • Paul Bowling

    I like your idea of repayment of loans by working as a PCP. In addition I think if the states that license ALL health care providers (Respiratory, Nurses, NP, PA, X-ray, EMTs, etc) would require that every licensed individual to “donate” 40 hours per year to a local “free” or “sliding scale payment” Primary Care Clinic that too would help. The government would have to cover malpractice but, hey free labor.
    Every MD, PA, NP and other licensed HCP (Health Care Providers) have to have continuing education for a license cycle, why not just add proof of volunteer in a clinic.
    It would also get some of the specialist in the clinics that otherwise would not accept some patients.
    Perhaps if a particular HCP refused or didn’t complete their required annual hours they could be fined an amount of their salary made in their most two productive weeks during the previous year. Gives some incentive as well as perhaps income for supplies and other necessities.
    My suggestion may not be popular with HCP but why not volunteer some time. I’m a PA (30 yrs) and would be glad to donate 40 hours per year if my expenses were covered.

  • DMS Student

    Thanks jhorstkamp. I’ll forward this on to some other students.

    I would like to add one additional concern that I and other medical students have which is (perhaps) not politically savvy to voice. I respect PAs and NPs and think they have a vital role to play in the health care system. I also, however, do not think their training prepares them for independent practice. PAs understand this, but I am worried by the recent moves by some at one nursing school (*cough* Columbia *cough) and national nursing organizations to push for independent practice for NPs and for the creation of DNPs (doctors of nursing practice).

    Some proponents of the DNP programs already claim that DNP training makes DNPs equivalent to physicians as primary care providers. DNPs, however, have much less training than primary care MDs. I think many of people entering med school worry about the effect of a flood of NPs and DNPs (many of whom claim equivalency with physicians) will have on reimbursements for physicians and the job market for primary care physicians. If DNPs are cheaper than primary care physicians and claim the same scope of practice with much less training, why will insurance companies reimburse MDs for seeing primary care patients instead of sending them to DNPs?

    This total usurpation of primary care by NPs has not occurred and likely never will. As Dr. Pho stated in the article, there aren’t nearly enough providers in primary care medicine. Many NPs and PAs, just like physicians, want to work in areas of medicine other than primary care because that’s where the money is. Still, many med students don’t know how the scope of practice wars will go in the future and they don’t feel comfortable with dedicating eleven years of post-secondary education on fields of medicine which may not be as welcoming to physicians in the future (like primary care). It’s unlikely that NPs or PAs will start stenting patients with CAD, reading MRIs or removing glioblastomas. It is possible, however, that they will take over primary care and either leave no room for physicians or further drive down reimbursements. I don’t think NPs or PAs are qualified to become unsupervised primary care practitioners, but nursing boards (and some medical boards) seem to be bowing to this pressure.

    I understand that the scenario I have described is a worst-case, but it is in the back many med students’ minds. I also want to emphasize that I agree that NPs and PAs are professionals who are vital to the delivery of medical care, within a well-defined scope of practice. Their scope of practice, however, seems to be dynamic instead of static, and this worries many med students.

  • gio ferraro

    You have to help Primary care providers.Everyone in the field is all stressed out. The physicians,FNP,PA,MA,medical receptionist etc. The field gets reimbursed the least and performs the most duties for a patient. If the field was reimbursed fairly all the providers and ancillary teams would be able to go into the field and supply the needed care . If the job is the lowest paying in the field why would any of these employees go into it. They cant survive on the salaries that are out there. We have to stress the importance of primary care and reimburse the field that is the gatekeeper for all other medical care. Who makes up these rates? How does it get changed?

  • SonofMD

    As the son of a Doctor who has been practicing medicine for close to 30 years, I have had a unique vantage point from which to view the change of the practice of medicine during that time. Although I think you covered some very salient point, I think you missed one major one. The simple cost of doing business, including but not limited to malpractice insurance. In some cases the cost of mal ins requires practioners to close their practice in areas where such insurance is the highest like New York and New Jersey. How about Tort reform (this coming from an attorney).

    How can PCP be expected to practice when their income to expense ration is already close to 1:1, with prospect of fees be lowered. In all of this, I find it unconscionable that no one has said to the insurance companies to get their act together. You can tell me…how much time and effort does it take for you to get paid by an insurance company? How often are you stalled by an insurance company to get paid? I have witnessed first hand, that insurance companies will send a $2.00 check that should have been $2,000, only later to be told – oh sorry, accounting error,,,send us that back and we will send you the right check (um..err…six months later if ever.) It is no wonder doctors have to charge more because they only get paid for 60% of the work they perform. So at 40% less income, with 40% more productivity (and the associated costs of a busier practice) can anyone blame physicians for having to charge more?

    I do not envy your position. I had always – and still do to an extent – wanted to practice medicine. I was nevertheless persuaded out of it by a man who once loved but now loathes such a nobel profession. That says a lot.

  • jhorstkamp

    DMS student, Thank you very much for your thoughtful and articulate comments. Scope of practice wars were not on my radar screen. This is why we need med students’ input.

  • Conan

    The other interesting thing to note is if PA wants to become an MD, doesn’t the PA have to start medical school from scratch?

    As for tort reform, it is probably needed but also there probably needs to be better oversight of doctors too. In legal firms you often have lawyers working side by side checking on eachother’s work and how they go about it, but in all my visits to doctors not once have I been in a situation where one doctor was evaluating how a colleague was treating me (I’m not advocating this to happen all the time but every now and then a doctor checking on another doctor would be great).

  • Gordon

    I am heartened to learn from “DMS Student” that the AMA has played no role in restricting the supply of physicians. Perhaps the AMA has become so “progressive” that it has adopted a policy position in favor of more medical schools? A link to their most recent piece on the subject would be appreciated. In any event, my point was that the author’s piece was long on diagnosis and short on remedy.

  • R Watkins

    Primary care exists in some sort of bizarro world, where, even though they are the most in demand and most highly recruited physicians, their pay continues to shrink in regard to other docs. A major, if not the major, force behind this is the specialist-dominated “relative values” committee of the AMA, which grossly undervalues the work done by primary care physicians.

  • DMS Student

    Here you go. The number of medical schools is not the only problem. Physicians may only practice if they have completed a residency. Thus, the AMA has pushed for more residency spots. It has also encouraged the AAMC to ask schools to expand med school class sizes (which many, including mine, has done). In addition, there are several new allopathic medical schools which are slated to open in the next few years, thanks to the AAMC.

    As was mentioned by another commenter, though, it doesn’t matter how many more medical students you train if none want to do primary care medicine. There is debate as to whether we need a greater number of physicians in the US (the Dartmouth Atlas Project research has suggested that we have more than enough, there is just a misallocation). While it is unclear whether we need more physicians, it is obvious that we need a greater proportion of the physician workforce to practice primary care medicine. You can open all the new med schools you’d like, but you can’t force medical students to pursue careers in primary care unless you address the disincentives of primary care medical careers.

  • Nuclear Fire

    @R Watkins: The major force behind it is that medicine isn’t a straight forward capitalist system. Supply and demand went out the window long ago. I pay my plumber, electrician, dentist, vet and mechanic more per hour than I get paid or than I pay for my own health care because they don’t have some third party dictating arbitrary pricers and concominant regulations for billing, BUT if I don’t have money because I decided to buy a flat screen TV that month and then my car breaks down, I’m taking the bus to the hospital for work.

  • primaryMD

    Everyone else out there who thinks primary care physicians need to be paid more (you too, KevinMD):

    If you support the increasing influence of “midlevel delivered primary care” how can you argue that doctors should be paid more than they already are for primary care services? If most of the work can be delivered by midlevels (which seems to the the growing argument, right or wrong), then it should be reimbursed at a discounted rate, not at a full MD rate.

    This is an obvious point, clearly absorbed by med students, who are wisely not entering a field where the growing wisdom is that providers with substantially less training should be doing most of the day to day work.

    Med students will go where their their hard earned training will be uniquely valued and rewarded appropriately.

  • John

    I guess I was just naive. Before Obama’s visit to the Cleveland Clinic, I figured all doctors were paid a salary. Before I paid attention to my new physician’s new exam room, I never dreamed there would be polished granite countertops and polished granite floor tiles. Or Bose speakers in the emergency room ceiling. And until I looked up the detail billing on my insurance company, I never dreamed that CT scanners would ever be a part of every medical office building and cost $3000-plus per scan. Or that my insurance company would have to be asked to provide me with wellness information, but ready willing and able to order demonstrably useless tests as a prerequisite to following my (top-rated) doctor’s recommendations for tests that would yield information. But here I am.

  • Sam

    Dr. Kevin:
    You said: “…it is a moral imperative for every American to have access to health insurance…”
    I wonder why only Americans? Why isn’t our responsibility as humans to provide health insurance for all other humans. Are Americans superior in some way? Why doesn’t the moral imperative obligate Americans to provide American wealth to all other nations so that they can all have the same health insurance that some Americans now enjoy? Isn’t restricting socialism to benefit just Americans non-socialistic and even selfish? We are all human beings, equally entitled to life, liberty, happiness, which must certainly include the same health care for all people everywhere, regardless of our geographic location. While some may argue that Americans shouldn’t be taxed to pay for the health insurance of non-Americans (either because there is a scarcity of resources or because there is no real moral imperative), wouldn’t that same argument suggest that Americans should not be taxed for other Americans’ health insurance? Shouldn’t right thinking Americans reject this because, as Americans, we already tax Americans to pay for a lot of other Americans’ health insurance (for example, Medicare,) Woiuldn’t you argree that expanding the reach of adequate health care just to uninsured Americans is not enough, and that if we have a moral imperative, it is to all mankind, and that whatever we must sacrifice, we will just need to do it… because our moral obligation should not have geographic boundaries?

  • R Watkins


    Agree, amost no physicians are working within a free-market system, but the AMA, in my opinion, is a major factor in primary care docs earning 30-40% as much as the average radiologist or anesthesiologist.

  • jsmith

    Discounted rates are great for insurance companies in the short term, “Wow, we just saved some money!” but maybe not so great for American society in the longer term, “Oops, we just wrecked our health care system!” But you’re right that med students need to consider their future. I don’t blame them. If I were in med school now I would never go into primary care.

  • Nuclear Fire

    Why is it a moral imperative? Why does anyone have a right to healthcare?

  • dianeviens

    Paul: point well taken. 40 hours a year of volunteerism from all health care providers would go a long way to help care for those who have no health care in this country.

  • Gordon

    I thank “DMS Student” for the link, but pointing out that residencies are a supply choke point in *addition* to medical school seats hardly serves to negate the larger point about supply problems. Also, Student’s concern about NPs and DNPs is part and parcel of the problem. “Nuclear Fire” is not quite correct that “supply and demand went out the window” (although his point about third-party payers is well taken). Specialization in any profession almost always commands a higher salary – that is an instance of supply and demand. If most persons admitted to medical school are going to specialize, then a different generalist category of health care provider is needed, e.g., the DNP. Yet, Student apparently wants to block that option even though he does not appear to be interested in practicing in that aspect of health care.

  • dianeviens

    to those of you out there that are worried about “scope of practice wars” between NPs and physicians, please I would urge you to learn more about nurse practitioners before you decide that this is what is going on. NPs ALWAYS collaborate when it is needed and necessary for the good of the patient regardless of what the law of the state mandates. I have practiced in a setting by myself many times. Did I consider myself independent? No. If I had to call to get advice because my patient needed it, you bet I found someone who knew more than I did and got them on the phone!!!

  • primaryMD


    “If I had to call to get advice because my patient needed it, you bet I found someone who knew more than I did and got them on the phone!!!”

    Thats what generalists physicians do too. The question is what training is required to independently evaluate patients and decide on course of treatment or appropriate consultation.

    That training has traditionally been MD level. We are challenging that tradition.

    Good luck getting med students to choose primary care if we decide that tradition is outdated.

  • DMS Student

    I don’t want to block NPs from doing primary care, just independent primary care. As part of my med school training I spent an afternoon every second week seeing patients with a family medicine physician in a fairly large outpatient practice. In that practice there were also a couple of NPs. The NPs were great: they knew how to manage most (especially common, chronic) diseases and they were definitely part of the health care team with the MDs. They typically had their own patients who they largely managed without any assistance from the MDs. These NPs also (like dianeviens) knew when they needed to consult with one of the MDs in the practice and did so. This is the ideal situation. NPs are well trained and have much to offer. I just think that NPs should always be required to practice in collaboration with/under the supervision of physicians because NPs do not have training equivalent to that of physicians and their training is not sufficient to warrant independent practice. There is a reason NPs and PAs are sometimes referred to as “physician-extenders.” Most NPs are perfectly happy with this arrangement and they serve a vital role in the health care system.

    As I stated before, my significant other hopes to go into general pediatrics, so I’m obviously not opposed to primary care medicine. I’m just trying to highlight the worries of medical students. You can dismiss these worries if you wish, but if you would like to increase the number of primary care physicians these concerns must be addressed.

  • Paul Bowling

    MLP services are supposed to be billed at lower rates and any physician who employs MLPs and are billing at higher rates under the Physician’s number is committing fraud. MLPs are issued their own Medicare / Medicaid numbers and services should be billed under those numbers. Medicare pays MDs 80% of the allowable fee and pays MLPs 80% of that 80% or essentially 64% of the allowable fee. This is NOT paid directly to the MLP (at least not to PAs) it goes to the MD’s practice where the PA is employed.
    PA have always worked with Physician supervision and that won’t (and shouldn’t) change. Many of us do work in speciality areas (I work Emergency Medicine / Critical Care Medicine) but not all. I work EM / CCM because I like the pace and challenge. There isn’t the pay differential (Primary care vs. specialty) with MLPs that there is for Physicians, or at least I haven’t seen it in the Washington, DC area.
    Another issue that the general public is probably not aware of is that Physicians and MLPs can not bill for Non-clinical time spent on behalf of the patient. Time spent the patient’s family or answering email, for instance, isn’t billable. In CCM a large amount of the MDs time is spent talking to families and updating them on the care of the patient – it is necessary but non-productive time. Time taken to review charts in the office and call in prescription refills isn’t billable. In every other profession – professional time IS billable. Hire and attorney – even the time spent researching legal opinions and law books are billable!!

  • FLRx

    As a pharmacist I feel like everyone “thinks” they know what a pharmacist is trained to do, but actually have no clue. Utilizing pharmacists to their full knowledge and abilities would absorb a lot of strain on primary care. The problem is that we aren’t currently reimbursed properly for cognitive services, despite being what I feel is the glue that holds the healthcare system together. We correct so many prescribing errors that the whole system would roll into a ball of flames without us (and get no reimbursement for it). Pharmacists are begging to be utilized. We need limited prescriptive authority. We have the education to do so, and successfully prescribe all over the world and in many institutions in the US.

  • jsmith

    PrimaryMD/DMS make a huge point. If insurance cos/society decide to let the midlevels be independent docs, med students will avoid primary care like the plague, locking in the primary care death spiral .Maybe that’s already happened. Maybe we just don’t realize it. I think a med student would have to be a damn fool go into family medicine these days. At least internists and peds can subspecialize if they have to.

  • Paul Bowling

    Hey FLRx – I work with several GREAT clinical Pharmacist in our CCM service. They make rounds with us as part of our treatment team and contribute greatly every day.

    jsmith – MLP, as I mentioned in a previous post, do not bill the insurance companies directly. It is done through the PHYSICIAN employer and the payment goes to the PHYSICIAN, not the MLP. I’ve been a PA for 30 years and do my best to make sure my employer (Physician Medical Group) is getting the best billing possible. My continued employment is dependent upon them being able to pay my salary. I do not think that MLPs should be independent practitioners nor bill directly for our services. We work for and with Physicians, they are our employers.

  • The Mommy Doc

    I like the idea of NPs and PAs working with primary care physicians. I remember reading a study 1 or 2 years ago which showed that NPs and PAs working independently (i.e. no PCP to collaborate with) tended to refer to specialists more often than MDs did. So although the physician extenders were paid less than MDs, the overall cost per patient was higher b/c of the increased specialist visits.

    And as a PCP myself in both peds and IM, very few private practices could remain solvent if they accepted an unlimited number of Medicaid/ Medicare/ and Tricare patients. In Peds, when you factor in the immunizations, we are often losing money on those patients. If you are in private practice, you HAVE to consider the financial aspect of practicing medicine. Not only are you trying to pay your own meal ticket, but also all of your employees.

  • Rezmed09

    “the lifestyle, paperwork and huge patient panels are not attractive. The culture of medicine, which at times looks down on primary care, puts up another barrier for students. It would take a substantial increase in pay for me to consider primary care” – Perfectly stated.

    But the solution is not more docs – we each will spend more money. The solution is not more reimbursement – the govt will spend more money. In addition to more midlevel providers, I think the solutions are: tort reform, to streamline payment and paperwork, require all forms of insurance to use the exact same form for reimbursement for primary care. We need laws to force insurers and the government to reduce the cost of office overhead by 50% – so you don’t need an army of billers and coders, and attorneys, and phone people to track down denied claims and collection agencies.


    Thank you Luke50 on your comment of being a “physician”. I am a surgical subspecialist in New Hampshire and have seen the deprofessionalization of our job title and position in what used to be the “Doctor / Patient” driven model of healthcare. In New Hampshire, only individual that have earned and MD or DO can be termed “Physician”. It is state law to attempt to clear the ambiguities of the term “Doctor”.

    Our local hospital administration refers to us as “LIPs” standing for “Licensed Independent Practitioners”. I was late for an executive meeting because the “Physician Only Parking” lot was full and I had to find more distant parking…so that I could volunteer my input as Chairman of our department. I asked the medical staff services director at the meeting if there could please be some enforcement of the parking spaces reserved for “physicians” as they are taken up early in the am by ARNPs, PAs, and Nurse Anesthetists. He looked at me, chuckled and said that we’ve always just let them park there, there’s really nothing I can do but I will pass your comments along.

    I bear no ill will towards these other folks. Silly parking issue was more symbolic to me than is the proximity to the building. It had been the ONLY perk we as physicians had and it was laughed away.

    I mentally “checked out” of my collegiality that day with the hospital. I spoke with a friend many years my senior about it and asked him when he “checked out”. He reflected for a moment and then said “about 25 years ago when I received a letter from BC/BS of Rhode Island who after 20 years of addressing letters to me as Dear Dr…….. sent me my first letter addressed as …Dear Health Care Provider….”

    Whether dealing with patients, hospitals, insurance companies or government agencies, again, we have nothing to apologize for.

  • Michael Campea

    It should be noted that the American Osteopathic Association’s Commission on Osteopathic College Accreditation is the accrediting agency for colleges of osteopathic medicine in the U.S. While it was most likely an honest mistake, DMS Student’s first post incorrectly identifies the accrediting body for these schools. Today, there are 25 colleges of osteopathic medicine at 31 locations across the country, which help to remedy the projected physician shortage by bringing health care services to some of the nation’s most underserved regions, including Appalachia, the Pacific Northwest and the Southwest. Approximately 60 percent of osteopathic physicians (D.O.s) currently work in the primary care fields of medicine, though they may choose to practice in any of the medical specialties. With the establishment of new D.O. schools—including five in just the past two years—and increases in osteopathic medical school enrollment, it is projected that at least 100,000 D.O.s will be practicing by 2020.

  • Shan

    Paul, I think you might be missing the point here. Some states grant NPs and PAs the license to practice independently of physicians. This is being seen as a serious encroach upon physician territory. PAs and NPs are an allied health field, but your health care provider is and has traditionally been known as your physician. Granting more autonomy to PAs and NPs begins encroaching upon territory that has traditionally been a physicians territory which is whats bringing fear to many PCPs and medical students.

    Question: Why don’t any med students/AMA/AMSA do anything to prevent the increase in such autonomy?

  • Shan

    And Paul, it seems like you have some bureaucracies to deal with wherever you may be. It’s an honest shame. I’m not a medical practitioner but I am working extremely hard (much harder than say a nursing student or some of my friends who are striving for PA school) to make my dream a reality.

    The only thing, the things that Luke mentioned and you (Paul) bring up are steering potential physicians (and even potential to-be PCPs (such as myself)) away from the field.

    On a side note: Every physician I have spoken to has told me to not enter the field.

  • Shan

    Wow okay sorry for confusion and triple post: 1st Paul is the PA, 2nd Paul is MD

  • Rich

    Like everything it seems, healthcare reform and solving the patient access problem comes down to money. Who gets paid for what service, at what reimbursement rate, and by whom affects medical students’ specialty choice and whether or not a patient can find a primary care doctor (or specialist for that matter!). When I went to college then medical school I avoided business classes because I didn’t want my idealism about becoming a doctor to take care of patients rather than make a lot of money corrupted by lessons in being profitable. How naive was I? So just like people in general have to learn more about how to manage their own health issues, physicians (and all “health care providers”) need to learn how to manage the money: costs of tests they order, drugs they prescribe, equipment they purchase, staff they hire, insurance they purchase, etc. etc. I think medical school (or premed) should include one year of business education. Not worrying about paying the bills helps keep you focused on the more noble work you do.

  • Susan H

    The patient and the doctor/nurse are the only first-order parties to the economic transaction of healthcare.

    However,both parties to that transaction have seen third parties step into the middle of the transaction and claim the lion’s share of the transactional expense.

    Monetize my consumer/provider power once, shame on you.
    Monetize me twice–shame on me.

  • jsmith

    Paul Bowling, I know that. I was talking about independent NPs (in a number of states) and possible changes in the future. If primary care continues its death spiral, both NPs and PAs might be able to practice independently. Who knows? Refer back to a previous post by DMS; this is on the minds of at least some med students. BTW, thank you for your long service to your patients.

  • Paul Bowling

    Shan – I’m involved in teaching PAs and I’m very knowledgeable of my profession. I do not know of ANY state that allows PAs to practice independent of a Physician (MD / DO) nor of any that is considering to do so. I’m in Maryland and NPs in this state may a Nursing Practice that is independent. I don’t know what that means or what NPs are permitted to do. I do know that CVS Pharmacies in this area have “Minute Clinics” staffed by NPs but have on idea what their oversight is. I must say I don’t know about the nursing laws and regulations for them.
    PAs are licensed and regulated by the Board of Physicians according to laws passed by Maryland’s lawmakers.

  • gromit


    I attempted to leave a comment with the piece, but they’ve apparently stopped moderating comments for that article.

    While I don’t question the difficult work environment you’ve described, you’ve not done a very good job supporting your assertion that universal health coverage in MA has been a major contributing factor in that environment. Consider:

    1. You provide data from MMS describing the wait times for new patients seeking care at a primary care practice, but do not indicate whether there has been an increase since the enactment of universal health coverage. How could you reach such a conclusion with just one data point? Looking at previous years, it appears that wait times for new patients have been a long-standing problem that has not changed substantially with universal coverage.

    2. You link increased waiting times for new patients at primary care practices with an increase in ED visits. A patient looking to schedule a new patient physical with at a new primary care practice would not present to the ED if there were a month wait. More logical would be to look for an increase in *existing* patient wait times, and fortunately MMS keeps that data as well. There doesn’t appear to be a trend since the enactment of universal health coverage – wait times have remained about the same.

    3. You point out an increase in ED visits in MA and suggest a link to universal health coverage without any comparison to ED visits in other states. ED visits seem to be up across the country, not just in the one state to enact universal health coverage. Just as in MA, patients heading to the ED in other states are insured patients, so perhaps there are other reasons you should be considering. Analysts in PA have suggested that a high percentage their increased ED visits are the result of employed and insured patients who do not want to take any time off for illness or its treatment for fear of losing their jobs (and health coverage).

    4. You mention the MA legislature’s financial difficulties without providing proper context: nearly every state has significant budget issues this year, and state-funded health care programs across the country have been affected. MA isn’t unique in this problem. A federal program would have significant advantages over state programs in this respect due to the economic flexibility of the federal government.

    There are a great many issues adversely affecting our health care sector. Providing universal coverage will not fix many of them, but this does not preclude the pursuit of this goal. More importantly, the experience in MA does NOT appear to support the argument that universal coverage will substantially hamper access to health care.

    Finally, I must confess to being more than a little dismayed that of all the commenters on this article – including many claiming to be health care professionals or students – none have questioned the poor support for your conclusions. Unfortunately, I suspect they’re just all too familiar with the poor working conditions described in the rest of your commentary and have seized primarily upon the accuracy that aspect of the article. Still, I can’t help but think that these MDs, DOs, NPs, PAs, etc. would benefit from some government-funded comparative analysis.


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