Primary care physicians are rebelling against the system

I believe primary care docs are rebelling against the system.  The system has made primary care physicians suffer emotionally and financially.  The system has taken the greatest form of medical care – that consisting of continuity, comprehensiveness, complexity and completeness – and denigrated it.

Now I talk about “the system” in an anthropomorphic sense, but “the system” is virtual.  “The system” has no conscious, it is not deliberate, rather it represents the constellation of ignorance that the insurance companies, CMS and policy works have wrought.

The system has constrained primary care fees while systematically increasing overhead.  The system has listened to well meaning researchers and -ologists to declare primary care physicians in need for quality improvement.  The system has undervalued the value of a good primary care physician.  The system has, without consciously meaning to, held primary care in contempt.

So what do primary care physicians do?  They do what any sensible economic citizen would do, they alter the rules to their benefit.

So decreasing numbers of primary care physicians are taking Medicare or Medicaid.  So primary care physicians are leaving their jobs to do hospital medicine.  So many primary care physicians are leaving the CMS/insurance company grid and retreating to retainer practices or cash only practices.

The rebellion is a quiet one.  No one has declared this rebellion.  This rebellion has no Glenn Beck or Sarah Palin; no Abbie Hoffman or Che Guevera.  This rebellion occurs one physician at a time, as that physician finds continuing their practice undesirable.

Some believe that NPs and PAs can fill the void, but those who believe it do not understand the complexity of primary care.  Retreating from physician led primary care will increase costs by increasing subspecialty referrals.  The problem is that too many see primary care as simple, when in fact it is complex.

So I believe the rebellion will continue.  Every anecdotal sign that I see tells me that the rebellion is gaining speed and power.  Now if Congress is dumb enough to once again fail to fix the SGR, they will encourage more rebellion.

One day the wonks on Capitol Hill will realize the problem.  AAFP and ACP (amongst others) have tried explaining the problem to the politicians.  Until they understand that their constituents are angry because they cannot find a physician, they will not focus on the problem.  The quiet rebellion will eventually stimulate a response.  Unfortunately, the fix will cost so much more then than it would have 5 or 10 years ago.  Our health care system will be changed, and likely in a very negative way.

And the quiet rebels will not be the ones suffering.

Robert Centor is an internal medicine physician who blogs at DB’s Medical Rants.

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  • Jackie

    Perhaps all specialists should pay the primary physician a small amount of ‘referral’ fee. I remember my neurologist’s note to my primary physician about the finding of my life-long brain tumor. At the end of the letter, he stated “I appreciate your referral.”

    This way, instead the fear of losing their end-of-the-year bonus for referring too many patients, the primary doctors can feel comfortable sending their patients to other specialists for furter investigation of a illness/complaint.

    • Doc99

      Uh, Jackie, the name for this is Kickback.

    • jsmith

      Kickbacks is what that’s called. You’d be lucky to get away with a reprimand. Loss of license and jail time would beckon.

    • Jack

      In Texas it happens all the time. In fact PCP will come out and ASK outright. If you don’t promise a kickback, they will not send you a single patient. It’s sad. These PCP should all be reported.

      • Amy Townsend

        Jack, I am a physician in Texas and have never heard of PCPs getting kickbacks from specialists. Texas is a big place. Don’t over generalize.

        • Jack


          I don’t like badmouthing other physicians. My friend is an IR doctor down in one of the biggest hospital in Houston. Their practice expanded into the Woodlands area and some of the PCPs down there came right out and asked for kickbacks. When their requests were denied, they stopped sending their patients for imaging services. According to him this occurs in this region more than they care to admit.

          btw I am a physician as well and I am outraged.

          • ninguem

            These “kickbacks” described are forms of “fee splitting”, and have been specifically prohibited by the AMA and state associations, for half a century. Maybe longer.

            Now hey, murder has been illegal since the Ten Commandments, yet it’s still done. I would not be surprised to hear that someone may still do it. I’ve never seen it in decades of practice.

  • Vox Rusticus

    That is called a “kickback”, Jackie. Unless a specialist wants to be pruning hedges at FPC Vandenberg and waiting for his prison mail as a retirement, no doctor with an instinct for self-preservation would do that. It is illegal under federal law–a felony– and it is also unethical, just as it is illegal to refer patients to one’s own testing facilities.

    • Jackie

      That’s why there should be a ‘legal’ way for the Primary doctor to get paid for their ‘professional opinion’. How do those smart lawyers figure out ways to refer their clients? I went to a ‘well-advertised’ attorney in town for a personal matter, and he referred me to an attorney in another town (where I last worked) who took care of the issue for me. I think he owns the law firm there as well.

      If we can make the health care system affordable and accessible, then there won’t be those horrifying illegal abortion clinics sprouting in the dark corner. Anybody from Massachusett can comment ?

      • elmo

        ” How do those smart lawyers figure out ways to refer their clients”

        Just because the legal profession has fanagled an unethical (and illegal in medicine) behavior to be legal and widely used system of referral kickbacks in their field doesn’t mean it is right in to extrapolate to medicine. Lawyers also charge you for increments of 10 minutes on the phone with them. When is the last time you had a doctor do that? Using sleazy legal professional activities which are legal as a reason why it should be legal in medicine is not a justification.

      • Jackie

        By the way, I think my Neurologist was just being courteous because doctors worked for the same hospital/clinic.

        • Jackie

          ‘Both’ doctors were working for the same hospital/clinic. He’s the only neurologist of the clinic, so I don’t think there’s any ethical problem involved.

          The neurologist was actually a very ‘ethical’ doctor as he had recommended the ‘right’ neurosurgeon for my craniotomy which turned out to be a 23-hour marathon operation. We had to get a special contract for that operation because the surgeon’s hospital was not covered by the HMO I was using at the time even though it’s only 10 minutes away from our house.

          I love all my doctors. I think 99.9% of the doctors are smart, hard-working people who are trying their best to help their patients.

          • Jackie

            My family doctor at the time, by the way, was trying to persuade me to use the ‘In-network’ neurosurgeons. I opened the AMA Directory (21 years ago – before the Internet) and looked up their credentials. None of them could be compared to the recommended neurosurgeon who’d had trainings from the best medical school in the country and is board certified for neurosurgery, pediatric neurosurgery, and neurology.

            I happened to have met him at a physician friend’s house a couple of years back, so I called his office. He answered my call while in the OR and saw me as soon as he’d finished the operation. My family doctors never would even take my calls! 15 days later, after my boss had helped us get a ‘special contract’ done, I was wheeled into the OR…

            I think the best insurance model is the one affiliated with the hospital itself. After we had switched to the health insurance plan managed by Dr. R, one of the past AMA Presidents, we are finally free from all the insurance nightmares.

      • Alice

        Jackie……sometimes the end doesn’t justify the means. I am old enough to remember referral fees, and as a patient it was bothersome. You felt like a pawn in a sales transaction. It did not make care of the patient better. Actually, doctors are usually poor at knowing who is the “best” because of their seat in the arena. Their firsthand experience will differ from our own even though the situation could be the same.

        Abortion is a moral matter that has now come under the sphere of dollars and the good of mankind type of debate with the Planned Parenthood funding.

        Doctors are facing some of the same challenges patients are……figuring out how to work within the system to get/give the best care (which seems relative some days).

  • jsmith

    I would not have chosen the word “rebellion”; perhaps “desertion” or “abandonment of one’s profession.” But Centor is right that the decisions PCPs ( and, more importantly, med students) are making bode ill for America’s future health care system.
    Predictions are often wrong, but I do worry about a collapse of primary care.
    PCPs will land on our feet. Employed practice and hospitalism are always back up plans. They’ll be a need for us. The HC system has no back up plan.

    • Alice

      Won’t demand and supply take care of this problem?

      • Dave Miller

        To invoke “supply and demand” first requires that we have a free-market medical system. Unfortunately, private insurance virtually negates any chance of that. How can free-market principles have any impact in a system where the consumer is never exposed to the real cost of the item. In an age of co-pays and negotiated reimbursement rates, free-market is a myth and supply and demand have no relevance.

        The exceptions are lasix and plastics, which are almost always elective and, as such, subject to supply and demand. However, I don’t think you’re gonna be doing much comparison shopping in the ambulance on the way for your emergency appy, especially since laws pretty much demand that you be sent to the closest receiving facility and that facility MUST evaluate you before sending you away.

        No, supply and demand have little impact on medicine in the US these days I’m afraid.

        • Alex Fair

          I beg to differ Dave. So do the 100 million Americans paying for a significant portion of their own care (uninsured, underinsured, and high deductible or HSA.)

          This is why sites like FairCareMD are garnering millions of searches for care and doctors like Pam Wible, who take great care of self pays, are thriving.

          Anyone who wants to know what something costs can come to our site or go to or various other useful destinations. A major carrier has also begun selling “smarter” health plans that enable shopping for care. For better or worse, the free market is here, both in network and out.

          True, a good 70% of Americans have not come to the market yet, but the 30% who have are finding better care at surprisingly reasonable fees. The doctors who participate with these marketplaces are doing better too – by 25% on average in our rapidly growing network.

          Your view was correct a few years ago but that is rapidly changing.

        • Alice

          Again..I completely disagree. Right now the government via the taxpayers (and bond markets that can’t sustain the growth of the government behemoths of SS, Medicaid and Medicare) is paying about half the bill. The patients get better care because we do have the free market involvement right now. It is vital…it allows innovation….because the supply and demand part of capitalism has not been squashed yet. I do not want a completely run government program. But our President recognized this when he said if you like your insurance you can keep it…….he was against mandates to at one time too….sigh…for another day.

          I disagree with you….but only time will tell…too many people want healthcare to be profitable to them….which drives capitalism…..and produces innovation. Seems to me an earlier post of yours suggested just that.

          • pj

            Hey Alice- did you mean future Dr Miller suggested that on this article’s postings? I sure don’t see where he did.

            your good buddy pj.

        • Jan Henderson

          Dave Miller – Supply and demand. Precisely. I was just writing about this ( Why medicine should not be a for-profit business like selling cornflakes:
          * There’s an asymmetry in the knowledge available to patients and doctors – a patient can’t possibly be as informed as a doctor about what’s wrong and what’s needed.
          * Patients can’t predict when they’ll need medical care and often seek care when their health is threatened and when decisions must be made quickly.
          * It’s the supplier – the doctor – who determines what the patient needs.
          * There’s an ethic that assumes doctors will not sacrifice the medical needs of a patient to make a profit.
          * There’s a very steep entry cost to becoming a doctor.
          * The health care market is basically not price competitive – a patient contemplating brain surgery is not going to be tempted by a surgeon offering a deep discount.
          * What’s at stake in health care – the consequences of making a mistake – is death and disability, not simply a case of buyer’s remorse.

  • Sharon Dietrich

    Dr. Centor has hit the nail on the head. As A Family Physician, I have watched this “quiet” rebellion, as Primary Care Physicians drop their Medicare and Medicaid patients, and as they go into hospitalist jobs. I work in a Migrant and Community Health Clinic that is currently struggling with the incredible load of these patients coming in every day from their former private Primary Care Doctor. So far we do not deny service to anyone, but for the first time in our 30 years history we are in the red and getting redder. This scenario is playing out all over the country, both in clinics like ours or in ER’s, who also are being overwhelmed. And our Administrators stay with the mantra–productivity and numbers, productivity and numbers–which means trying to properly take care of these folks(many of whom are older patients with multiple medical problems) in a 15 minute visit.
    The system has collapsed, and is collapsing, and our representatives in congress refuse to see or understand.

    • pj

      Dr Centor’s points are well taken, but he ends with,

      “And the quiet rebels will not be the ones suffering.”

      Most people rebel precisely because they are suffering. Why would we rebel otherwise? if PC is collapsing, how are we PCP’s going to be free from the fallout? Let’s not discount the hits we’ve taken for the team.

    • Alice

      This is a good article, yet to the average reader they are going to think it’s more ranting from the Chicken Little mindset.

      Part of the “system’s” stigma is specialist’s attitudes towards PCP’s. When prestige is attached to your acronyms that seems worth more than money to some.

      I do believe as demand increases it will help in the future…..shortages of one occupation can create higher pay to lure docs into those slots.

      • pj

        Well Alice, except for the fact as you wisely point out, that the gov’t interferes so much in the health care market- One of the few things uttered by Hillary Clinton I agree with is, “The health care market is broken.”

        That doesn’t bode well for the laws of supply and demand solving this problem.

  • Harry

    I couldn’t agree more with Dr. Centor. However, I think we need to be more aggressive with our efforts. Collective bargaining may be the only way to salvage any remaining hope this country has for it’s primary care docs. We’ve lost control of our own profession and find ourselves at the mercy of for-profit payers and administrators who are only concerned with the bottom line.
    I have heard mentioned that midlevel providers will fill the current void (and that which is to come) as far as primary care services go. Really? Are we to believe that these educated people have no business (or common) sense to see through the current system and the very payment debaucles that have negatively impacted so many pcp’s already? Why would they sign up to work in the same system that so many of us are struggling to survive in? If the payment system doesn’t change, I would imagine that the majority of midlevels would continue to work for specialists, where they can earn at least twice as much as what most pcp’s could afford to pay them.

    As far as Medicare/Medicaid go, I’ve seen some commercial payers in my area begin to pay at or below Medicare rates. This is a losing effort. As overhead continues to increase and as payments stagnate or even decrease, the only way we can make up the difference is by increasing patient volumes. Unlike most other industries,docs have no other way of offsetting those added costs. We are, in essence, operating our businesses on fixed incomes. And it’s the same government bodies and third party payers that continue to increase our administrative and documentation burdens, to the point where seeing higher volumes of patients increases documentation burdens, therefore increasing our already long work days and taking even more time away from our families.

    Concierge medicine is looking more and more appealing everyday!

    • Alice

      Collective bargaining may be the only way to salvage any remaining hope this country has for it’s primary care docs. [end quote]

      Not if people don’t stop shouting for the government to bail them out on every problem and regulate everything (sometimes into a type of oblivion). And the government is a huge player in this healthcare debacle.

      Doctors are at a disadvantage. You are a minority…..angry patients screaming to their representatives and hospital management about your every move.

      Some of the blame has to go on other doctors. There is prestige attached to specialties, and money is scaled to that. Sometimes your problems are in your own backyard.

  • pcp

    “AAFP and ACP (amongst others) have tried explaining the problem to the politicians”

    Disagree. The primary care societies (and ACP mainly represents proceduralists now) are more interested in ingratiating themselves with politicians than explaining the problem.

  • Jan Henderson

    There certainly seems to be more and more public voicing of this sentiment. There’s a book coming out by a PCP who quit practicing in disgust in 2007, when he was 51. It’s called “Out of Practice: Fighting for Primary Care Medicine in America.” More at

  • Jackie

    Medicare doesn’t cover any ‘major’ medical events. I have to pay several hundread dollors more each month for the Medicare Advantage plan in order to have the same level of care and continue to see the same doctors. I think it’s a system like Social Security – most people can not solely live on the Social Security check in their retirement. But it is important for everyone to pitch in so there is a safety net for everybody.

  • Brad

    I think midlevels (NPs, PAs) will be used more.

  • DIY Health

    For me its not rebellion but just a sure way to survive.

  • Pamela Wible MD

    Robert ~ Thank you! I’ve watched four female family docs in mid-career at my last employed position leave for careers in waitressing, teaching, homemaking and other “more meaningful” positions. I dreamed of returning to my waitressing job and escaping the medical mill, but then did something quite unusual. I held a town hall meeting and asked citizens to design an ideal medical clinic. We’ve been open 6 years. Finally, my job description has been written by patients, not experts, consultants, and administrators.

    video here:

    We need to take things into out own hands WITH our patients. Do not wait for politician-saviors.

    Pamela Wible MD

  • Smart Doc

    Excellent article: fairly accurate.

    I note that some practices combine annual fee (I despise the word “concierge”) with insurance coverage.

    An excellent example of a primary care practice prospering in the 2011 environment:

  • Pre-PA

    Dr. Centor,

    Thank you for the article and the insight. As a current applicant to PA school, I have often wondered and worried as to the impact this will have on the PA profession.
    Regardless of what we label the joint nature of mid level care (supervisory/collaborative/coordinated) with Physicians, I am worried PAs will find themselves without a place in Primary care fields since there is a dwindling physician interest in that sector. Everyone I know applying to med schools is gunning for surgery or other procedure laden fields. I personally look forward to a physician:mid level team approach, knowing what I don’t know. Many initially interested in PA programs are heavily considering NP programs due to the associated political clout and strength here in California.

  • jacomment

    Here’s a thought to fix the system – get Congress to lose their gold-plated retirements and full medical (after 2 years of membership in the Senate, as we in Illinois have learned), and let them get “vested” at 30 years of service, as most of their constituents have to do – and without retiree medical. Although they’re mainly multimillionaires, they’re not too eager to lose a penny of benes. If Congress had to put up with what the rest of us do, maybe things would change.

    • Alice

      If Congress had to put up with what the rest of us do, maybe things would change [end quote]

      Good idea…yet, most patients feel this way about doctors. Coddled people rarely feel the pain of others.

      Government employees do not pay Social Security either. The government has just shown that collective bargaining rights can be taken away. Elections are swayed by money….unions dues usually pay a type of referral fee to campaigns….get too loud and demanding….and the Republicans will try to control your public contributed paycheck that pays your union dues that your union will try to buy a rep with…. who will vote according to the union’s agenda (often not the members).

      Money can’t buy you love, but it can buy you votes….you need numbers….hopefully big givers…..then you have a voice to sway your republic rep. who is actually supposed to represent his constituents. It seems if you want a voice to bring about change you better have oodles of money backing that voice.

      Doing the right thing just doesn’t seem to hold the same level of value good, hard cash does….and one wonders if the PCP revolution has helped anyone except themselves. How many victorious success stories are out there? Seems to me the vast majority need to keep at least part of the system intact if they want to serve the majority of patients? The few examples I have seen will not be duplicated in big numbers.

  • Dr Chris

    I have effectively become a geriatrician. Once you throw in 4 or 5 diagnoses and all the drug interactions, and organ systems-I can’t believe PCP’s can be replaced by midlevels. For the average well care patient, absolutely. For this stuff, no.Just coordinating the specialist can take an hour after the visit. All of which is unpaid. There is a code for this, but the documentation is onerous and rarely flies…..
    For many of these guys, a 40 minute appointment is needed.
    But when I first got into primary care, I thought there would be universal coverage. Now, I am thinking dropping medicare in order to provide the care I think my patients deserve.

  • Dave Miller

    As a DO student who intends to go into primary care, I watch these developments with great interest. I find it really silly that, in order to “control costs” insurance companies and Medicare/Medicaid are pricing PCPs out of business but still paying healthy reimbursements to specialists (although that is also changing).

    Among my classmates, we’re looking at ways of running cash-based practices (or even simply having the patient to pay out of pocket and get reimbursed by their insurance on their own) or various forms of concierge medicine. In the rush to vilify “the rich” (defined as “anyone who makes more than [me]“), folks are forgetting that PCPs graduate with the same level of school debt as specialists and still need to make enough to pay off that debt and support their families.

    I contend that part of the problem is that the general public is not exposed to the actual cost of health care and, as a result, “free market medicine” is a myth at best. If folks understood the true cost of their health care, they would use it more wisely, I suspect.

  • Alex Fair

    Good article Dr. Centor.

    I am reminded of the dilemma of the producers in Atlas Shrugged when I read articles or hear from doctors who are opting out. This trend has been gaining momentum for a few years now. A Sermo survey of last year that showed 61% of all docs were opting out of more panels and plans was one of the reasons we created our efficient marketplace for care, where doctors have control. After piloting in New York, we are accepting Providers from all over the country now and the patients are following. It is a viable option for accepting new patients into your practice ready to pay fairly.

    I love what Dr. Wible was able to do and think it can be put into every practice a little bit at a time. Not every practice is ready to make such a split with convention so quickly, so we made a way that practices can go direct without giving up their existing practice. This is creating networks of doctors that accept direct pay for a reasonable fee. Once the network is strong enough, patients feel comfortable that there is a viable alternative and stay “in network”. In New York, that is already happening as we see repeat patients going to other doctors in the system for MRI, Podiatry, back pain, and GPs.

    The interesting thing is that when patients pay directly, they pay better than insurance companies do AND save money. Removing the middlemen, just as in the utopia created by Ayn Rynd’s industrialists, results in a more efficient market, thereby rewarding the best and giving the customer (or patient in this case) more value. One medical is a good example, as are Care Practice, Ideal, Exclusive, Qliance, and so many others. Specialists and diagnostics are going direct too. Joining together on our site, great doctors in fully direct and fully participating practices are making something that can address fix the Physician’s dilemma, a truly Open Network for Care where each individual sets their own rates dynamically.

    Be the change you want to make. Don’t wait for the change to make you be what it wants.

    • gzuckier

      “when patients pay directly, they pay better than insurance companies do AND save money”
      Hmm… actual figures from my recent EOBs:
      billed , insurance paid
      $120, $57
      $1452, $816
      $8217, $1849
      $2732, $1661
      $150, $90
      $180, $101
      $30, $28
      $215, $41
      $42, $42

      I only see a couple of places in there where I could pay directly and save money over the insurance company’s payment plus overhead; and one of those was a Minute Clinic and the other was an optometrist.

      • Alex Fair

        Hi gzuckier,
        You are correct, we get our doctors paid better than the least fair insurance companies pay. We also save patients money.

        How is this possible? In a word: “disintermediation”, or removal of the middleman.

        Let me explain: It is estimated that 30-40% of all premiums stay in the insurance company (aka the middleman) and go towards administration, marketing, contracting, negotiation, and profit. An efficient system that replaces the administration, negotiation, and contracting functions and obviates the need for marketing and third party profit leaves a great deal of savings and revenue improvement for the two parties left in the contract. This is the same middleman removal process that enabled the success of Dell, Apple, Priceline, eBay, and myriad other new business models.

        So to answer your question, do we get patients better prices than insurance companies could? Not generally, nor is this our goal. We get them better prices than they could have gotten if they didn’t have insurance, have a high deductible plan, or want elective or dental. This is only about 100 million Americans, so it isn’t for everyone. Besides, we want to get doctors paid fairly, not how the insurance companies often pay.

        The ultimate savings come from shopping though. We know that price is not the most important aspect of selecting where people get their care. Quality, convenience, reputation, and even photos are more important for most people. This is why our marketplace includes all the information about the doctors that they can put down or pull in. Coupled with great descriptions of the care, we bring shopping for care to a whole new level.

        The current healthcare payment system does not work for doctors or patients. It was time for a change. This seemed like the logical next evolution. Simple, efficient, cheap,… just get listed and put in what you want to be paid. I designed it after interviewing 500 doctors and am still listening so please be welcome to send me your thoughts on it.

        I hope that helps clarify matters.

        Stop by the site and sign up as a provider or patient and request or give the care you want at a fee you can afford to pay or be paid.

        • Alice

          Let me explain: It is estimated that 30-40% of all premiums stay in the insurance company (aka the middleman) and go towards administration, marketing, contracting, negotiation, and profit.[end quote]

          But that formula just changed. Regulation changed it to the minimum is now 80% the insurance company has to use towards patient care (big insurers are at the 85% mark).

          In my simple mind it seems the middle man has many faces these days.

          • Alex Fair

            The current system of insurance-based contracting, payment and network management is grossly inefficient by design. If it takes 1-2 full time staff members per physician to get paid, how many people do you think it takes for an insurance company to manage those denials and payments? Many insurance companies go bankrupt for just this reason. Inefficient systems are expensive and insurance processes are highly inefficient by nature in their current iteration. The limit on non-medical costs will be difficult to meet, but it is an excellent goal that we whole-heartedly support.

            If there is to be a middleman, let it be one that doesn’t require 15-40% margins to be profitable, let it be more like 5-6% like the real estate industry charges. This is only possible with efficient systems and markets. All of that paperwork, contracting, and management is quite expensive.

            Efficiency is what EMRs, ACOs, and Direct Contracting systems like ours are all about. All automate and provide feedback for bad behavior or results. Such potential efficiencies are the true funding of our health care reform. A clever solution, if we can make it work.

            Dr. Wible talks about needing a movement and she is right. Unlike Luther though, we don’t have 95 theses to nail to the church door, we have 70,000 patients waiting for you to join them on the first truly open marketplace for healthcare. No need to suffer selflessly for the cause, just be more efficient and reap the rewards.

      • JustADoc

        $120, $57 $80
        $1452, $816 $1000
        $8217, $1849 $4000
        $2732, $1661 $2000
        $150, $90 $120
        $180, $101 $140
        $30, $28 $29
        $215, $41 $150
        $42, $42 $42

        3rd column is theoretical charges if the doctor doesn’t have to deal with insurance at all. In addition, you aren’t payign for insurance except catastophric coverage which costs $500/year instead of the $600/month($7200/year) it is costing you and your employer for a savings of $6700/year on premiums. Add in extra $3000 in costs and you still came out $3700. And you actually had fairly high costs in this case with one $8217 charge.


    Nothing changes until you say “NO”.

    I am an -ologist but also a patient. I can’t blame the primary care providers for looking for better opportunities. I would do the same. We will all suffer for the PCS (Primary Care Sublimation) that is inevitable under the current cliimate and conditions.

  • Steven Reznick MD

    Wonderful synopsis . Replacing primary care physicians with NPs and PAs who receive about 640 clinically supervised hours before they can put out a shingle and practice is not the solution ( typical physician receives 12,000-16,000 clinically supervised hours before qualifying for licensing exams.).
    Congress and Insurance companies have effectively pitted medical and surgical specialists against PCPs when it comes to payment reform, which is unfortunate.
    Hospital and insurance systems buying up PCP practices, low choice of general medicine by medical students as a specialty and an aging physician workforce all are forcing this problem to crisis proportions.
    There are many solutions to the problem but no one in state legislatures or Washington is taking them seriously because no one in the AMA or ACP are truly advocating for PCPs

    • gzuckier

      “Specialized” PCP fields may provide different opportunities for NPs and PAs; the people who put casts on at the ski slope for a classic example. On a completely different level, the local HIV clinic has 1 MD supervising like 3 PAs, 1 NP, a nutritionist, and a nurse or two, and they do seriously competent work. You want to really practice general medicine, try working in an HIV clinic. And, as a bonus, they not only get to fight all the various bureaucracies, both corporate and governmental, but also get to deal with the enormous life problems of the underclass which in many cases actually overwhelm the fact that they have HIV. All on a PA or NP’s salary.

      • Family Doctor Against Mid-Levels

        Dear gzuckier
        You are WRONG. NP ‘s & PA’s CAN NOT provide compent care in HIV/Primary Care. I’m board certified in Family Medicine & then did a fellowship in HIV Medicine. My current practice is about. 75% non HIV primary care & 25% HIV medicine. I have worked for several years in clinics very similar to the above clinic you describe. I watched (silently) as these mid-level providers gave substandard care, refered everything out of what was seemingly easy diagnoses for me, & gave their patients the illusion that they were providing excellent care. It takes 4 years of medical school & 3 years of a residency in Family Medicine (or Internal Medicine) to become a competent, safe, & articulate a Primary Care Physician. HIV is a complex disease process with multiple presentations, complications, & treatment options. There are ever rapidly evolving science & pharmaceutical interventions. I took a full YEAR after residency in a fellowship to obtain these skills. YET, you are gonna try to lead the readers of this blog to believe that an NP or PA can provide “seriously competent work”?!?! It took me EIGHT years to become a good PCP/HIV specialist & you are gonna try to delude these readers that these mid levels can do the training in TWO YEARS? IMPOSSIBLE. It takes alot of work to become a competent PCP (try 7 yrs). That hard work continues. It took more work to become a competent HIV specialist. Also more work to continue to assimilate new evolving care. To say that I am professionally challenged to keep myself update in both fields is an understatement. I’m doing it, but it takes work on an eight year foundation. Yes, I saw mid-levels do the same work I was doing. Doing it poorly. Not cost effectively. Primary Care & HIV Medicine are BIG fields. Put them together & it’s ENORMOUS. Gzuckier, you have described a frightening clinic, not a competent one. I know because I may have worked there. Or in a place very similar. Do the readers of this blog actually believe an NP or PA can actually provide to an HIV infected individual competently ALL the primary care & ALL the HIV care with only TWO years of training while I needed EIGHT? Mid-levels are dangerous in this scenario.

        • Alice

          It takes 4 years of medical school & 3 years of a residency in Family Medicine (or Internal Medicine) to become a competent, safe, & articulate a Primary Care Physician. [end quote]

          I am not a supporter of the Canadian system, but they do one thing well and without all the prerequisites we have in the states (their best surgeons do not do 20 different varieties, they do a few and do them really well). You would be surprised to read their resumes (Dr. Gywande covers this in detail). I share this because it would seem this argument would have more authenticity if it were rookie nurses…but if they have worked with HIV patients for years they are competent.

          I think with doctors the most valuable learning is firsthand…..sure the book learning is important…but learning to put that book knowledge to use creates skill (like parenting books…they are our Bible until the baby is driving us wild and we figure out for ourselves what works….experience can be priceless).

  • Michael

    Reimbursements aside, I feel that the primary care shortage has been solved already. With all of the new schools opening, increased enrollment, increase in medical education cost, and increased competition to gain admittance to school the primary care physician is coming back in a “tidal wave” fashion. There are very few new residency positions being opened each year and the hundreds of new MD/DO grads from all of the new schools who will have no choice (because of their huge financial burdens)other than to take any residency they can get their hands on. If this means family medicine (which it does from the 1000+ unfilled family practice slots not filled each year) then that is where they will end up. Do patients really want to go see a family physician who never wanted the job? Looks like they won’t have a choice, and with the amount of debt accrued by the average med grad creeping over $200k neither will the physician.

    • anonymous

      if the difference between new med school slots and new residency slots does push an increasing percentage of students unhappily into primary care, how does that impact the prospective medical student’s decision to attend medical school. if medical school becomes a risk analogous to law school, the quality of candidate will decrease. of course, those jaded students “forced” into primary care residencies likely won’t stick around any longer than it takes to pay off that $200k debt and then find a position in another field.

      • Michael

        I wouldn’t call the students that don’t get the profession they want jaded. It’s a raw deal to work so hard just to be told that because of the number of spots and applicants there just isn’t enough room for you to get where you want to be… but if you were just 10 years younger you could have been in “X” field no problem. I doubt most of us will move on once we pay off the debt. At that point the money will likely be better than we could receive in any other field and since we’ll have figured out the gig I imagine most of us will just work to play and be with our families. Most people hate their jobs anyway. It’s just unfortunate that this field which has such an intimate relationship with people and their well-being will succumb to “industrialization” and the true passion for a field of interest will be less and less available to those who have sacrificed their 20′s and early 30′s 80+ hours a week in a book just to be told they will have a job they don’t want because otherwise the Feds will come after their money in a nasty way.

        If the benefits if FP were better maybe more of us would choose that route. However, nothing makes me yawn more than being in an outpatient clinic doing a routine physical or seeing a mild fever. Luckily, when I go to match I should have no problem going into something I like, but in ten years that will not be the case for many new grads. I think that’s a terrible future for medicine. Being told your dream career will not come true after working harder than most anyone your age for all of your younger years does not make one “jaded”, it shows that you’re human and have true passion for something you have worked so hard to become.

  • anon PCP

    Great article, I agree this is a quiet and insidious rebellion. I found myself dropping one insurance after another, adding more and more cash based ancillaries, until my practice is now 99% cosmetic (botox, laser, etc.) and 1% internal medicine. My next decision is whether to bother spending the time and money to recertify in internal medicine this year. I probably will not. Sad situation for medicine in America, but the reality for most of us.

    • Jack

      It is truly sad when physicians have to turn their backs on their training and doing things that almost anyone can do (giving botox, laser etc).

  • Dr Chris

    The PCP solution from Michael sort of makes sense-but if it works is still 10 years down the pipeline. It takes about 3 years in practice to know when you should ignore a guideline, how to do without all the specialists immediately available in the hospital based setting, and get the “art” of medicine, whatever it is, we all know it.
    Regarding the “kickbacks” are you talking about the referral circles that build up between physicians that trust each other work, or a true quid pro quo. It is courtesy to write thanks for this referral.That’s different from a kickback.

  • Pamela Wible MD

    Rebelling against the system, but here’s why I can never leave primary care:

    I bet others out there feel the same way.

    Pamela Wible MD

  • Robert Centor, MD

    I have written a followup to my original post. I encourage all readers of these comments to read –

    Thanks for your thoughtful replies.

    • pj

      I disagree with the notion that patients play no part in the devaluation of primary care Docs- Our culture is ingrained with the notion that we must “Do something” when one is hurting or ill.

      The proceduralist becomes the hero/savior while the steadfast PCP who has mainly cognitive skills and compassion to offer, is marginalized.

      What about all the patients who self refer to specialists and never see a PCP because they don’t realize or believe we can handle most of their issues?

  • Brad

    Before everybody feels that the PCP is hurting, i personallyI know of a couple of groups in town who see thirty patients each every day, bill for annual visits, do labs in their office, and do all sorts of imaging, rehab etc. They work four days a week and no weekends. They each take one call a week night only. They make more than any specialist in town. They work efficiently and do all sorts of ancillary services. They have the volume
    and they take advantage of doing other paying
    procedures. Thy don’t refer out anything. By and large they are a good group of doctors. At this point they hired their own hospitalist so they don’t even go to the hosital. I know how much they make and please understand it is twice the average and then some. Those who are claiming that try can’t make it in primary care aren’t working hard enough or aren’t business savy.

    • Dave Miller


      I understand what you’re saying. However, having been in the business world prior to going to medical school, I can tell you that many (if not most) of us will remind you that we’re in MEDICAL school, not BUSINESS school.

      It’s interesting to note that one of the growing new dual-degrees is the MD/DO, MBA to help with that some. However, for many docs, the business-side of medicine is almost just not something they know how to do or even care to do.

  • Dr Chris

    What Brad describes involves a lot of investment up front-we have looked into it. It requires buying autoclaves, then meeting CLIA requirements to use and maintain it. It requires the same for liquid nitrogen, etc. Buying the equipment (nevermind the space) for a lab again is $10,000 up front, unless you sublease to a commercial .Doing rehab in your office requires at least a PT aide, and the space to do it.
    Some of this may have been easy if you got a large group of people to co-invest, bought an office condo ten years ago.
    But you can’t see 30 geriatric patients a day and do a good job. Can’t be done. Period.
    And that paid annual physical-it’s a form of concierge medicine

  • KateA

    It sounds like Brad is talking about a veterinary hospital…. virtually every one has x-ray unit, surgery equipment (and specialized plates/instruments can run in the hundreds of dollars), blood work machines, autoclave, microscopes, and more are getting things like dental rads, dental drills, endoscopes, ultrasounds, etc. And veterinary clinics are failing by the hand full because it does not make sense for 2 practitioners to generate enough business to pay for a $100,000 digital radiograph machine. It is economy of scale.

    And honestly, I cannot imagine having an NP or PA handle multiple complicated problems like concurrent renal disease, heart failure, DM, etc at the same time. I want someone that has the education and clinical hours to be my doctor. I get very unhappy when I tell a nurse that I had WPW syndrome and they give me the “what?” look.

    • pj

      So there! Thank you Kate. As a Doctor, I strangely feel a bit more professional esteem now.

      I hate to “pile on” to midlevels, but I worked alongside an NP who saw pts after MI (heart attack) hospital discharge, and didn’t put them on aspirin, or check their cholesterol. Scary.

  • soloFP

    My suburb that is 20 min from a major midwest city had 2 concierge docs. One specilist who left the hospital system and insurance companies; last 6 months and rejoined all the insurance companies. Other one was Fam Med doc who went under in 18 months. Most of the docs in my area are suviving month to month on Insurance/Medicare payments and have no chance of joining the rebellion. Patients are fixated on the $20 copay and don’t understand that to get the $55 office visit, they give the insurance company thousands of dollards in premiums for this privilige of lower costing office visits.

    • Alice

      This post is informative. I remember healthcare when we had a type of catastrophic care and patients battled with hospitals, insurers, and doctors. It was so frustrating you put off care until you thought you were dying (or you became a hypocondriac who thought you were dying, hence, racking up bills were no longer worrisome….you would either die and leave the debt…or survive and gratefully pay it off).

      It seemed to discourage early intervention….a type of hesitant healthcare.

      I know I am really grateful for our co pays. I pay it gleefully. It improved my daughter’s care during this cancer battle, my husband’s heart care. Compared to our other son’s brain tumor care, even the potholes seem to be causing less damage on this journey.

      Maybe doctors makes less….but you still make many times more than the average patient….and even though Americans are negligent about their own health….we created quite a good market for you copays and all.

      Just as auto repair shops know their income relies on insurers, and so do you. It is providing income amidst travails for patients and doctors.

  • Amani

    Yup, kickback for sure. Not to say it doesn’t happen!

  • Pamela Wible MD

    Now Hiring: Medicine’s Martin Luther King

    Enjoy year-round sunshine with a month paid vacation. Earn 300K plus production bonus. No state tax! No call! Daily I’m bombarded with glossy postcards promising the good life.

    With so many options, why are physicians fleeing medicine? Some leave for teaching, waitressing, even homemaking. Others escape into administration, insurance or pharmaceutical positions. Many simply retire in despair.

    Robert Centor MD writes about our quiet rebellion: “This rebellion has no Glenn Beck or Sarah Palin; no Abbie Hoffman or Che Guevera.  This rebellion occurs one physician at a time, as that physician finds continuing their practice undesirable.”

    And the truth behind the exodus?

    There can never be year-round sunshine for physicians working in an unjust health-care system. And $300,000 can never be enough to numb the pain of dedicating one’s life to a profession that has lost it’s soul. A month’s vacation can only distract us from our suffering for about thirty days.

    Now is not the time for doctors to give up call but to accept a call to action. Ours is a sacred obligation, a covenant with patients. America’s greatest dreams can never be delivered by politician-saviors. We are the saviors we’ve been waiting for.

    Years ago, I stopped pursuing the elusive production bonus; I stepped off the treadmill to follow my heart. And I discovered: To heal my patients, I had to first heal my profession. So I led town hall meetings inviting citizens to design their ideal clinic. Celebrated since 2005, our model has sparked a populist movement: Americans are creating ideal clinics and hospitals nationwide. One hospital CEO now affectionatley calls me “his MLK.”

    More than a quiet rebellion, we need a non-violent social revolution led by doctors. Medicine needs a Dr. Martin Luther King Jr. I think I’ll apply for the job.

    Pamela Wible MD

  • alice

    Pam….this is a very good piece of writing. Witty…anecdotal….but as we have seen doctors do agree in healthcare. Rallying the troops in an MLK fashion is comparable on some levels…but patients are the ones with tragedies that stirred a conscience within the very soul of medicine….then the government started to regulate. I do not foresee the regulating of patients to make a paid for relationship more comfortable.

    I don’t know…I am think you need another Luther type…the one who was a minority….who started the Reformation…and lived by example….his ex nun wife had cots all her home filled with sick and hungry people she fed for no pay and no government assistance. They led by self sacrificing models…heros….who waited on no one…and changed history by their sacrifice.

    • Dave Miller


      Primary care docs have chosen to ply their craft for a mere fraction of what the specialists earn, working much longer hours and with much less respect. It is short of nothing less than, to invoke your imagery, medical asceticism.

      By definition, primary care is a sacrifice in our current system. You sacrifice better pay, better hours, time with your family, esteem, vacations. For many, there’s not much left to give up, which is why they’re leaving in droves. And you’re accosting this group for not being willing to sacrifice?!? You’ll pardon me for saying so but I think you need to think a bit more before you post things like that.

      • Alice

        Dave…you completely read into my point…which means others may have. Thanks for posting. My post and example was two fold. Pam wrote with a flair for involvement. I believe politicians who actually give of themselves before asking us to elect them is important. Service in action…not just words for our money or votes speaks multitudes. Second my point was you are a small group….this means you are at a disadvantage politically and socially…hence why social action is vital.

        You have a PR battle to win and that will start in the hearts of your patients…then spread.

        Truly, there was a misunderstanding. Probably from the missing words…that post was from my cellphone in a crowded place.