The slow, painful death of primary care: "Idealism loses out"

One of the better articles I’ve read outlining why primary care is doomed.

On fast-food style McDoctor NP/PA clinics:

What we should all be concerned about, however, is what these “walk-in care centers” represent: a McDoctor franchise at a convenient intersection that will (for cash payment) provide a mediocre but quick and fragmented fix for a perceived urgent need. Such encounters will ultimately detract from continuous doctor-patient relationships and will skim the easily handled minor acute problems from the revenue stream of dedicated primary-care providers.

Preying on the naivete of idealisic PCPs:

There will always be people willing to take financial advantage of anyone they can. They prey on naive idealists without remorse. Whether it is patients who don’t keep their promises to pay, or a dishonest employee who steals from an employer while maintaining a facade of sincerity and loyalty, a physician-business owner must be vigilant and even suspicious, setting limits that protect the practice’s assets and financial viability.

The difficulties of shunning poor insurance payers:

To remain independently viable, a private primary-care practice might have to shun such contracts and expect full payment at the time of service, leaving the red tape to the patient. But patients wouldn’t tolerate this for long. Historically they gravitate to a practice that will shoulder the burden for them, which ultimately leaves the first practice with too little volume.

The ridiculous reimbursement system:

When a medical practice has contact with a patient, a bill can be generated only if the patient is actually seen. Time on the phone for our staff and us produces no revenue, and it is unreasonable for patients to expect that their problems can or should be diagnosed and treated by phone.

If I was able to bill like an attorney by 10-minute increments, I would be happy to chat with you, call in your prescriptions and review your child’s immunization record or discuss travel preparation with you. But in the current medical payment system, it can’t work that way.

If I were a retail merchant – selling shoes, for example – and I lost a dollar on every pair I sold, it wouldn’t make much sense for me to work harder to sell more. If I get no commission, I’m certainly not interested in selling shoes by phone or mail order.

Why single-payer is not the answer:

My concern about a single-payer system is that it would become Medicare-like. We would be obliged to accept a single entity’s assessed valuation of our services and, as is currently happening, be subjected to capricious reimbursement cuts dictated by government budget constraints.