A few months ago, the NEJM published an article outlining The Future of Primary Care Medicine. That article drew several responses. The first states that the “ideal” primary care setting outlined in the article is not grounded in today’s reality:
To the Editor: Whitcomb and Cohen and Fincher (Aug. 12 issue) call for changing the training settings for students and residents in primary care to reflect the types of environments in which high-quality primary care can best be provided, with use of “models of efficient, interdisciplinary, patient-friendly care in academic medical centers and exemplary community-based practices.” Although I agree with these sentiments, if these training settings do not reflect practice in the real world, we run the risk of alienating potential future primary care trainees with “bait and switch” tactics. Unfortunately, although the chronic care model, for example, provides a reasonable blueprint for how such care could be structured, implementation is precluded by the current health insurance and health care systems in the United States. A recent article on the Pursuing Perfection initiative suggests that, even with substantial grant funding, such exemplary practices are not financially sustainable. It seems unlikely that anything short of complete reform of the U.S. health care system will make primary care attractive to large numbers of medical students.
The second minces no words – primary-care medicine is a business:
To the Editor: Students shun primary care because primary care today is unattractive. We are trapped in a catch-22. Insurers, both commercial and governmental, try to reduce payments for medical care whenever possible. When they reduce their payments per visit, we increase the number of visits. So they cut payments again. If more patients are to be seen, visits must be shorter, and problems simple and discrete. Indeed, the coding system rewards us for seeing new patients with acute problems. People do not go to school for decades at tremendous expense to work on a production line, and that is what primary care has become. “Productivity” “” patients per hour, not improved health “” has become critical, whether we work for ourselves or others.
Yet there are many patients with complex, chronic illnesses who need our help. If we are paid the same for everyone, we cannot afford to see them. The solution? First, we need to be compensated for work done without the patient present, as are other professionals. Second, insurers should pay more for complex cases and less for easy ones. That approach may require some form of national health insurance.