Thursday, August 7, 2008

How To Save Primary Care

I was listening to talk radio today when one of the daily shows devoted a full hour to the challenges of rural medicine versus urban medicine. Their guest was a physician who had substantial experience practicing in an area of the United States far more rural than even I would ever have dared tread.

For nearly an hour I listened to him field questions about the unique challenges of being in a rural setting, the problem of access to healthcare, the need to expand medical school enrollment to fill this unmet need, and even universal healthcare. The elephant on the radio was just too great for me to bear, and so I did something fairly uncharacteristic and called in.

I made it known I was a young physician who had just recently escaped primary care (but did not elaborate -- I was time-crunched). I asked:

"Even if we doubled medical school enrollment and found a way to instantly insure 100% of Americans overnight, that doesn't solve the problem of who is going to be seeing these patients and staffing their 'medical home.' How will this ever be solved when medical students are tempted with subspecialist salaries that are 5-6 times what a primary doctor can make, often with better hours?"

Predictably, you could tell I'd struck a chord. He said that it was an excellent question, and that something that was going to have to happen would be a "very painful" reduction in subspecialist salaries. I resisted. I did not say another word. He neglected to mention CMS had attempted a modest shift in the RVU values to do just such a thing.

Sidenote: Many hospitals in our area (including mine) took cue and reduced their subspecialist salaries. But the primary care guys? Our RVU thresholds were compensatorily increased to completely negate the positive income effect that Medicare intended to happen. How they got away with it is truly beyond me. They literally pocketed the difference.

What it got me thinking about was this most recent prevention of the 10.6% cuts that nearly went through. (I'm of the mind that it would have been better for the cuts to go through, and truly watch the shit hit the fan, but oh well.) The biggest asset physicians had was the senior population. When patients stood behind physicians, the policymakers got off their asses.

It's awfully hard to convince the average American that someone making $170,000 a year deserves more (or at the very least, deserves to spend more time with less patients to make that amount of income). But that's precisely what primary care has to do. Unfortunately, I think the only way to get the general public to care about the relative-bottomfeeders in medicine is by focusing their attention to those being hand-fed olives plucked from the vine in the ivory tower.

I don't like the idea of "turning" on our overpaid proceduralist colleagues. But it has been physicians in those very fields sitting on the AMA and other policy-guiding groups who have protected their own turf at the expense of primary care. And it's time for it to stop.

Why is it for decades on end residents were allowed to work 40-hour "days" and 120-hour weeks? Because only after the public started getting wind of "medical errors" by "fatigued doctors" was pressure applied to put an end to it. If Joe Blow couldn't care less about medical errors, believe me, residents today would still be risking their lives on the post-call drive home from work.

Just because I escaped the cracks of the whips being applied to the backs of primary care doctors doesn't mean I care any less about the state of healthcare in our country. But if we truly expect anything to change, you have to get the public on your side. Just exactly how we do that... I haven't figured that one out yet.

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