Washington Times Op-ed: Finding a new way forward starting with primary care
December 18, 2016
This week I had an op-ed published in the Washington Times. In it I argued that sensible reform of our health care system requires more than the cosmetic changes currently being endorsed by the incoming administration and Congress. The three linchpins of successful medical reform are in fact issues that are never discussed: an increased focus on primary care, the ability of patients to be treated at home instead of in the hospital, and the facilitation of shared decision making by enabling an accurate dissemination of medical information to patients. These seem like simple fixes when juxtaposed against the complex and convoluted reforms being churned out by Medicare and other organizations, and yet they address what is genuinely wrong with our health care system.
Soon after this article was published, I gave a talk to a large group of seniors and described several health care proposals being scripted by Republicans, including privatization of Medicare and the dismantling of the ACA, and what that could mean to them. Many were justifiably frightened by what lies ahead and were smart enough to know that even when people like Paul Ryan suggest that these draconian changes will not impact those already in Medicare, that is a false statement, because once Medicare becomes privatized for only future enrollees, its mission and its focus will shift away from those currently enrolled. And most also were aggravated by their inability to know which medical interventions were actually beneficial and which ones may be harmful; they felt that the information to which they had access was misleading. This fact is of crucial importance, especially since many doctors and organizations that do provide health care information are rewarded if patients choose the most aggressive path of care, a path often riddled with adverse consequences and uncertain benefits. These were smart people, far wiser than those who are currently crafting health care policy. But who in Washington would dare listen to the consumers of care when there are so many lobbyists and “experts” telling them what to do? Even our VA system is being targeted for privatization; see the excellent article by Suzanne Gordon talking about that. Privatization does not solve any problems. It simply passes the buck to someone else. The system needs more than just empty gestures to help rescue it.
Many in the room were shocked to hear about how dire our primary care crisis is, with few students entering primary care, and the number of primary care doctors proportionally shrinking at an alarming rate. To me, this is where health care reform must begin, because it strikes at the very root of what has gone wrong in our health care delivery system. After my article came out, a primary care doctor in Florida, Michael Middleton, reached out to me offering similar ideas as mine. He wrote an excellent piece in Athenainsight that is worth reading. When specialists are earning hundreds of thousands of dollars more than primary care doctors in a year, making their money by performing procedures that often are medically useless or even harmful, then our crisis will only deepen. Given the financial strain that specialization is placing on our health care system, feeding into the nearly $1 trillion-dollar waste that is squandered every year, and given the erosion of a primary care presence that could buttress some of that waste by facilitating patient understanding of how to best navigate our system, it is very clear that rescuing primary care needs to be on top of the list of reforms.
How do we convince medical students to enter primary care fields while at the same time enabling primary care doctors to be able to take care of their patients? The first step is pay equity. The obscene differential between primary care and specialist pay is not derived by the free market or any other forces over which patients have control, but rather is created by a contrived formula that is passed from a specialty-dominated committee on the AMA to Medicare and then to every other insurance company in the country. This pay inequity, which occurs nowhere else in the world, needs to be fixed immediately if we are to have any meaningful health care reform. By paying doctors just as much to think and discuss complex medical issues with their patients as we pay doctors to perform technical tasks we will be taking a great leap in health care reform.
An engineering friend of mine, with whom I will be writing another op-ed, prefers to view the problem not as pay inequity, but rather as the fault of a system that is paying more for low-value care than high-value care. To him, the technical difficulty and length of training needed to perform a task is not what should determine payment, but rather payment should be driven by outcome. Value can be measured objectively using such parameters as cost reduction, saving lives, helping patients avoid bad outcomes/functional decline, and preventing disability. Value can also be measured subjectively by rewarding patient-centered care and complex decision making. Hence, a primary care physician who helps guide a patient through a diagnosis of heart disease using medicines and engaging in discussions about exercise, diet, smoking cessation, and the risks/benefits of tests and procedures would offer more value in most cases than a cardiologist who puts in a stent, and hence the primary care doctor should be paid more for that intervention. Pay that favors outcome and relies on complicated medical thinking and shared decision making would enhance primary care pay over specialist pay and be of value to patients and to the financial health of our medical system.
Once we acknowledge that primary care doctors should be earning about as much as specialists, and that their skills are just as or even more valuable than the technical skills of specialists, then we will see an influx of medical students entering primary care fields, as well as a reduction of tests and procedures that (since they no longer pay very well) will only be performed if they are medically necessary. From there, we can start talking about how to help doctors spend more time with their patients, how to eliminate protocol-based care and replace it with patient-based care, and how to make the electronic medical record our ally and not a wedge shoved between doctor and patient. Reform is quite easy. It starts with primary care. But giving lip service to primary care, which is done by so many pundits in both political parties, accomplishes nothing. Pay equity derived by rewarding value and de-emphasizing procedure-based care is the first step. Is should occur before we meddle any further in feckless reform.
How do we go about convincing the politicians talking about health care to listen to all of us and offer realistic solutions? I encourage everyone reading this to sign up for the primary care council of the Lown Institute. Simply enter the Lown website, sign up, and then check off primary care as your interest. Lown is not only for doctors; it is a forward-thinking organization fighting for common sense health care changes that benefit all people, and thus it is an organization that embraces everyone interested in our health care system. We must start somewhere, and we need a home to put our thoughts together and to advocate for change. To me, Lown is that home. Please spread the word, sign up, and let’s stop taking and let the pundits know that it’s time we make some real changes in health care, starting with primary care.