Isn't it time we finally stop this nonsense and actually fix the system???


On Monday I participated in a Politico event in Washington DC called “The doctor-patient relationship.” The link to the event is here, and to hear my panel you can forward to the first small video. The three of us on the panel, all primary care physicians including one Congressman, agreed on virtually everything: we need to change quality measures so they empower patients and facilitate shared decision making, we need to reward primary care as much as we reward doctors who are focused on procedures, and we need to recruit more primary care doctors if we want any meaningful reform to succeed.

In my work with Alan Roth on the Right Care Alliance Primary Care Council we are trying to construct a position paper to show how our health care system can be reformed by putting primary care back in the forefront. This will not occur without a huge commitment to and investment in primary care training and practice. But money spent on primary care is money well spent. Studies show consistently that the more primary care there is in a community, the lower the costs are, the better the outcomes are, and the happier patients are. In Curing Medicare I made a compelling case for primary care, and showed how fixing the system is actually quite easy. We know how to do it, and we have the tools to make it happen.

So why is this so difficult? We will spend several of the next few blogs discussing why health care reformers cannot seem to grasp the simple concept that a primary care based health care system is the only one that makes sense. And this is not a problem of either party. Bernie Sanders in his push for Medicare for All would simply superimpose the specialist-dominated Medicare system on all Americans, bankrupting us in the process while perpetuating a doctor-centric strategy that pushes patients to take more drugs, undergo more tests, and be subjected to more procedures, all of which have questionable utility and high cost. Republicans, meanwhile, have no plan or strategy at all. No one apparently values our current system that squanders a trillion dollars a year to provide substandard care, but no one too is willing to fix it.

Here are the facts. Primary care is disappearing. Few students go into the field, and many who are in the field now are fleeing. The vast majority of primary care doctors increasingly are owned by large corporations that force them to see patients in 15-20 minutes where they become referral factories who send patients to specialists and for tests rather than speaking with them. We in primary care are slaves of the computer, having to spend more time checking boxes on our mandatory electronic notes than conversing with our patients. Our visits are orchestrated by “quality” indicators that typically have no relevance to the patient in front of us, and often lead us to make decisions that are both antithetical to patient choice and also medically dangerous, typically not based on any quality medical data. But unless we satisfy these guidelines, our pay will be dropped, and we already are paid less than all other doctors, typically half of what most specialists make. And we are hit by Medicare audits (I am grappling with a vicious one now) that are inaccurate and arbitrary, and that again pull our focus away from our patients, as well as having to navigate the complex formulas that have been introduced into our payment scales that can make or break our practices, and which again having nothing to do with patient care.

While reformers from the left and the right give lip service to primary care, they are doing all they can to kill the profession. As I struggle through my audit for often 10 hours a week, as I work with my ACO to satisfy our requirements to meet Medicare’s new “quality and value” mandates, as I run my business and try to make sure we are compliant with the vast web of regulations, I find myself, for the first time, questioning if it’s worth it. I consider myself the last optimistic primary care doctor in America, one of the few who still encourages students to enter my field. But now I am jaded and I worry. We have no allies. We even have very few in the seats of power who understand and value our worth. Rather, they enact convoluted strategies to fix the health care system, and they watch as we whither an die. What is left is a specialist dominated and hospital based health care system that feeds patients with inaccurate medical information and thrives by encouraging ineffective, expensive aggressive care.

So where do we go from here? It’s time we become more serious about primary care and about the primacy of a patient-centric approach. That’s the fight in which we must engage if we really care about our health care system and about our patients. It’s time we don’t simply let Congress and reformers put gift wrap on a failing system and tell us that it’s fixed. We must fight back and demand real reform. I am going to start a video podcast to try to get the word out. I will continue to talk and to write op-eds. I will continue to work with my colleague Erik Rifkin to help insurance companies and patients understand the risks and benefits of medical interventions, since our medical community, its doctors, and the media are doing just the opposite. I have been working with our local hospital and state government to try to put a primary care presence back in our hospitals, where it has been yanked out to make way for squadrons of hospitalists and specialists who do not know anything about the patients they are treating. There is so much we can do, but we have to take the initiative. Really, the solution is easy. Too easy. But it will clearly lead some doctors, hospitals, and institutions to lose a share of the money they are siphoning from our wasteful medical spending spree. So, even though the solution is easy, it will also be met with opposition by these doctors and institutions who will pretend to be high and noble in their defense of the status quo. Those are the groups we are going to have to fight if we are going to institute real reform. Moving forward in this blog, we will look for strategies to make change possible. Only by revealing the truth, and showing how simple the solution is, will we succeed. I can’t wait to try!

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