COMMENTARY

Physicians Rise Up to Save Primary Care

Nancy R. Terry

Disclosures

January 02, 2009

"I laugh every time they discuss healthcare policy," says a family medicine doctor. "The real issue should be how to save primary care."

Recent articles in the medical and lay press have focused on the growing shortage of primary care physicians in the United States and the crisis that that shortage is causing in the nation's healthcare system. A long and animated discussion on Medscape's Physician Connect (MPC), a physician-only discussion board, sizes up the problem.

"The only ones of us left in family medicine are those that are too young to retire and too old to retrain into another specialty," says an MPC family medicine doctor. "The major reason?" he continues, "It's underfunded. Salaries need a major increase. I would say double at least, probably triple." A recent article in JAMA documented that family medicine, at $185,740, has the lowest average salary of the medical specialties.

"Primary care physicians are being relentlessly hammered each year. They are getting burned out, and many are going broke," says an MPC internist. A preventive medicine doctor comments, "In the UK, whatever the defects of the system -- and they are many -- they build around GPs, who get $230,000 a year plus 25% performance bonuses. And, of course, they don't have huge medical school debts. We have it backwards. The most valuable doctors -- primary care physicians -- get paid the least."

Money aside, for many MPC contributors, professional dissatisfaction stems largely from the burden placed upon them by insurance companies and Medicare and Medicaid, which demand that physicians comply with an ever-growing number of documentation requirements.

"The intrusion into medicine by third-party payers (better known as the insurance industry, Medicare, and Medicaid) has been coming since the '60s, but this effort to control costs has really become burdensome over the last 15 years," says an internist, "and it has not controlled costs and has not improved quality."

Another contributor remarks, "Every visit has its own catch-22, whether that's a prior authorization, a formulary, a HIPAA rule -- it never ends."

How can the system be changed? One family medicine doctor suggests that doctors largely stop accepting insurance and return to a fee-for-service, out-of-pocket system of payment for routine care. "Why are we even dealing with the insurance companies?" says one contributor. "Go cash-for-service. Supply and demand. As long as we play along, we are doomed to ever-decreasing salaries, increasing hours, and less job satisfaction."

"It makes no sense for insurance to cover routine office visits," offers another family medicine doctor. "If third-party payers no longer covered office visits, the cost of out-of-hospital healthcare would drop considerably."

"Overhead in primary care is ridiculous," says one contributor, "Let's get rid of the billing and coding system. Pay primary care doctors for time spent, by the hour, like lawyers."

One of the major overhead expenses in primary care is the skyrocketing rates of malpractice insurance, which many MPC contributors see as a major target for reform. "End the malpractice lottery," says a family medicine doctor. "Require a review board that has no conflict of interest to decide whether a malpractice case has merit. If it does, send the case into binding arbitration. Only if binding arbitration fails should the case proceed to a malpractice suit. Strictly limit lawyers' compensation and allow no payments for pain and suffering."

The level of dissatisfaction with their practice has led some physicians to advocate for change. "If we don't get politically active and start standing up for our rights and our patients' rights to quality care, then we have no one to blame but ourselves," says one contributor. He recommends that the AAFP or the AMA pay a number of doctors to go to Washington, DC, to lobby and educate lawmakers about how dire the situation has become for primary care physicians.

One internal medicine doctor is investigating the possibility of forming a physician's union. He initiated talks between his local medical society and the Service Employment International Union (SEIU). "Word has it," he says, "we will be sending a representative to New York to meet with the SEIU." He recommends that physicians spur their local medical societies to get involved in talks with the SEIU.

A family medicine doctor concludes, "Let's stop complaining and start coming up with specific recommendations for improvement. Let's be a voice for change."

Many MPC contributors have offered specific strategies for overhauling primary care. The following are some of their recommendations:

  • Eliminate multiple insurance companies and use a single payer. If a system of multiple insurances companies is retained, make the costs transparent, fair, and reasonable to encourage competition.

  • Provide everyone affordable coverage for catastrophic care.

  • Make office visits reasonably priced but require payment at the time of service. Require small copay from Medicaid patients to limit overutilization.

  • Increase primary care physicians' salaries and award performance bonuses.

  • Give primary care physicians the freedom to order tests and make referrals without subjecting them to red tape.

  • Implement tort reform that limits physician liability, sends most suits into binding arbitration, caps lawyers' fees, and eliminates compensation for pain and suffering.

  • Allow physicians to bill for payable hours, such as time spent with patients, in answering email, and in returning phone calls.

  • Mandate that hospitals operate 16-hour-a-day centers offering urgent care to the working poor at reduced rates or risk forfeiting their tax-exempt status.

View these and other discussions in Physician Connect (physicians only; click here to learn more).

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