- I work for a health-insurance company, and my brother
is a primary-care physician. As he tells it, my industry is responsible
for the death of his. Insurance companies, he argues, have killed primary
care by grinding down reimbursement and compelling doctors to see more
and more patients just to make a living.
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- I sympathize with my brother, because I know that doctors'
business with insurers isn't always easy. I'm also aware of the market's
price sensitivity-and reimbursement paid to doctors comes from premiums
paid by customers. Insurers must keep costs down.
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- Remember Marcus Welby, M.D.? He defined the family doctor
on TV in the 1970s, exemplifying the four Cs: caring, competent, confidant
and counselor. In the mid-'60s, I remember my father-in-law, a real-life
Dr. Welby, telling me the exciting news that the federal government was
going to start paying him to see seniors-patients who before he had seen
for the proverbial chicken (or nothing at all). That fabulous deal was
Medicare.
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- Associated Press
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- Medicare introduced a whole new dynamic in the delivery
of health care. Gone were the days when physicians were paid based on the
value of their services. With payment coming directly from Medicare and
the federal government, patients who used to pay the bill themselves no
longer cared about the cost of services.
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- Eventually, that disconnect (and subsequent program expansions)
resulted in significant strain on the federal budget. In 1966, the House
Ways and Means Committee estimated that by 1990 the Medicare budget would
quadruple to $12 billion from $3 billion. In fact, by 1990 it was $107
billion.
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- To fix the cost problem, Medicare in 1992 began using
the "resource based relative value system" (RBRVS), a way of
evaluating doctors based on factors such as education, effort and specialized
training. But the system didn't consider factors such as outcomes, quality
of service, severity or demand.
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- Today most insurance companies use the Medicare RBRVS
because it is perceived as objective. As a result of RBRVS, specialists-especially
those who perform a lot of procedures-do extremely well. Primary-care doctors
do not.
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- The primary-care doctor has become a piece-rate worker
focused on the volume of patients seen every day. As Medicare and insurers
focused on trimming the costs of the most common procedures, the income
and job satisfaction of primary-care doctors eroded.
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- So these doctors left, sold or changed their practices.
New health-care service models, such as the concierge practice and the
Patient-Centered Medical Home, drew doctors away from the standard service
models that most patients rely on for coverage.
-
- All of these factors have contributed to a fragmented,
expensive health system with most of the remaining doctors focused on reactive
instead of preventive care.
-
- The solution to the problem is making primary-care physicians
the captains of the ship. They must have the time and financial resources
necessary to take care of their patients, tailoring care to patients' specific
conditions and needs. And they need the data to track their patients' results,
so they can guide patient progress. They will then be able to slow (and
sometimes reverse) their patients' illnesses, keeping them out of hospital
emergency rooms and specialists' offices. The end result: reduced costs
and improved quality of care.
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- So, who really killed primary care? The idea that a centrally
planned system with the right formulas and lots of data could replace the
art of practicing medicine; that the human dynamics of market demand and
the patient-physician relationship could be ignored. Politicians and mathematicians
in ivory towers have placed primary care last in line for respect, resources
and prestige-and we all paid an enormous price.
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- Mr. Hannon is senior vice president of marketing and
provider affairs for Blue Cross Blue Shield of Arizona.
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