By Benjamin Brewer, MD
I wasn't invited to any inauguration parties for President Obama. If I had been, I would have tried to bend his ear with some ideas on how to revive primary care in this country.
It's high time to build a modern primary care system that meets the needs of all Americans. It won't be easy and will require an uncomfortable discussion about medical costs and benefits. But judging from Mr. Obama's inaugural address, he may be the man to get change started.
I would have told him to fund primary care adequately. We also need to change how we pay for it, starting with an overhaul of Medicare, so our medical system gets the results we deserve for the money we're spending.
I agree with his call for better use of technology to improve care and lower costs, and I would have told him that the country needs to put in place standards for health information technology and infrastructure.
The need for change is clear. We spend twice as much as many other developed countries on health care, yet we have worse quality. The countries that do better all have systems that are based on effective primary care.
My patients intuitively understand where we need to go. The hallmarks of an effective system are ready access, a provider who can be the main source of care for most needs, comprehensive care and coordinated care.
Decades of research have shown that good primary care reduces costs and improves outcomes, yet we have ignored these fundamental facts to our detriment. I see this blind spot as the biggest flaw in our current system.
Medicare, Medicaid and private insurers all contribute to poor quality by providing incentives for primary care doctors to churn patients through their offices as quickly as possible.
A lot of the great care I give is viewed as worthless by the folks who control payments. If the care didn't happen during an office visit, then Medicare, Medicaid and most commercial insurers pretend it doesn't exist.
Services that earn me the least are often the ones patients value most, such as email messaging, phone advice, and calling in prescriptions to avoid an ER visit.
Why doesn't Medicare pay me to hold a family meeting for a patient suffering from Alzheimer's or to coordinate care among multiple consultants? How about the uncompensated work I do researching cases, reviewing charts and completing disability reports.
I think every small town and urban neighborhood should have a family doctor, just like my community of Forrest, Ill. Sadly, few medical students want to take the modest pay or put up with the hassle to practice primary care practice where it's most needed. We have a problem with an inadequate primary care work force because we have a problem in funding.
Over the long haul, flooding the country with foreign trained M.D.s won't cure the primary care shortage. Even these doctors will find soon enough that they won't be able to cover their operating expenses with what the government is paying.
To get real reform we're going to need to put more money into primary care. I have a few suggestions about where to start looking for it.
The first dollars can come from the Medicare Advantage program. We can lower payments to hospitals for surgical care, radiology and other high-margin services and move the money to primary care.
We can revoke the tax exemptions of supposedly nonprofit hospitals that don't fulfill their mission of community service. We can cut down on costs for office visits to doctors by paying a lesser amount for phone and email contact instead.
We can lower the Medicare pay scale for specialty care, lab tests and procedures. Let's expand the use of non-physician personnel to deliver repetitive procedural care like colonoscopies, not just simple checkups or minor illnesses. We already use advanced practice nurses in specialized and technical fields like anesthesia and neonatology.
There will be tough challenges. An expensive, national health information project won't solve the bulk of our health-care problems, despite the hype.
One reason is that slapping software on top of screwy systems for documenting care only goes so far. It's essential that we simplify the delivery of care and ease the administrative burden on those providing it.
In the end, an adequately funded system of primary care is the key to the health-care reform our country really needs. The community of primary care physicians, nurses and physician assistants stand willing and able to do this work, if the tools and resources are made available.
Posted by Scott W. Yates, MD, MBA, MS, FACP
