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Who Will Do the Work?

Healthcare will remain a focus of Congress and the White House for many years.  All involved state their goal is to cut wasteful spending by insurance companies and our current delivery system while providing access to care for all Americans.  Regardless of what changes occur over the next 5 to 10 years,  there is a missing piece to this healthcare puzzle.  Specifically – who will do the work?

By ‘the work’, I mean the primary medical care of these additional 48 million people.  Primary care physicians handle not only day-to-day illness, injury, and disease management, but preventive care such as vaccinations, periodic physical exams, and well child exams. The uninsured (along with many who have insurance) currently utilize urgent care centers and emergency rooms for their primary care, which is episodic and without a preventative focus. In the end, this makes for an unhealthy population with poor disease prevention and a severe burden on our national healthcare expenses.

Over the past 50 years our system of healthcare delivery has changed dramatically.  Fifty years ago, family doctors cared for everything from broken bones to cardiac arrest in the hospital and performed basic surgeries.  During this time, patients managed payments, and the doctors in conjunction with the hospital managed costs.  Insurance companies paid the patient and the hospital.  Although not a perfect system, among the benefits was comprehensive continuity of care with reasonable charges.

A paradigm shift occurred when insurance companies saw the advantage of managed care and consolidated the industry while medical centers began to over produce medical specialists and under produce primary care physicians.  Why?  Quite simply – cost vs. benefit.  Today, a medical student spends nearly $200,000 to become a doctor with most of these expenses paid for by loans.  After accounting for mounting malpractice insurance and overhead costs, the median income for primary care physician is $137,000 per year, less than half the average salary of any sub-specialist. Considering school debt and mounting loan interest, this is a major problem. 

New doctors have examined the burden of debt against future income and decided to become specialists.  This shortage of primary care doctors is at a critical point. Today, less than 3 percent of graduating students will become the primary care doctors that the new medical reform measures require.  This shortage brings other cascading issues.  Instead of integrating our system by coordination via the ‘family doctor’, we further fragment it because patients see multiple independent specialists and receive care through hospital ERs and urgent care centers.  This fragmentation, redundancy and poor communication increase costs and jeopardizes care.   

Family doctors face yet another dilemma.  In order to ‘make ends meet’, primary care doctors are forced to see 30-40 patients daily.. This leads to limited knowledge of the patients’ history and delays necessary visits, tests and consultations. Doctors are left frustrated and unable to do their best work.  The anticipated influx of new patients, combined with a shortage of ~ 200,000 primary care doctors, is nothing short of frightening. 

These factors have discouraged doctors from becoming family care physicians at a time when they are even more necessary.  Any reform proposed in the current debate merely provides an insurance card to 48,000,000 new patients, while not addressing the critical shortage of skilled primary care physicians   and plans to spend an estimated $2 trillion over ten years in an industry that already accounts for 18% of GNP.   

I propose that we first enact changes to support the doctors we need to do the work .  Our energies, both politically and financially, should be focused on developing incentives to accelerate the production of primary care physicians, such as targeted medical school loan forgiveness, relocation costs, and allowances to support underserved areas. We need a legitimate medical malpractice solution that doesn’t pander to the Trial Lawyers Association, and we need to reduce health insurance companies overhead without adding more government regulation and cost. Then our political leaders can seek a reasonable solution to the uninsured crisis.

Some physicians, like me, have eschewed the current system’s limitations on personalized care and mandates for volume practices. I practice in a direct care (“concierge-style”) medical practice in Reston, Virginia. I can deliver comprehensive, coordinated care for my patients, and they have 24/7 access to me and my staff.  In doing so, we have temporarily solved the problem for our patients.   If the currently proposed “reform” passes, however, I believe we will find that most everyone will have insurance – but not a doctor.  I believe everyone in America should have both.

Kevin J. Kelleher, M.D.

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