Tuesday, January 6, 2009

Oh, Canada!

As primary care gets more attention in the health policy blogosphere, we are seeing increasing pushback from those who have something to lose.

Jacob Goldstein reports in yesterday's Wall Street Journal blog that "if Barack Obama makes good on his promise to increase access to health care for America's 45 million or so uninsured, a lot more people are going to be trying to squeeze in appointments with busy primary care doctors." Citing a story in Canada's National Post Goldstein writes that some Canadian doctors fear that U.S. demand might be met by recruiting their family doctors to cross the border.


(Wikepedia tells us that Canadians use eh, in place of huh? or what? ... My reaction to the idea that we'll solve our primary care crisis by raiding Canada's family docs)

Last month, in the same WSJ blog, Sarah Rubenstein wrote about ACP's proposal to use the stimulus bill to fund a 10% increase in Medicare payments for primary care.

The many comments she received are well worth review and commentary by The ACP Advocate Blog readers. Among them:

"Primary physicians really need this 10% increase in fees, at least until we decide what physicians should earn."

"This investment makes sense for the long term. 80% of our doctors are specialists while in other industrialized countries 80% of their doctors are GPs. America spends more but ranks lower than other nations so it would seem this is "carrot" to improve our primary care system will pay off."

"A highly appropriate and justified request. Primary care is a pillar of this country's health care infrastructure, it is in grave need of repair and restoration."

But not everyone agrees, to put it mildly:

"It boggles me how some of you say that primary care physicians are 'ridiculously underpaid' ... I work in 2 hospitals and I've seen the payroll and to think that they deserve even more than that is ludicrous."

"The letter from [ACP President] Dr. Harris is mostly nonsense anyway. The 'shortage' of primary care physicians in Massachusetts for example is due to the sudden increase in patients stemming from the availability of insurance to otherwise uninsured individuals. It has nothing to do with physician pay."

"Pathetic! Next the primary care docs will claim hunger and homelessness."

The comments on primary care, even the extremely negative ones, show that ACP is succeeding in making the public and policymakers aware of the crisis. Otherwise, why would people care about what we say?

But it also shows that even a very modest first step to help primary care, like ACP's proposal for a 10% bonus, will bring out opposition.

Today's questions: What do you think about the idea that the U.S. will solve the primary care crisis by taking doctors away from Canada? And how would you respond to comments like it is "pathetic" and "nonsense" to seek higher pay for primary care?


Jay Larson MD said...

It would be a great idea to do a physician trade with Canada. In Canada you can see a primary care doc within a day but there are long waiting lines to get an elective procedure done. Canada needs more specialists. In the U.S. there are long waiting lines to see a primary care physician but a patient can get an elective procedure the next day. The U.S. needs more primary care physicians. We should swap 1 Canadian primary care doc with 1 U.S. specialist until there is more balance in both systems.

On the more realistic side, it is unlikely that a Canadian primary care doc would leave a health care system that supports primary care to work in a system that does not support primary care.

As for negative comments about primary care by other M.D.'s...it only shows how unprofessional they are and only emphasizes their greed.

Steve Lucas said...

First, when a doctor states "I am just a poor doctor" the veracity of everything that follows is immediately questioned. So just stop it. Doctors have the potential to do well financially in every community they move too.

The real issue is the disparity between primary care doctors and specialist followed by some very real and legitimate working conditions issues. The nagging fear of legal action, internally financed technology upgrades, and simple hours worked are all issues that need to be addressed. A 10% fee increase would be nice, but will not change the above issues, nor will it produce changes in the business side of running a practice.

The challenge will be in moving specialist back into the generalist field. We have enough doctors, and we spend enough money, the problem is the distortion towards specialist. The Jan. 6 WSJ highlights in Health-Care Outlays Climb at Slowest Rate in Years how medical outlays still exceeds growth in GDP or wages.

We cannot import the doctors we will need in the near term. The rest of the world is playing musical chairs with medical specialist, with places such as Germany, Australia, and the UK, constantly recruiting doctors.

The real shift needs to be in making primary care a viable option for those graduating medical school. This will require a shift away from the technologically orientated way we practice medicine today towards a patient centered concept. We need to move away from a system of counting heads to solving problems, and this will require a change in the way we compensate primary care doctors.

In my first economics course I learned money is made on change. I was also taught that people resist change even when they are in a dysfunctional situation. Today, both doctors and patients, are pushing for changes that will allow them a better experience and better outcome. Many will resist this change.

Steve Lucas

Jay Larson MD said...

If a physician has a heavy medicare practice (like many internists who have practiced for many years) financial viability is an issue. The Medicare reimbursement for office visits is just enough to cover office overhead. Seeing Medicare patients is charity care. Yes it is possible for a very good internist to be making less than minimum wage depending on his payer mix.

Unfortunately physician income is the 800 pound gorilla in the room that has to be dealt with and thus discussed. It is not something most primary care physicians like to talk about.

The January 8, 2009 New Enland Journal of Medicine (which should be available on line tomorrow) has a nice 2 page perspective on "Money and the Changing Culture of Medicine". The gist of the article was that there are 2 interactions a physician has with patients…Communal (an expectation and obligation to help when assistance is needed) and Market (receiving payment for services). Obviously the culture of medicine has shifted towards Market interactions, but this is at the expense of essential parts of the medical profession including pride, sense of duty, altruism, and collegiality.

Medicine does not fit a traditional business model, yet several CEO's and Managers continue to pound a square peg in a round hole.

Unknown said...

"The real issue is the disparity between primary care doctors and specialist..."

I believe this is the key point right here. Imagine if all PCPs received a whopping 50% raise but at the same time we gave specialists the same raise. Would PCPs be content? I doubt it.

People will always compare themselves with their peers. If all doctors were paid similar salaries, and had to share the burden of paperwork and other administrative tasks which cannot be billed for, I'm sure doctors across the board would be happier.

Having said that, nobody in their right mind would willingly take a pay cut. But what about future physicians? What if we decided that every graduating medical student starting from, say, 2015 will receive $200k +/- 15%? Would we then have such a shortage of graduating medical students choosing primary care specialties? The incentive to choose an eight-year residency such as neurosurgery would be much reduced, lest the student had a keen interest in it (which is a very good thing).