All Physicians Are Not Created Equal: How to Fix Medicine’s Two-Party System | Hello Health | Fast Company

Here’s my first column on I’ll be regularly writing about healthcare issues. This is the first post:

Imagine there is a committee of politicians made up of 24 republicans and 5 democrats. Their job is to decide a politician’s salary–for democrats and republicans–and decisions are made by majority rule. Which party do you think would have the highest salary?

Much like American politics, doctors have a two-party system. It’s the Primary Care Party versus the Specialist Party. For the past 20 years, the specialists have been pummeling the primary cares. In 1991, the AMA formed an expert committee called the RUC in response to a Congressional mandate to provide recommendations to the Center for Medicare & Medicaid Services (CMS) on the worth of every visit and procedure a doctor can perform. CMS then accepts, rejects, or modifies these recommendations and effectively places a dollar amount on the thousands of codes doctors use to get reimbursed. CMS sets the standard. Private insurers then use these standards to decide how much they reimburse physicians in their own networks.

At the tip of this convoluted payment pyramid lies the RUC, composed of 29 physicians, each representing the 29 specialties. Five of them are primary care doctors. Majority rules. It is the reason our nation’s doctors practice quantity medicine, not quality medicine.

Our current health-care malaise is the result of the federal government making policy around recommendations from specialists who are looking out for their own, while ignoring the needs of a highly functioning system. The backbone of an efficient, cost-effective health-care system relies upon a strong primary care workforce to manage the common problems and refer for help in managing complex and rare problems. Other countries in the world that rank far better than the U.S. in medical services have about 75% generalists and 25% specialists. The U.S. is exactly opposite: 75% of our doctors are specialists. And about 94% of graduating physicians in America chose a specialty over primary care last year.

Med students, while inexperienced, aren’t dumb. They follow the money and the lifestyle. There are two vastly different worlds available to them: Start at $80,000, work 60 hours a week on the eight-minute visit hamster wheel, drive a Toyota, and play on the public golf course; Or specialize, and start at $250,000, work 40 hours a week, spend 30 minutes with each patient, and enjoy the newest BMW and country club membership.

The primary care docs in America have been virtually eliminated by the Specialist majority. We, as a nation, are just starting to feel the hurt this is causing. The feds may soon mandate insurance coverage for us all, but there are so few primary care docs around that we won’t be able to use our new insurance. Most of these new insurance plans will be micro-managed primary care gatekeeper-type policies. The ERs will be flooded because primary care won’t be available. The cost of health care will skyrocket. And the waits to see a doctor will trump Massachusetts’ 52-day wait.

The Obama administration has three proposals–increase the number of medical students, use more physician’s assistants and nurse practitioners, and expand the National Health Service Corps. None of these will work. They are all band-aids that won’t stick for more than 30 seconds. Increasing the number of med students will simply increase the number of specialists driving BMWs. The American public still wants to see doctors, not PAs and NPs. The National Health Service Corp will offer generalists another low-paying option to practice in areas where no docs want to practice.

Reversing the effects of the RUC will take 20 years, and a new generation of physicians. The first policy change needed to solve the primary care crisis is to remove the conflict of interest within the RUC. It should either be staffed with health policy experts, or with 75% generalists and 25% specialists. If that happened today, twenty years from now our actual physician workforce would reflect what’s needed. Unfortunately, this would also be the beginning of the health-care war. We’ll see lobbyists for specialists teamed up with the hospitals who profit massively from specialist care versus the lonely 25% of doctors who represent primary care fighting for equal pay, lifestyle, and a strong health-care system. I have a hunch which party is going to win this one. What are your thoughts, Hillary? Remember 1993?

All Physicians Are Not Created Equal: How to Fix Medicine’s Two-Party System | Hello Health | Fast Company

Very cool indeed; instead of changing the entire system, he’s creating a new system that works around the existing; it will start in current un-served and under-served segments and spread to the currently mis-served segments once they realize how much better the solution is; a “quiet” revolution from the quiet masses; I’m excited.

CG – Thoughts on 2.0

A comment on a blog post In response to a video of me describing Hello Health.




Kickstarter is a funding platform for artists, designers, filmmakers, musicians, journalists, entrepreneurs, athletes, inventors, bloggers, philanthropists, explorers…

Kickstarter just launched, and I think it’s a great idea. Go check it out.

This is amazing! Simple, Free, and only limited by your ideas and what people think of them.  This is what I love about the internet!

Yeah. Definitely. Awesome.


Magic Doesn’t Make Things Happen


The following are some general rules that seem to be forgotten in the modern political debate.

#1: You cannot make things happen with a philosophy of government. If I have a philosophy that says that the government should take care of the poor, and I vote for people who espouse that philosophy, it doesn’t make the government take care of the poor. What it does is generally give more power to the people in government to take money under the auspices of giving it to the poor. Whether this actually happens or not can be a matter of great debate. In other words, I cannot vote to make something happen, I can only vote to give the government the power to do something. This is a VERY IMPORTANT distinction.

#2: Getting things done is 10% inspiration and 90% perspiration. No matter how high and mighty my cause, somebody has to actually do the work to get it done. I usually fail to understand why we are progressively giving more functions of everyday life over to the same organization that we berate constantly for inefficiency. Around election time, everyone screams and moans about the lack of good choices and votes for “the lesser of two evils.” They then proceed to turn progressively greater amounts of function over to “the lesser evil,” who they all believe isn’t actually that good. Considering that the work on the part of this individual is what gets things done, this is a recipe for progressively diminished efficiency.

#3: Giving the government power makes it more powerful. When it becomes more powerful, it is less likely to listen to you. As our good friend DeCartes said, “power corrupts, and absolute power corrupts absolutely.” No matter how much you believe in the redistribution of wealth within society, you cannot do it yourself. You are actually voting for the government to do it. You are thus giving a central source of power a progressively greater say in the overall wealth in the nation. There is absolutely nothing that I have seen in my life that leads me to believe that anyone within this institution possesses some sort of superior moral or market insight.
Just remember, when you vote for a bill to save hurricane victims or provide healthcare to children, you are actually voting to give the government the power to take money from someone and use it to provide these services. This makes the government more powerful. It also means that any mistakes by the middle man prevent the actual implementation of the lofty goal (Katrina *cough* *cough*). It also makes it less likely that a progressively more powerful government will actually be held accountable for its failures. We might ask whether using the government to implement our desires is necessarily the best thing.

#4: The government is only force. The origins of government lie in defense. The only difference between the government and a private organization is that we let the government use force to accomplish its goals. What’s the difference between the government providing health insurance to children and a private charity doing so? The government can use force to fund its program. Without the force, the government would be nothing more than an EXTREMELY inefficient form of charity in this instance. Voting for a bill to provide health insurance to children (as an example) DOES NOT provide health insurance to children. It gives the government the power to use force to take money from the taxpayers with orders to provide health insurance to children. This is an EXTREMELY important distinction.

Remember, magic doesn’t make it happen. It’s all about implementation. No matter how many warm fuzzies you get thinking about some political agenda, it doesn’t change what the agenda actually means. We can want something until we are blue in the face, but nothing will actually happen unless we do it. Likewise, you cannot vote to make things magically happen in society. You can only vote to give power to the government to do things and hope for the best. Next time you hit the polling station for a proposition, ask yourselves whether whatever you are voting for is worth the cost of implementation. Ask yourself whether whatever you are voting for has any practical chance of happening at all. We could all vote by consensus that everyone gets a Mazzerati and a trip to Mars. Magic doesn’t make it happen.

An email I received from a second year med student

Posted with permission:

Dr. Parkinson:

What can I expect when I graduate? It’s a bit silly to wonder that now, considering I should be cramming away for finals and the USMLE Step 1, but after stumbling across your site I had to ask.  I’m an Indian born, Canadian raised future physician attending medical school in the American south (Georgia).

Every time I turn on the news or step outside the comfort of the local coffee shop, I’m constantly reminded about the gross dissociation between the ideal perception I have of medicine and the reality.  I applied to medical school to help alleviate the pain and suffering of those in need.  Why is it then, whenever I turn on CNN or head over to the New York Times, that I see headlines that insist physicians are doing the exact opposite?

“The cost of health care is too high”
“the uninsured number in the tens of millions”
“people cant decide between paying their health or the electric bill”.

Is this what I should expect once I have the letters MD beside my name?  What can I do as an individual to address just one aspect of this enormous problem?  I read your philosophy, and I’m a bit torn.  I completely agree that reform is needed, but I’m not sure that it begins at how physicians are compensated.

I spend a lot of time talking about which residencies my peers are interested and find that only a tiny fraction of them look to primary care.  I wish I could say I’m considering primary care, but that would be a flat out lie.  This isn’t because I think primary care is any less valuable, but with student loans that rival my parents mortgage, primary care is a non-starter.  Does this seem reasonable? Without the weight of student loans shackling us to the pursuit of high paying specialties rather than those that are needed, how can we expect the current crop of medical students to take a future as a family practitioner, pediatrician etc. seriously?

Have you considered the cost of medical education as a factor?  Is mine a valid concern?

Just a few thoughts, and some random questions.

Sunny Sambhara

p.s. I realize there were many questions in there, but I’m hoping you can draw out the gist of my concern, mainly, should we address the cost of medical education when we look at addressing the soaring cost of health care?

These are the issues med students face. This is why they’re not going into primary care. This is why there is a physician shortage and, keep in mind, nearly 95% of them think this way and are not going into primary care.

So what do we do about it? It’s a crisis and will seriously affect the quality of care we receive in the US until we fix this problem.

Honda Insight – Let It Shine on Vimeo

Please don’t watch this within Tumblr. Click on the link to visit Vimeo to watch it. You won’t get it if you don’t watch it on Vimeo. Wow, this rocks and one of the main reasons why we chose Vimeo for all things related to the new Hello Health site.