Here’s my first column on fastcompany.com. 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?