Early in the prolonged economic crisis a patient who had lost his factory job came to see me. He no longer had insurance, but he had plenty of health problems. Our office normally doesn’t see uninsured patients (we simply can’t afford to) but from time to time we make exceptions. I changed his prescriptions to the cheapest possible effective medications and gave him an online resource for the meds that did not have inexpensive alternatives. I referred him to a clinic that has the resources to care for the uninsured and that may be able to help him get his diabetic supplies.
By doing this, I shifted the cost of this man’s care from my small office to a larger entity. But the money for his care still must come from somewhere. It’s possible that his new clinic may get “disproportionate share (DISH)” dollars from the federal government if they care for many uninsured patients, but it’s also likely that the clinic will never completely recoup the cost of his care.
The uninsured are an unnecessary burden on our health care system. Treating someone without insurance is the most expensive way to provide care. Rather than having the cost and risk of their care pooled with others, the cost falls directly on the patient, who cannot afford it, and is taken on by hospitals and clinics struggling to stay open. Doctors’ fees are only a small part of this burden.
One of the tactics being taken by the anti-health care reform movement is to hype the doctor shortage. Doctors have been kvetching about our health care system forever. When HMOs rose in popularity in the late part of the 20th century, doctors found the increased paperwork, patient loads, and capitated reimbursement unconscionable. And so did patients. HMOs have changed dramatically since then partly in response to these forces. One glaring fact in health care is that it is difficult to make extraordinary profits while maintaining a significant level of customer satisfaction. Health care is about people’s lives. It is not just another commodity.
But HMOs didn’t kill medicine, and neither will the health care bill likely to pass tonight. Primary care medicine is not a lucrative profession and most primary care docs are in it for the right reasons. That doesn’t mean we won’t quit if practice becomes overly burdensome, but the thought of PCPs quitting en masse is laughable. But we are already having trouble creating enough PCPs. About four percent of American medical graduates choose primary care. One of the reasons for this is the enormous debt they incur during their education: close to 200K average. Primary care medicine simply doesn’t pay well enough to manage the debt well. And primary care is becoming more important as we learn more about medicine. We have measures of effective care now that should be tracked, such as how often a diabetic receives foot and eye care. Private insurers have discovered this, and want the data to help reduce costs: prevent progression of diabetes-related diseases, and profit goes up. Private insurers have started giving “bonuses” for this data, which in effect means withholding money to doctors unless they get the data. Collecting and reporting this data, without a unique, national database, is a huge burden.
If health care reform passes, it’s unlikely that this would change. This is coming one way or another—it’s good for our health, and we physicians will have to find a way to adjust, as we always have. But we’ll need some rational actions to help us. Creating a national database, one that is compatible with our own electronic health records; creating interoperability between EHRs; and providing the resources to help physicians track this data is something that cannot be done on the level of individual practices.
Our health care “system” is being hobbled by millions of uninsured and lack of any support for prevention. If health care reform fixes only the first problem, that’s a start. I love having full exam rooms a crowded waiting room. Hopefully, we will keep an eye on part two, and make it possible for people to choose to practice primary care, and to do so effectively.