To put that in perspective, we've spent somewhere around $600 billion thus far to finance the war and occupation of Iraq since the 2003 invasion. And that's over five years. Our government just forked out 30% more than that in a matter of weeks. We throw these numbers around like it's nothing. The word "billion" apparently has lost all connection to reality because, hey, the federal government can just dole out checks with nine zeroes after the integers whenever they feel like it. But it's a lot of money. The entire budget for the Departments of Education and Labor combined for fiscal year 2009 is "only" about $120 billion.
So what does this have to do with medicine? Not a whole lot. I admit that I'm probably stretching it a bit here. But we do have a crisis of epic proportions in health care. Too many people either don't have enough coverage or aren't covered at all. Morever the cost of health care is rising at astronomical levels. In 2007, we spent $2.3 trillion dollars on health care expenditures. That's 16% of our entire GDP. Finally, we face an impending shortage of the very professionals needed to provide the sort of cost-efficient, excellent care that any all-inclusive health care reform would hope to implement. Younger doctors are opting to pursue careers in higher paying, less stressful specialties rather than slogging through the rigors of a standard primary care practice setting. And who can blame them? Graduating from an accredited medical school in the country oftens saddles you close to $200,000 in student loans. Now we have a President who has made it very clear that he has every intention of rectifying most if not all of our deficiencies. And he's going to need doctors who buy into it and want to make it work. So that puts us in the driver's position, right?
Well then I read the vitriolic op-ed piece in Emergency Medicine News by the eminent Dr. Jonathan Glauser (from the Cleveland Clinic Foundation of Higher Medical Instruction and Sophistication) where he basically embarasses himself in front of the country in writing. The article is hilarious.
Countering the idea of improving payments to primary care physicians he writes:
Say what? Fund physicians to promote primary care? Why throw good money after bad? If ever there was a group that has failed in providing care, it is our primary care system. To fund such a venture for groups that are singularly inept at performing anything of value to society is pure folly and a waste of precious health care dollars.
Now that's just schoolyard bully talk. It's harmful only in the sense that it damages the professional reputation of a singular ER physician on the banks of Lake Erie (I'm sure Toby Cosgrove's henchmen have "taken care" of this little problem). It's a rant by a nut-job. Why should any of us be bothered by it? This is like being worried about the state of the NFL just because OJ Simpson is in the Hall of Fame. Dr Glauser wrote an extremely shallow, poorly thought-out, amateurish, overly emotional piece that surely, given his education and prominent position, he now regrets. And that ought to be the end of it.
But my concern is with a commonly held position that this sort of attack on primary care is just the beginning. The Medical Webmaster himself, Kevin MD, hints at this in a post from last week:
The nature of budget-neutral reform means that physicians like Dr. Glauser will take a substantial pay cut to adequately fund primary care.
He's merely laying out the groundwork for a furious specialist assault on primary care that will be sure to come.
In other words, all specialists deep down harbor a fear of any sort of remuneration reform and it's going to lead to irreparable animosity between the overpaid specialists and the true soldiers of American health care, the noble internists and family practice docs.
Unless I'm misinterpreting things, this is an entirely disingenuous stance. As Max Baucus avers, any payment reform will need to be conducted in a "budget neutral" manner. That means the current pool of health care dollars that is directed toward physicans will not be increased, it will just get divvied up differently.
And why are we comfortable with this? Why, as professional group are we content to passively take whatever federal regulators want to give us? Why is it a done deal? This "spat" between the Kevin MD faction and the Jonathan Glausers of the world is just what the government and insurance companies and everyone else wants. Infighting and disunity. Physicians battling each other over ever diminishing scraps. It's the wrong outlook.
I have my own issues with the theory that simply increasing your family practice doc's pay is the fundamental solution to our nation's health care ills. If a doc has to see 30 patients a day to make 130,000 grand a year and you increase his pay so that he is compensated, let's say $150,000 a year, you really haven't solved any problems other than the one specific problem of low primary care pay. That family doc still has to see 30 patients a day. He still will need to keep his office booked for months in advance. He still won't have much time to take care of emergent issues, shunting acute problems off on the ER. The internist will still need to see the same number of inpatients to reap the rewards of higher pay, thus perpetuating the shotgun consult method of practicing medicine. Nothing really is going to change with a modest alteration in the salary structure. We need to aim higher. After all, there's plenty of money out there, apparently. Just ask the failed barons of Wall Street.
Rather than dutifully accepting "budget neutral" reform, consider the following:
1. Make it financially doable for doctors to spend time with patients. Instead of thirty a day, what if you could see five in the morning and five in the afternoon? And you had scheduled gaps to account for acute care issues that arose unpredictably? Think of how thorough you could be. Think how many fewer consultations would be necessary.
2. Student loan forgiveness for those who pursue primary care/internal medicine.
3. We'll need more doctors
4. Market forces alone will make it unsustainable for graduating medical students to opt for speciality careers, assuming that better paid doctors who can spend more time on individual patients will not need to rely on specialist consultations as before.
5. It's going to cost a lot of money
Listen, change is coming. It's inevitable. Obama has his mandate. But he's going to need us, and I stress us, all physicians, to make it work. Without the cooperation and enthusiasm of all doctors, the Obama revolution is doomed to a similar outcome as that seen in the 1990's with HillaryCare.