05/31/2007 - 22:00

The exodus of general medical physicians

Laura H. Kahn

Laura H. Kahn

A general internist who began her career in health care as a registered nurse, Kahn works on the research staff of Princeton University's ...

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One of the greatest challenges facing health care is figuring out how to assess the worth of thoughts. It is far easier to put a monetary value on a specific task such as a colonoscopy or cardiac catheterization than on the nebulous efforts of thinking and talking. This difference is reflected in how insurance companies reimburse physicians' services, as they typically pay physicians far more money to do surgeries than for spending time with patients and thinking about how to best diagnose, treat, and manage medical care. It's one reason why so many physicians are going into well-compensated surgical and procedurally oriented fields such as orthopedic surgery, interventional cardiology, and interventional radiology, rather than poorly paid "cognitive" primary care fields such as general internal medicine, geriatrics, and pediatrics.

Given our aging population, this trend is worrisome. Wouldn't it be preferable to prevent serious cardiac, lung, and kidney disease with quality medical care rather than treating these conditions with expensive surgeries and procedures at a later, more serious date?

I have discussed the problems of the uninsured in a previous column ("The Security Impact of the Uninsured"), but the problems with the health-care system are not limited to those without insurance. All is not well with the insured either. There has been talk about expanding Medicare to provide universal coverage to all Americans, but before we do that, we should examine what is happening with Medicare.

According to a July 2006 Government Accountability Office report, "Medicare Physician Payments", Medicare uses a "sustainable growth rate" (SGR) system to determine the annual changes to physicians' fees based on spending targets. In 2002, the SGR system reduced physicians' fees by almost 5 percent, and if no administrative or legislative actions are implemented to override this system, the Medicare trustees project that starting in 2007 physician fees will be reduced by about 5 percent per year for the next nine years.

Combined with the lack of tort reform, this system is having a deleterious effect on how physicians practice medicine. For example, the number of tests physicians are ordering have increased dramatically. From 2000 to 2005, the percent change in magnetic resonance imaging tests per Medicare beneficiary has gone up 94 percent, and laboratory tests have gone up a whopping 530 percent. In contrast, the percent change for office visits of established patients has gone up only 12 percent. (See "The Primary Care-Specialty Income Gap: Why It Matters.")

In addition, many Medicare beneficiaries are unable to find general internists, the physicians who provide nonsurgical medical care to adults, because Medicare reimburses too little to allow these physicians to cover their costs, particularly if they have a predominantly geriatric practice. As a result, many are no longer accepting Medicare patients.

According to the American College of Physicians, the nation's largest specialty organization (of which I'm a fellow), from 1998 to 2006 there has been a 54 percent decrease in the number of medical trainees pursuing careers in general internal medicine. More than 86 percent of the graduating medical students have some educational debt; those whose debt exceeds $150,000 are the least likely to pursue a career in primary care.

Plus, people who practice "cognitive" primary care medicine are leaving the field in droves. For example, since the early 1990s, more than 20 percent of board-certified general internists have left the practice of medicine compared to only 5 percent of those who have procedure-oriented practices. Those who stay are increasingly practicing assembly-line medicine, seeing as many patients as possible in short periods of time.

In essence, our health-care system is evolving to provide Wal-Mart-style care. The question is whether people prefer to get their medical care in a "mom-and-pop" setting instead. For the public, the answer is still unknown, but the physicians, particularly the primary care docs, are not happy working in assembly-line-type environments.

Part of the problem is the whole notion of third-party payment. No lawyers, architects, engineers, or accountants would accept payment for services through an intermediary that takes some of the revenue. So far, veterinarians have managed to keep third-party payers at bay.

In a letter to the Journal of the American Veterinary Medical Association, Peter W. Farrell wrote that his veterinary medical colleagues should eschew this model: "The idea that I need to give away some of my hard-earned profit to belong to a network or insurer's group so that they will send patients my way means that I will work longer and harder, see more patients, and earn less. Even a poor businessman can see the error in that logic. . . . Veterinary medicine is vastly more productive and efficient because people must pay for our services out of their own wallets; thus, we have a vested interest in keeping our own costs down."

At least our pets are getting personalized, quality medical care.

By divorcing people from paying directly for services rendered, they no longer understand the value of good medical care. As a result, they expect good medical care to be cheap. It's not. While it's unlikely that the high costs of medical care will decrease, there is a strategy that could save primary care. Insurance should continue to cover tests, procedures, surgeries, and medications; however, instead of insurance companies reimbursing primary care physicians, people should pay directly for their cognitive services. There could be sliding fee scales according to individuals' ability to pay.

As our health-care system continues to value only expensive tests, procedures, and surgeries, these services might eventually become the only game in town. The end result is that no one will be happy as they bounce from test to test and procedure to procedure, trying to figure out what everything means because the generalists who put the picture together and serve as patients' advocates are rapidly dwindling. Their thought processes are critical for the care of individuals with multiple, chronic medical conditions such as diabetes mellitus, high blood pressure, emphysema, cancer, and chronic immunosuppression. An older, sicker population requires patient-centered medical care that oversees all these conditions in an integrated fashion.

From a public health and national security perspective, piecemeal, procedurally oriented care makes no sense, and planning for crises such as epidemics and bioterrorist attacks is virtually impossible without a large cadre of physicians providing general medical care.

Since insurance companies aren't adequately assessing primary care physicians' worth, many are opting out of the system altogether and only accepting cash payments up front. (Indeed, many surgeons are doing this as well.) In the long run, the decision to no longer accept insurance might be the only way to save primary care because the physicians who provide this care cannot afford to make ends meet. In other words, "a penny for your thoughts," isn't working anymore.