You May Have Missed the Obituary for the Primary Care Physician

 

Strangely, healthcare reformers — both the Obamacare and the emerging Trumpcare varieties — still speak in pious terms about the importance of the primary care physician to whatever plans they have in store for our American healthcare system. These people are lying. Many of them are members of the enlightened leadership that has purposely and systematically wrecked primary care medicine. The primary care physician is dead, and the reformers know it. The obituary has not only been written, but has been duly published in the Federal Register as the law of the land.

The death of primary care was a culmination of two fatal disorders. The first was a chronic, debilitating illness that systematically deprived the practice of primary care medicine of its very purpose and meaning. This illness took hold long ago, back when Mr. Obama was still organizing sundry communities, and Mr. Trump was still enthusiastic about the casino business. Consider the long-term effects of this illness. if you ask a primary care physician what their medical practice is like today, you are likely to get an answer like this:

“Our pay is determined arbitrarily by Acts of Congress, like workers in the old Soviet collectives. We are directed to “practice medicine” strictly according to directives (quaintly called “guidelines”), handed down from on high by panels of sanctioned experts, and accordingly we are enjoined from taking into account our professional experience, our intuition informed by judgment, or our specific knowledge of our individual patients when we advise them about their medical issues. We are strictly limited to 7.5 minutes per patient “encounter,” and the content of this brief encounter is determined by certain Pay for Performance checklists which have been given to us by yet other expert committees. These checklists assure that most of our 7.5 minute encounter is spent asking about important medical topics such as the storage of handguns in the home and sodium in the diet, for if we skip any items on the list we define ourselves as substandard caregivers. This expediency has had the effect of greatly limiting any discussion of topics or concerns that are not on the list, and thus do not meet the approved agenda. Our every move must be carefully tabulated according to incomprehensible rules, on innumerable computer forms and other documents, that confound patient care but that greatly further the convenience of the stone-witted bureaucrats and forensic accountants who are employed specifically to second-guess every clinical decision and every action we take. 

“We are expected to operate flawlessly under a system of federal rules, regulations and guidelines that cover hundreds of thousands of pages in immeasurable volumes that are never available in any readily accessible form. If we do not operate flawlessly according to those rules, regulations and guidelines, we are guilty of the federal crime of healthcare fraud. Furthermore, the specific meanings of these rules, regulations and guidelines are not merely opaque and difficult to ascertain, but indeed they are fundamentally indeterminate — that is, they have no inherent meaning. So, we must proceed under a massive quantum cloud of rules as best we can, but our actual status (regarding healthcare fraud) is, like Schrodinger’s cat, fundamentally unknowable — until the “box is opened” (such as, through criminal prosecution), whereupon the meaning of the rules is finally crystallized in a court of law, and we who had been practicing in good faith find that we have at least a 50- 50 chance (like the cat) of learning that we are actually professionally dead.

“We have been given the overriding charge of becoming the primary mediators of covert, bedside healthcare rationing, and to this end we have been pressed to ignore the classic doctor-patient relationship by the healthcare bureaucracy that determines our professional viability, by the United States Supreme Court (see Pegram et al. vs Herdrich (98-1940), 530 US211, 2000), and by the bankrupt, new-age ethical precepts of our own profession, that require us to practice for the benefit of the collective instead of the individual patient.”

Sad!

By such insults, even before Obamacare became the law of the land, primary care medicine had been reduced to one of the most frustrating, enervating and demeaning endeavors a physician could imagine. Many if not most practicing PCPs even then were looking to either retire early or change careers. Medical students — even the most idealistic ones who were actually not lying when they said on their applications that they wanted desperately to practice primary care medicine — end up avoiding primary care in droves, especially if their training exposes them to the palpable despair radiated by actual primary care physicians in the wild.

But the second fatal disorder (either of which would have been sufficient) has nothing to do with policy or politics. Even if doctors had perfect control of the healthcare system and the political realities, primary care medicine (as we know it) would still be in trouble. This is because of an axiomatic truth revealed by the annals of human progress, to wit: As knowledge increases and technology improves, activities that used to require the services of highly-trained experts become available to non-experts who have much less training. A lot of what PCPs have traditionally done — check-ups of well patients, screening for occult disease, controlling cholesterol, advising on diet, weight loss and exercise, managing hypertension and diabetes — really can to a large extent be reduced to a series of guidelines and checklists, which can be adequately followed by individuals with much less training than these doctors receive.

When any area of expertise evolves to this level, it is inevitable (in a free economy) that lesser-trained individuals will inherit it. This event greatly increases productivity, makes the services in question more readily available to many people at lower cost, and (ideally) frees up the experts to take on more challenging endeavors. While this kind of transition is nearly inevitable, it is often painful and disruptive. The pain and disruption are being experienced by PCPs today.

It is in fact true that medicine has advanced to the point where it really would make sense to turn over to non-physicians many of the routine, mundane, and reducible-to-checklist tasks that PCPs traditionally perform. PCPs who are fighting against this inevitability are wasting their time and energy. They are fighting both history and the laws of economics, so in the end it is a losing battle. It is time for PCPs to move on.

It is of course immaterial whether you agree with me on this point. It is immaterial because this is how the Central Authority sees it, too.

My dear PCPs: Having painstakingly reduced you and your fellow PCPs to tools of the state — whose chief job is to follow the guidelines and place chits on the checklists, &c. — it is only natural for the Central Authority to eventually notice that you really don’t need all that training to do the kind of job they have invented for you. Nurses and other non-physicians, who can be “trained up” much more rapidly than you, and who will work for much less money than you, and who will be much less recalcitrant about following handed-down directives than you — will fill the gap. 

And you, doctor, can go pound salt.

So it was really only a formality when the Obamacare legislation made the death of primary care official. The new law did so by stating explicitly that PCPs and nurse practitioners and physicians assistants are now legally equivalent, one and the same. They are all PCPs under the eyes of the law. The actual language of the obituary is as follows:

The term ‘primary care practitioner’ means an individual who —

(I) is a physician (as described in section 1861(r)(1)) who has a primary specialty designation of family medicine, internal medicine, geriatric medicine, or pediatric medicine; or

(II) is a nurse practitioner, clinical nurse specialist, or physician assistant (as those terms are defined in 9 section 1861(aa)(5))

What this means is that today there is more than one pathway to becoming a PCP. You can spend four years in college, four years in medical school and three years in a clinical residency — or you can go to nursing school and do another year or two of clinical training; or go to college and train for two years to become physician assistant. Anyone who wants to become a modern PCP might reasonably find themselves having to defend their intelligence if they still, after this obituary, chose the former pathway. 

And so the issue is decided. PCPs: by virtue of your specialty you have been formally (and legally) reduced to the status of a nurse-equivalent. Your specialty, as you have known it, is dead. It is time to decide what you’re going to do about the demise of your chosen career.

There are, of course, several options. Maybe we will look at them another time.

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  1. MLH Inactive
    MLH
    @MLH

    Metalheaddoc:

    DrRich:

    cdor:I don’t know. My Doc teemed up with a concierge service that works with doctors all over the country. They operate in the wide open, holding very public sign up meetings. I just called him to verify that what I said is indeed correct.

    They obviously have had some very smart lawyers look over and sign off on their business model, and so it must be OK. I wish them the very best.

    I bet that business model doesn’t last much longer as is. There is nothing to stop the licensing authorities in the states from requiring a percentage of patients be from Medicare/Medicaid. They could easily make it a requirement for renewing your license in the state. Don’t like it? Practice medicine somewhere else. They know most docs would grin and bear it to avoid moving and starting up practice somewhere else.

    Isn’t the annual fee charged supposed to help offset some of the loss from billing insurance?

    • #61
  2. Chuck Enfield Inactive
    Chuck Enfield
    @ChuckEnfield

    Great post!  Looking forward to the follow-up.

    • #62
  3. Ontheleftcoast Inactive
    Ontheleftcoast
    @Ontheleftcoast

    Metalheaddoc: I bet that business model doesn’t last much longer as is. There is nothing to stop the licensing authorities in the states from requiring a percentage of patients be from Medicare/Medicaid.

    Yep. Concierge practice is vulnerable to things like that; or when single payer care starts up, just strip any doctor of her license if she’s not accepting that. Because fairness.

    When HIP started up in New York City in 1943, my grandfather z”l had been in practice 20 years. He had been one of three Jews in his medical school class; there were hospitals where he couldn’t get privileges because they wouldn’t let Jews in. But that’s not what he meant when he said that HIP meant the end of medicine as we knew it.

    • #63
  4. cdor Member
    cdor
    @cdor

    Metalheaddoc:

    DrRich:

    cdor:I don’t know. My Doc teemed up with a concierge service that works with doctors all over the country. They operate in the wide open, holding very public sign up meetings. I just called him to verify that what I said is indeed correct.

    They obviously have had some very smart lawyers look over and sign off on their business model, and so it must be OK. I wish them the very best.

    I bet that business model doesn’t last much longer as is. There is nothing to stop the licensing authorities in the states from requiring a percentage of patients be from Medicare/Medicaid. They could easily make it a requirement for renewing your license in the state. Don’t like it? Practice medicine somewhere else. They know most docs would grin and bear it to avoid moving and starting up practice somewhere else.

    That will work well, instead many will just retire.

    • #64
  5. PsychLynne Inactive
    PsychLynne
    @PsychLynne

    DrRich:

    PHCheese:She hasn’t said but I think she will open a concierge practice, and I w not blame her.

    Not only should you not blame her, you should admire her as one who is striking out against the machine.

    My doc does this in a non-concierge way. His practice bills for time and doesn’t submit insurance. Same day appointments, calls returned quickly, actual care coordination, phone calls returned quickly.  Able to avoid urgent care and the ER for certain problems (e.g., the occasional kidney stone).

    For specialists we use our insurance, but for everyday care, we go with a little more money for a lot more convenience.

    Plus, my husband will actually go see this doctor so that is worth it!

    • #65
  6. She Member
    She
    @She

    I just noticed that this is one of the linked posts on the Powerline home page.

    • #66
  7. Chris Campion Coolidge
    Chris Campion
    @ChrisCampion

    Eugene Kriegsmann:In my late teens about 50 years ago, I dated the daughter of a General Practicianer. He was a wonderful doc who knew all of his patients, their lives, their personal histories. He made a good living, but worked very hard for his money, long hours, and frequent calls during the night. Even though he had survived rectal cancer he continued his practice well into his 80s. I was surprised to see his shingle still hanging in front of his home/office more than twenty years after his daughter and I had broken up. He told back then in the early 60s that the age of the GP was rapidly coming to an end. Specialties had been growing and it was very difficult for a GP to keep up with all the changes. He said the best docs were ones fresh out of med school because they were current on all of the new stuff. I had thought at the time of going to med school, but I wanted to be a doctor like he was. His words discouraged me, and I pursued studies in biology and marine science instead. It is sad that medicine has gone in this direction, but it also means that those treating us are far better prepared in their particular area of expertise, if not in the essentials of the “whole patient.” I have been fortunate in belonging to one of the oldest and best HMOs in the country since coming to Seattle in 1969.

    You became a….marine biologist?

    • #67
  8. cdor Member
    cdor
    @cdor

    DrRich:

    cdor:In my case, my doctor bills insurance as usual–medicare or private insurance–his patients pay an annual fee to have access to his services, same day appointments, minimal wait, maximum time with the doctor. Instead of needing to see 2000 patients, he can make a living seeing only 400 patients while still maintaining a full office staff. Why would that be a problem?

    Why would that be a problem? The whole point is to make doctors beholden to third parties, and separate their interests from their patients’ individual interests. That’s the only way to control the doctors, which, in turn, is the only way to control costs (i.e., covert rationing at the bedside).

    Obamacare by its very nature centralizes medical decision making. That’s the fundamental structure of it. Doctors who take money directly from patients for their services constitute a major ideological problem for Progressives.

    Doctors who take money from Medicare and then turn around and take more money directly from their patients, to the best of my knowledge, are in substantial trouble if the gaze of the Feds should ever fall upon them.

    Just to clarify, the name of this operation is Concierge Choice, http://www.choice.md , and I spoke with the COO just a few minutes ago. Everything I said is accurate. What I probably left unclear was that there is certifiably no “double dipping” involved. The concierge services are completely independent of Medicare services. Thus all is legal.

    • #68
  9. MLH Inactive
    MLH
    @MLH

    cdor:

    DrRich:

    cdor:

    Just to clarify, the name of this operation is Concierge Choice, http://www.choice.md , and I spoke with the COO just a few minutes ago. Everything I said is accurate. What I probably left unclear was that there is certifiably no “double dipping” involved. The concierge services are completely independent of Medicare services. Thus all is legal.

    Until they make it so that a physician who has opted out of Medicare can’t still refer to providers who do bill Medicare.

    As a side note: it is my understanding, as a physical therapist, that if I opt out of Medicare and then decide to opt back in I have to get a new license.

     

    • #69
  10. DrRich Inactive
    DrRich
    @DrRich

    cdor:

    The concierge services are completely independent of Medicare services. Thus all is legal.

    That makes all the difference.

    • #70
  11. DocJay Inactive
    DocJay
    @DocJay

    DrRich:

    cdor:

    The concierge services are completely independent of Medicare services. Thus all is legal.

    That makes all the difference.

    I used to also bill Medicare but stopped years ago just to keep someone in government from closing the dubious concierge loophole and fry my bottom.

    • #71
  12. Aaron Miller Inactive
    Aaron Miller
    @AaronMiller

    Y’all have talked about how physicians are compensating for or circumventing present regulations choking the industry. What are your most daring hopes for what Republicans might legislate or repeal in the coming years?

    Can PCPs be saved?

    What do y’all think of Price’s legislative proposal, now that Trump has fingered him for HHS?

    • #72
  13. cdor Member
    cdor
    @cdor

    Aaron Miller:Y’all have talked about how physicians are compensating for or circumventing present regulations choking the industry. What are your most daring hopes for what Republicans might legislate or repeal in the coming years?

    Can PCPs be saved?

    What do y’all think of Price’s legislative proposal, now that Trump has fingered him for HHS?

    Good questions. I was wondering the same. @drrich stated in his post that this problem started well before Obamacare, even though it has been exasperated by the ACA. Perhaps, indeed, new legislation can begin to reverse some of the disease that is killing PCP’s. However, there is no doubt that cost pressures will give Physician Assistants and Nurse Practitioners  a greater role in the future of health care. The problem with that is large problems sometimes can be reversed if realized sooner. That is where the knowledge and experience of a real Primary Care Physician can make a huge difference in a persons life.

    • #73
  14. MLH Inactive
    MLH
    @MLH

    I met the wife of one of our local GPs. She told me that some months he barely cleared enough to pay himself.

    If one did not have to  pay office staff to deal with billing, calling insurers to find out a patient’s coverage (this is a courtesy BTW, it is YOUR responsibility to know what your insurance covers and if it turns out that it doesn’t cover something YOU signed papers saying you would pay, not that the provider would waive the fee), submitting billing (I remember my dad paying the our GP and then submitting paperwork to the insurer).     sorry,

    I’ve lost my train of thought on this. . .

    • #74
  15. cdor Member
    cdor
    @cdor

    MLH:I met the wife of one of our local GPs. She told me that some months he barely cleared enough to pay himself.

    If one did not have to pay office staff to deal with billing, calling insurers to find out a patient’s coverage (this is a courtesy BTW, it is YOUR responsibility to know what your insurance covers and if it turns out that it doesn’t cover something YOU signed papers saying you would pay, not that the provider would waive the fee), submitting billing (I remember my dad paying the our GP and then submitting paperwork to the insurer). sorry,

    I’ve lost my train of thought on this. . .

    That’s OK, MLH…it’s early in the morning…have another cup of coffee.

    • #75
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