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Viewpoint: Primary care fixes come too late


Medical Economics readers argue that the fixes to primary care are already too late; that Newtown, Connecticut, should focus more on the human element than guns; and that doctors that insurance brokers want what's best for both the client and the agent.

With apologies to Mark Twain, the death of outpatient adult primary care is not “greatly exaggerated.” (“Saving primary care,” November 25, 2012.) A storm is coming, and a newer “model” for healthcare is too little and definitely too late.

I was recently given the data on medical students in Ohio. Only one out of 20 is planning on going into outpatient primary care. Many are entering emergency department and hospitalist programs-but not outpatient primary care.

In our city of 35,000, the disaster is only 5 to 7 years away. At that time, many of our family doctors and outpatient internists will be retiring with nobody on hand to replace them. Thousands of Medicare patients will be affected. Their healthcare will suffer significantly. Our patients over the age of 65 are those with the greatest health needs, and in my view, they are the most deserving of quality care as well.

The rhetoric of the government not withstanding, there is an amazing lack of alarm amongst the public. They either don’t know it’s coming or feel that there is nothing they can do to change it. The news media concentrate on “Obamacare,” with its potential problems. Whatever your view of our president’s plan, it pales when compared with the present-day Medicare crisis that is a most certainly coming.

Here is the bottom line of why those over age 65 will not be able to find a doctor: My office overhead is roughly $180 per hour. Medicare patient visits do not even come close to covering that. During the past 3 years, and for the first time in 28 years of practice, we are losing money on each and every Medicare patient who walks in our door. I have had to expand my payroll to meet the ever-growing paperwork and administrative duties of a primary care office.

While home health agencies are pulling in millions of dollars in revenue, we are paid nothing for our time and energies. Medicare is not fee-for-service, it is “free for service.”

The group home is a valid idea but not as cutting-edge as you may think. The same promises of “greater input and control by primary care” simply means “greater paperwork.” Many of my peers in family medicine took the bait on these promises in the 1990s. Primary care will be the gate keeper. All that really means is this: “Every last little thing your Medicare patients need (administratively) will be done by their primary care doctor-for free.

Medicare recipients: A storm is coming, and very soon. Batten down the hatches, and try to get established in a medical practice while you still can. Time is running out.

I know that it is much easier to recognize a problem than to fix it. Nevertheless, here’s my 2 cents: We must pay off medical student loans in return for service in primary care, such as group homes that accept Medicare patients, for a given number of years.

Graduating seniors owe upwards of $300,000 in undergraduate and medical school loans. If they buy a house, it puts them $500,000 in debt. No wonder they will not-they are not-choosing to go into family practice.

I am in the winter of my practice, and with little debt, I will never refuse to care for my Medicare patients. They are dear to me; however, I mourn for the death of our specialty, and I worry that there is no one to pass the torch to.

I am often asked if I would recommend primary care to our youth. Let me think... Absolutely! For me, there is no higher calling than to care for the health of our county’s people. You will never regret such a decision. I cannot imagine a more fulfilling profession.

Kristofer Sandlund, MD

Zanesville, Ohio

MOC opinion misses important points

Dr. Lois Nora’s article, “Maintenance of certification has value for physicians and their patients” (“Viewpoint,” October 25, 2012), contains serious inaccuracies and ignores obvious questions.

First, her answer to the “grandfathering” exemption granted to older physicians is inadequate and completely misses the point. How can the public differentiate between two board-certified physicians when only the younger one has to comply with maintenance of certification (MOC)?

 She also failed to address the fact that many other board-certified providers, such as nurse practitioners, and physicians assistants, also do not participate in MOC or re-examination and yet can still call themselves board-certified just the same.

Her assumption of improved patient outcomes cites a couple of retrospective cohort studies that have limited applicability or relevance with a level of evidence of 2-C at best. Surely, the multitude of recent quality initiatives such as the Physician Quality Reporting Initiative and the Healthcare Effectiveness Data and Information Set score are more relevant and cost effective.

 The fundamental problem is Dr. Nora’s misunderstanding of the function and role of board certification. Traditionally, it was a test after residency of a minimum absolute level of knowledge that was necessary to gain admission to the rights and privileges of a specialty. The protection of public trust has always been delegated to the state licensing boards.

 Today’s board exam for family medicine, for example, seems “fixed,” whereby 10% to 15% are failed annually. This “pruning” of previously competent graduates to satisfy a statistical cut is not only unfair but unethical and wrong.

In conclusion, I urge Dr. Nora to rethink what the true role of the American Board of Medical Specialties is and to put an end to the “mission creep” that has set in, whereby the boards now function more like licensing departments without jurisdiction or any regard to the extreme time and financial requirements imposed on physicians and their families for little or no proven benefit.

George Toth, MD 

Tampa, Florida

Brokers do what’s best for clients

As an independent insurance broker who has worked primarily with physicians for close to 35 years, I take exception to James Dahle’s comment in the December 25 issue (“Money Management Q&A” ) that “A commissioned sales agent is incentivized to sell products that are good for the agent .... but not necessarily for you.”

I have grown my practice-as is the case with most insurance brokers-by doing what is best for my client. If I do not, my client soon discovers that fact and takes future business elsewhere.

 Just as a good doctor does not order unnecessary tests simply to produce practice revenue, I do not sell products simply to produce commissions. A good doctor builds his or her practice by doing what is best for the patient, and a good commissioned sales person builds his or her business by doing what is best for the client.

Alan Resnik

Chagrin Falls, Ohio

Focus on violent behavior rather than guns

Jeffrey Bendix’s editorial, “Gun Violence: A public health problem” (“From Med Ec,” January 10) fails to correctly address the real public health problem. The user, not the tool, is the problem. Your editorial should be titled instead: “Human violence: A public health problem.”

Our focus should be on the violent person, not the gun, the bomb, the knife, or the subway tracks. Identify the part that single parent or broken homes have in producing violent people: emotional and physical abuse and neglect, sexual abuse, drugs and alcohol;. domestic violence, interactive video games that desensitize children to the pain and suffering of others, or violent movies.

When police and surveillance video catch the shooter in the act, the shooter brags about the violent feat. We accept a plea of “not guilty,” and a trial is postponed almost indefinitely. If convicted, the perpetrator is ultimately back out among innocent citizens. The justice system is broken.

Eileen Marie Wayne, MD  

Moline, Illinois

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