Commentology: Thoughts on the Death of Primary Care

Commentology: Thoughts on the Death of Primary Care



Vance Harris MD writes:

We are our own worst enemies, as we have allowed insurance companies and Medicare to set the value of our services. Clearly those values they impose have nothing to do with our contribution to the health of our patients or the cost savings we bring about.

Case in point:

How many dozens of chest pain patients have I seen in the last month who I didn’t order an EKG, get a consult, set up nuclear imaging or send for a cath? Only I have the advantage of knowing just how anxious most of these patients are and that they have had the same symptoms time and again over the last 20 years. After a pointed history and exam, I am more than willing to make the call that 27 hours of chest pain is most likely not angina in nature. When I take the responsibility on my shoulders I am saving the system tens of thousands of dollars. Most of these patients present to my office directly and are worked into a busy day pushing me even deeper into that mire of tardiness for which I will be chastised by at least 6 patients before the end of the day. Most of those who scold me are retired and have more free time in a day than I get in a month. My reward for working these people in and making a call that puts me at some risk is at most $75 if I count the less than $25 I get paid for being able to read an EKG without sending it off to be interpreted by a cardiologist. My incentive pay for saving thousands of dollars on each patient for 1-2 days in the hospital, stress treadmill and cardiologist referral is $75. Now there is motivation on a busy day to not send someone to the ER.

How many times has an anxious patient come in, almost demanding an endoscopy, who I examined, after taking a good history, and then decided to treat for 3-4 weeks before making the referral? Few of these patients are happy with me after the visit, no matter how many times I explain that it is reasonable to treat their reflux symptoms for several weeks before considering endoscopy. This delay in referral has lead to many a tense moment in the last 20 years. Cost savings to the system is again thousands of dollars each and every time I do this. I am willing to make the call and go with the treatment first before getting the scope. My reward is about $55 from Medicare and the Big Blues.

How many low back pain patients have come to the office in agony knowing that there has to be something serious to cause this kind of pain? Again a good history and a directed exam allows me to reassure the patient that there is nothing we need to operate on and that the risk of missing anything in this setting is low. This takes a lot of time to explain as I teach them why they don’t need, and better yet, why they don’t want to get an MRI at this point. If someone else ordered the MRI guess who gets to explain the significance of bulging disks and narrowed foramen to an alarmed patient? Setting realistic expectations on recovery and avoiding needless imaging that rarely helps, in the acute setting of a normal exam, saves the system thousands of dollars again. My reward is another $55 if I am lucky.

How many times does a good shoulder exam allow me not to order an MRI giving the patient time to heal and recover before imaging racks up another couple of thousand dollars followed by orthopedic referral for a shoulder that doesn’t need surgery? Another $55 will shower down on me at the end of the day when I send off the bill for that exam.

How many basal cell and squamous cell cancers have I discovered while examining some ones shoulder or abdomen or even a sore throat? How many of those was I stupid enough to remove the same day, only to find out that I would be paid for only one procedure and it would always be the least expensive of the two? How many appeals have been successful to Medicare when I performed the service and was denied payment?

How many diabetics do I struggle with, trying to get them to take better care of themselves? How many hours have I spent with teenage diabetics who will not check their blood sugars and forget half of their insulin doses? I have spent hundreds of hours dealing with them and their families trying to effect changes that will someday allow them to get their disease under control. I do this because the only Endocrinologist in the county will not see pediatric diabetics. I can’t say that I blame him as the time spent seems like a total waste. That is, until one day they open their eyes and want to take care of themselves. My reward for years of struggle and years of 30 minute visits trying to get them to take responsibility for their health is a few hundred dollars at best. The savings to society for my hard work and never give up attitude is in the tens of thousands of dollars.

I continue on in my 22nd year giving advice and services to 30 plus patients each and every day. Having me in the system has resulted in savings in the hundreds of thousands of dollars each and every year. My financial incentive to hang in there and work hard is the following. Twenty years ago I made about twice as much as I do now. This year I will make less as it seems even more of the claims are being reviewed while payment sits in someone else’s account drawing interest.

I have always served my fellowman out of a sense of love and compassion and for those reasons I went into medicine. I have been richly rewarded by my patients over the decades as they appreciate my judgment and skills. Isn’t it a shame that after all this time and with skills honed by decades of experience, I can barely afford to work as a physician? Taxes will be collected, no pass for the working physician, not like the Goldman Sacks guys and their buddies with the 9 billion in bonuses given last year after the 58 billion in funds we gave them.

My parting words next year will be good luck having PA’s provide the safety net with their 2 years of training. Good luck getting newly trained physicians to take over once they see my salary. Good luck having internists in your community with only 1% of medical students going into Internal Medicine. Good luck recruiting the primary care specialists when you are short 70,000 now and 1/3 plan on retirement within 3 years.

If there is any irony in this at all, it is that I will find myself in the same boat as I struggle to find a doctor to take care of me. Now that is ironic. Anyone know who is taking new patients in California?

Vance Harris, MD

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34 Comments on "Commentology: Thoughts on the Death of Primary Care"

Amanda S.
Oct 1, 2009

This is a very good post. You make a great point about patients. We are anxious, always expecting the worst and demanding unnecessary treatment. In actuality, after a good physical exam, a doctor can give you a pretty good idea about what’s going on.
As a patient, I always have this desire to be immediately diagnosed, and I can see your point about how primary care is dying. I’m sure people are thinking why go to my primary doctor when I can have an MRI, X-Ray, etc. done right away … if I go to the ER?
Of course, I would never go to an ER before seeing my primary care doctor, but I know a lot of people who do. It’s a waste of money, in my opinion.

Sep 14, 2009

You are due for your Haldol shot.

Christina Marlowe
Aug 27, 2009

MD as Hell is quite obviously a brainless thug–probably lobotomized in the late 1970’s, and then injected with venom. Probably carries a gun, too. You see, I live in a world, Mr Mad as Hell, where people help each other. We are kind and compassionate, and yes, we all work hard; we walk the walk while you and all the others just like you, are devils incarnate, if you believe in such nonsense. Yes, you are plain evil and really quite hateful. All of this is truly your fault, all of it. Blame yourself, you idiot, because you certainly cannot blame ME. Furthermore, Mr. Mad as Hell, as you burn in your own stupid and blind fury, I, on the other hand, enjoy thoroughly the world in which I live. It really is a very happy place as I chose to keep people like you where you belong: in your very own, self-made gutter.
By the way, I don’t believe for a second your rap about god and Jesus and all of that other hypocritical right-wing garbage; you see, I AM A PERFECT HUMAN BEING!!
CHRIST…ina Marlowe

Aug 25, 2009

Brave words. all this reform has come to a point where i am seriously thinking about leaving the US just for health care, A friend did it already and he had a tremendous success. see more at

Aug 24, 2009

“Christina was dropped from her insurance when she got sick.”
This is a complete and utter lie unless it happened 15 years ago. The ONLY ways for an insurance company to drop an individual is to pull out of the state and stop offering insurance to all of those policies. The second way is fraud, if she lied to get coverage in the first place then they found out they could cancel her. It did not happen like she is trying to lead people to believe.
“Then, if they have a pre-existing condition, they are in trouble.”
Again with HIPAA and various state laws this is just no longer true. There is a very very small % of the population that wants insurance and is denied and even they almost always made mistakes that created the situation. Your chastising a system for short comings that where fixed 15 to 22 years ago.
“It’s not “free lunch”, it’s the way “insurance” works.”
Actually that is not how insurance works. What we pay for Medicare is a tax to pay benefits for existing policy holders, it is by no means premium for our future benefits. This is evidenced by the fact today’s premium could not even begin to be covered by what beneficiaries paid in premium. Even with Obamaesqu return projections what today’s seniors paid in “premium” would not buy them half the coverage they have today. MD’s argument is still accurate that if you paid premium for your standing house and MD waited till his burnt down you would be upset if the insurance company sold him a policy, rebuilt his house, then raised your rates.
“A young person can buy an individual plan for about $120 per month.”
Actually they can buy one for $40-$50 a month. Since they are young and healthy the smart thing to do would be to buy an HSA for $40 a month and then put $20-$30 a month into the account and start building it up. If people saved in their younger years we wouldn’t have the financial issues in our older years. Before Medicare passed 85% of seniors had enough savings to pay for all of their healthcare, that is a scenario we need to return to.

Aug 24, 2009

I believe young people should have health insurance. I do not believe they should be forced to have health insurance.
A young person can buy an individual plan for about $120 per month. That is a lot of money for a 22 year old male who is unmarried and not likely to ever need anything major. That person runs a small risk which he can choose to take or can choose to buy coverage.
The government wants to force him to buy coverage. The only reason they want to force him to buy coverage is to get money from him that is not a “tax” in the political sense. He will likely never need to use the coverage.
My point is freedom of choice. Freedom from government.
The ideal time to buy insurance is when your health and costs might impact your spouse or child. In addition, women should buy insurance when they may become pregnant.

Aug 23, 2009

Well, $75 is not bad at all. If you were a Canadian primary care doc, your fee would have been around $40 canadian dollars and that’s with higher taxes. We all know how wonderful Canadian system is so cheer up and look forward to getting paid $35 for the same work in a few years time. :)

Jitesh Chawla
Aug 23, 2009

In response to Economics 101’s comment, I think the reason a lot of doctors don’t go into Family Practice or Primary Care is because it is easier to let someone else deal with the headache of “being on the frontline” with patients’ call for narcs, etc. while being paid much more.

PA in Montana
Aug 23, 2009

Dear Dr. Vance,
There are probably a few really good PAs who are taking new patients in California right now, and who could care for you with excellence not found in recent MD grads…
One cannot perpetuate the same arrogance and bull shit that is bringing you down and blame somebody else…yeah, the system is broken…we all make less than we made 20 years ago…may we find a way to get health care for all…in spite of the arrogance of medical professionals (like guess who?) who believe their years spent in medical school equal excellent care for human beings.
I know many mid-level practitioners doing brilliant and compassionate work, just as I know many MDs who fail to pass the tests required of humans to treat other humans well.
So complain, if you like, but don’t put down my profession. It makes our battle even harder. It turns those of us providing primary care against each other…and guess who wins? (not the people, not the primary care providers, be they MDs, PAs or FNPs) but the same status quo insurance companies that have been dictating health care for many years now.
The death of primary care?


Excellent post, I would add that this plight affects most of medicine, not just primary care. Try explaining my call schedule of every third night, an average work week of over 100 hrs, caring for the complicated post-surgical patient for a single fee for 90 days where I sit at the bedside for nights on end neglecting my family and personal life, assuming care for anyone in the ED and treating them exactly the same regardless of insurance or legal status…the hourly reimbursement would shock any worker….but I wouldn’t trade it for anything…and therein lies the problem.
We are the easy targets because as long as we relish our art and hold to the altruistic motives, our apparent worth to society will continue to diminish. It is beyond logic to understand why we continually bear the brunt of cost-reduction, when the insurance and pharmaceutical executives would never budge from their salaries..and worst of all they are not even being asked to.
Its time to wake-up docs. If we don’t join our collective voices and press the true value of what we offer to the health care collective, then we deserve what we get. Unfortunately it may be too late.

Aug 23, 2009

MD as HELL, you outdo yourself with stupidity in this thread. “No fee no service?” Really? You mean like the horrible Mayo Clinic and Cleveland clinic? What about the many millions of salaried employees working in productive and profitable industries across the United States? You don’t even have a point, just bile.
As for Christina, I’m not sure her story is true, but if it is: of course she paid for MediCal and Medicaid; they are funded through taxes. She indicated she had a job before she got into medical/financial trouble, so she has paid some if not all of her coverage through taxes.
Incidentally, for her to say that MediCal and Medicaid are excellent is a little strange. As we all know, they pay so poorly relative to other forms of insurance that physicians often avoid these patients or refuse to see them entirely. I’d like to know more about what was so awesome…low cost-sharing?
And Christina, you are out to lunch on the profits of insurers. Private health insurance has become (once again) the scapegoat in the health reform debate, and you are just along for the ride. It is not even remotely one of the most profitable industries in the US. Average net income (profit) is around 3%. Compare that to Big Pharma at 17%. Also compare it to the hospital industry, also around 3%. The average profit margin for all US industries is over 5%, so health insurance is a sub-par industry for profitability.
I remember the dog days in the run up to the Iraq war when we were being fed dubious rationales for invasion. Hyperbolic, paranoid thoughts were presented as though they were the shrewd conclusions of deliberate people. I felt like we were sliding into a dark age, and so I joined the Howard Dean campaign and spent the next 9 months of my life devoted to electoral politics because I felt like I had to do something. In some ways, the vilification of insurers now feels quite similar to me. But this time the Left has lost its way and is working itself into a self-righteous rage to remove private insurers from the face of the earth.
It isn’t as sinister, but it is as misguided, unnecessary and ultimately probably self-destructive. I’m proud to say that I’m one of the very few to have not lost my mind in either of these episodes.
More cortex, less amygdala.

J Bean
Aug 23, 2009

You are actually having some reading comprehension trouble there. Christina was dropped from her insurance when she got sick. It happens. People also lose their insurance when their employers stop buying it, when they get laid off, when a spouse retires or dies, and when they get divorced. Then, if they have a pre-existing condition, they are in trouble.
Cnristina is lucky, because she has been paying for state-sponsored disability insurance her entire working life. (Socialized disability insurance … ooogah-boogah … scary!) Now that she is sick, she qualifies to collect it. It’s not “free lunch”, it’s the way “insurance” works. If, god forbid, your house were to burn down, your insurance would pay to rebuild it. Meanwhile, I’d be paying for homeowners insurance on my own, perfectly intact house. You wouldn’t be getting a “free lunch” at my expense, either. By your standards, it appears that anyone who is too sick to work should just die.

Aug 23, 2009

There is something I don’t quite understand. I may be totally misunderstanding your posts, but at times it seems that you don’t necessarily believe that the young and healthy should purchase health insurance. On the other hand, you just said above that you shouldn’t expect to be able to purchase insurance after you get sick. So what exactly is the optimal time for one to buy health insurance?

Aug 23, 2009

Christina, you ignorant ingrate.
Both Medicare and Medical are “excellent” because you paid NOTHING…everyone’s dream. Every free lunch is excellent. Those excellent programs are going broke because they had no actuarial foundation.
If your condition was pre-existing, you knew that. What are you mad about? It is not insurance if you can sign up after you are sick…it is fraud. You cannot get flood insurance on the coast of North Carolina when the hurricane is already eroding the beach. What makes you think pre-existing conditions should be covered? If you had no insurance before, it was poor planning on your part.
Next you will want life insurance without underwriting.
Do you not realize this is all about more revenue from people who at this time choose to not pay for insurance? Those already paying are already paying. Watch out, young and healthy people. You are the next contestant on “The Tax is Right”.

Christina Marlowe
Aug 23, 2009

To all the [health care] industry whoring politicians who are lying, treacherous and, of course, in cahoots with the industry titans:
When my private (and expensive) health care “insurance” company dropped me, citing my illness as not only pre-existing but excluded from coverage anyway, I had to go onto Medi-Cal (California’s Medi-Caid program) and Medi-Care. Both are government-run programs. Both are excellent. I couldn’t be happier.
It just amazes me that a full and startling half of all Americans are not only completely uninformed but so, well, so unbelievably stupid. Each one of these idiots shoot themselves in the foot every time they cast a vote and none of them even realize for what or for whom they’re fighting. Is it that they really want to keep the health care industry CEO’s, CFO’s, et al raking in billions of dollars for themselves, while they, these morons, keep paying more and more for (increasingly) ABSOLUTELY NOTHING?!?
If I was mean-spirited I would wish for them, that is, for each one of these idiotic Republicans, to have a serious and/or chronic illness which would not be covered by their wonderful (preposterous) health care “insurance.”
By the way, if people have not figured it out yet, I’m happy to spell it out here: [Profit-driven] Health Care “insurance” is one of the biggest and most profitable SCAMS in history…
The (mostly) Republican politicians are greedy, thieving, self-centered and quite hypocritical while the Republican citizens are incredibly stupid and self-defeating.
Christina Marlowe