I can recall it like yesterday. It was 2004, and I had become the CEO of Blue Cross & Blue Shield of Rhode Island. I was in the middle of my annual physical with my long-standing primary care physician, Dr. Richard Reiter (true). Dick Reiter is my age and is an old school doc. He caught my cancer before it got too serious, and had been yelling at me about things like cholesterol, stress, and exercise for years.
During a lull in the exam, I turned to him and asked, “Dick, I’m the CEO of Blue Cross. What do I need to know?” He paused, looking down. Then his cheek started to twitch. I actually saw him lose his temper for the first time in 25 plus years. “Jim, you want straight? What the bleep are you doing to us? A monkey can do a colonoscopy and yet they make four times what we primary care doctors make. What you are doing is a disgrace.” He was some pissed!!
I then had lunch with Dr. Al Puerini, a highly regarded PCP of 30 years with a full practice. I asked him how much he netted before taxes, and when he told me, I was appalled. He made some aside about it not being about the money, but it IS in part about the money. He also told me about how difficult it was to recruit new PCPs in RI.
Those two encounters started me down my path of alarm about the future of primary care. Rhode Island is a small (40×30 mile, one million population) microcosm of the country. While we have our accents and quirks, and people still think we’re overrun by the mafia, we’re not all that much different. Just wicked smaller. Our PCP population was aging and shrinking rapidly. The best and brightest from Brown Med School and others of its ilk were decidedly not swarming into primary care. Practices could not recruit new members. We were, and still are, in a crisis that is nation-wide.
And it didn’t stop with just the poor PCP reimbursement. PCPs cannot survive financially without untoward volume. This has all sorts of negative consequences. Moreover, on the totem pole of respect, PCPs do not seem to rank high for reasons that I simply cannot fathom. It seems that the more “miracle machines” a physician uses, the more respect he or she gets. While the poor PCP does what we in the billing world refer to as “E&M” (Evaluative and Maintenance). The look-you-in-the-eye, known-you-for-years sort of thing. In other words, taking basic tests and extrapolating health trajectories. Wading into gray areas. Knowing the patient and her family, and making informed prognoses. All difficult stuff. Not something that shows up on an LED screen. Ahhhh….judgment and perspective.