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Primary Care Docs Ask Permission To Be Next In Line: We Need A Bailout

By Alan Dappen, MD

Photo of Alan Dappen

Alan Dappen, MD

Believe it or not, this headline paraphrases the recent lead article from the American Medical News,  covering a comprehensive, white paper published  by the American College of Physicians (ACP).  The article reviews the state of primary care physicians.  The conclusion: since primary care doctors are essential to control the spiraling costs of health care, a bailout is necessary to shore up their rapidly shrinking ranks.

To understand why they argue a bailout is needed, we must look at what caused the crisis. Primary care doctors are drowning in red tape, as my partner Steve Simmons mentioned last week.  Over the past 20 years have come bureaucracies and regulations with acronyms like OSHA, CLIA, HIPPA, CPT, ICD-9, P4P.  Drops led to trickles: more complex certification and increasing malpractice risk.  Then trickles formed streams of data that is required of practitioners: quality reporting, management reports, productivity measures, electronic medical record systems, billing reports. Finally, the flood of information needed to stay in compliance with Medicare, Medicaid and insurance regulations swamps primary care providers.

The creative and intellectual focus of primary care physicians has been diverted to understanding this new world order of business contracts, negotiated rates, billing details, payment denials, coding, and non-compensated services. This is no game. It means the difference between medical practices staying afloat or going under. There are now thousands of reasons a doctor can lose money by getting fined, sued, or refused reimbursement.

Family doctors and internists have grown weary. They feel underappreciated by their patients, undervalued by the specialists, underpaid by the insurance company, overworked to meet expenses, and overexposed to malpractice risk.  U.S. medical graduates entering family medicine residencies dropped by 50% over 10 years and are now filled mostly by non-US trained physicians. American medical graduates now rush to specialties where they make better money, gain higher status and/or achieve better control of their work schedules. To keep primary care doctors in adequate supply, so the argument goes, system subsidies and readjustments are needed.

Outsiders easily “get” what went wrong the auto and financial industries.  These industry execs standing in line for handouts make most of us angry. They refused to do so many things to avoid their plight: innovate, stand up to wrongs, worry about sustainability, take responsibility, invest in a new future, even ”bending the truth” and turning  a blind eye was fine as long as there were profits. They say that Americans didn’t want “the truth.” They want us to believe that they are victims of circumstances beyond their control. What should we think of primary care doctors who put themselves on the same playing fields as these execs asking for a bailout?

Internists and family doctors are the backbone of a vibrant healthcare system that is cost-effective [see later blog post to learn why]. But, for far too long we in primary care have piggybacked on the insurance systems, relying on them to pay the bills, even when the costs of administering that is more expensive than the care provided in most cases.  This has slowly weakened our doctor-patient relationships and our advocacy for patients, thus compromising our power and professionalism. By casting its lot with third party payers, primary care essentially has announced that it wants someone else to fix the problem of affordable care.

I feel that the solution to primary care is simple. We should not be looking for a bailout. Instead, primary care doctors must step up to initiate change. Personally, I stopped waiting for someone else to rescue me or tell me how to do my job, promising they could make me happy. The restructuring I’m suggesting to revitalize primary care is that patients retain control of the funds they (and their employers) have been giving to the insurance companies for their day-to-day care (which now account  for about 30% of total costs), and directly purchase the services they need from doctors who serve them best. Doctors in Oregon (, New York City ( and Northern Virginia  ( already have set up such practices. These doctors have developed innovative business models that deliver better care to patients at much lower cost.  But these will only spread on a large scale if patients understand the value of these new business models, and flock to support them.

More details about the changes needed can be found on our website or by listening to our story with “The Story” on National Public Radio, and in this blog in the coming weeks.

Until then, I remain yours in primary care,

Alan Dappen, MD

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