QUALITY: Valuing Primary Care

Stop the world. Primary care doctors want to get off.

A survey by the Physicians' Foundation, which promotes better doctor-patient relationships, found that nearly half the primary care physicians would do something else if they could. Patients aren't the headaches, as much as red tape from both private insurers and government programs.

We already have a shortage of primary care doctors (family medicine, internal medicine, pediatrics, geriatrics etc). A CNN report on the survey noted that the AMA recently predicted the shortfall would grow to around 40,000 by 2025. For reasons of prestige, money and lifestyle—some of which is built into a medical payment system that favors specialty medicine over primary care—med students are opting for specialties like orthopedics and dermatology over primary medicine. (The New England Journal of Medicine recently published a series of Perspectives on Primary Care, and the full texts are available free here)

Ted Epperly, president of the American Academy of Family Physicians, told USA Today that the health care system "tends to undervalue what it is that a primary care doctor does."

CNN spotlighted Dr. Alan Pocinki, who began practicing 17 years ago around when insurers were turning to the PPO and HMO models. He says he was both surprised and frustrated when he began spending more time on paperwork than patients and found he was running a small business, instead of a practice.

"I had no business training, as far as how to run a business, or how to evaluate different plans," Pocinki says. "It was a whole brave new world and I had to sort of learn on the fly."

Some doctors are going into "boutique" medicine, charging patients an annual fee but promising to spend more time with them. Others, like  Pocinki, are limiting the type of insurance they'll take and the number of patients on Medicare and Medicaid. According to the foundation's report, over a third of those surveyed have closed their practices to Medicaid patients and 12 percent have closed their practices to Medicare patients.

Some people worry that expanding health coverage could exacerbate the primary care shortage. But health reform should be more than expanding coverage (although that of course is essential.) It should be about reorienting the whole system, making it more about wellness and prevention and coordination and disease disease management. That means changing how we deliver care, changing how we pay for care. And that means making sure that we begin to show that we understand the value of primary care.