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The week of June 15 to 26, 2009, was bittersweet for those of us who care about primary care. President Barack Obama addressed the American Medical Association, emphasizing the central role that primary care must play in health care reform.2 We then learned of the death of Dr. Lynn Carmichael, a founder of the modern field of family medicine.3 The roller coaster continued with the publication in the Journal of two articles about the crisis in primary care, detailing the moribund state of primary care4 and the policies proposed for resuscitating it.1 I believe that these proposed policy reforms are doomed to fail, because they ignore the impact of managed care on remuneration.
Primary care was supposed to be paramount under managed care. "We need you to be gate keepers," we were told, "and we'll pay you well to perform that service." In actuality, remuneration for primary care decreased under managed care, as contracts were negotiated solely on the basis of cost. Continuity of care was disrupted, as managed care relegated primary care doctors to ambulatory settings, replaced them with nurse practitioners or physician assistants, and utilized hospitalists for inpatient care. Worse, patient panels were dissolved and reassembled annually during open enrollment, as companies negotiated not with doctors, but with employers.
So how can we fix the problem? Why not simply mandate that all payers, public or private, pay a capitation fee or salary designed to assure that primary care doctors can achieve a professional standard of living? In exchange, primary care doctors would provide continuing, comprehensive primary care (including night call and preventive services) for a reasonably sized panel of patients. For the sake of discussion, I would suggest a salary and fringe benefit package of about $300,000 per year (in 2009 dollars) to care for 2000 patients, ($150 per patient), with incentives for special circumstances (e.g., working in underserved communities) or special services (e.g., delivering babies). All other fees, deductibles, and copayments would be waived. The problem of physician-generated demand would be eliminated, which would radically reduce costs to insurers. Billing would disappear. Patients would have open access to their primary care physicians. Freed from the constraints of billing for the traditional encounter, primary care doctors could employ innovative methods to deliver primary care, including the Internet and group encounters.
Arthur M. Fournier, M.D.
University of Miami Leonard Miller School of Medicine
Miami, FL
This article (10.1056/NEJMopv0907129) was published on August 19, 2009, at NEJM.org.
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