Where is Marcus Welby when you need him?

By Philip Caper, M.D.
Bangor Daily News (Maine), April 19, 2012

Marcus Welby, M.D., the iconic general practitioner of 1970s TV, will probably never make a comeback. As I described last month, the overwhelming preference of young doctors is to go into medical specialties rather than primary care, mostly due to the much greater earning power of specialists.

But there is another reason for this trend. During the past few decades, medical knowledge has dramatically expanded and many doctors decided that to keep up in their fields, they had to specialize.

This has led to a proliferation of specialists and subspecialists, resulting in growing fragmentation of medical care from a patient’s perspective and creating a medical maze that many have trouble negotiating. It has also created gaps in the continuity of care.

The federal health care reform law creates many programs designed to deal with this problem. They may not be enough. But even without them, changes in the way medical care is delivered are taking place at an accelerating pace.

Hospitals are consolidating and buying up doctors’ practices and other health care providers such as home health agencies, nursing homes and laboratories. Four systems are emerging in Maine centered around Bangor, Augusta, Lewiston-Auburn and Portland, and around 80 percent of Maine’s doctors are employed by one of them.

As a result, solo practitioners such as Dr. Welby will mostly be replaced by teams of health care workers who will function under the umbrella of these emerging health care systems, no longer earning money solely by directly providing services. They will earn their increased incomes by saving money through better management of more expensive technology.

Spurred on by the federal government, doctors and hospitals are adopting electronic systems for financial, administrative and clinical records to help control costs and improve quality or efficiency. But they will succeed if, and only if, the financial incentives that drive so much of our behavior in health care are reformed.

Already under way is a movement away from fee-for-service and toward so-called bundled payments. Rather than paying for each individual service, payers such as health insurers and government will pay a flat rate to a health care system for all services for a group of beneficiaries.

Health care systems, no longer constrained by a specific list of reimbursable services, will be able to expand the range of benefits they provide, as long as they don’t exceed their budget. They can do this by substituting low-cost services that are not now reimbursable but may be more appropriate, such as nursing home or home care, for more expensive high-tech services such as hospital care.

But just as fee-for-service can be abused by encouraging too many services, bundled payments can be abused by creating incentives to provide too little care. Most health care professionals would fight energetically against this temptation. The majority of us are committed to doing what’s right for our patients and are not businessmen at heart.

The culture of health care must change, and return to one driven by a nonprofit mission of healing, not the bottom line.

Rising health care costs are crippling our ability as communities, states and as a nation to address other needs. They are eating into our wages and our ability to fund education, infrastructure, public safety, economic security and other priorities.

In almost all other wealthy countries, the level of public satisfaction with health care is much higher than it is in the U.S. despite much lower spending. In those countries, everybody is in the same nonprofit system, and people feel they are being treated fairly.

Compare that with the endless bickering, disinformation, class and age conflict and fear-mongering that permeates the debate about health care in the U.S. Much of that conflict is driven by arguments about money — who pays, who benefits and how much.

A single, nonprofit health care system in Maine and the U.S. would go a long way toward fixing that problem.

Physician Philip Caper of Brooklin is a founding board member of Maine AllCare, a nonpartisan, nonprofit group committed to making health care in Maine universal, accessible and affordable for all. He can be reached at