Primary care doctors are going the way of the dinosaurs

By Philip Caper
Bangor Daily News, March 15, 2012

Health care reform has to be about more than just expanding health insurance coverage. It also has to be about making sure everyone has access to high-quality health care at a reasonable cost.

Most other wealthy countries provide health care to all of their residents, get as good or better results and pay an average of about half what we do per person. It’s generally agreed that one of the important factors is heavy reliance on primary caregivers.

Primary care is the portal through which most of us should enter the health care system. Other countries have about two primary care doctors for every specialist. We have about two specialists for every primary care doctors and it’s about to get worse. The number of young doctors choosing primary care in the U.S. is declining. It’s now fewer than 20 percent.

Yet the demand for primary care is growing due in part to the aging of our population. This is a big deal. The reasons for the dwindling numbers of primary care physicians are not hard to understand. Specialists have more prestige, generally have more control over their lives and can make much more money.

If young doctors, who often incur a lot of debt during their education, choose to specialize, they can make two to four times as much as they can as a primary care physician. That adds up to several millions of dollars over the course of a career.

This huge difference in earning power is largely a result of how doctors are paid and is pushing them away from primary care and toward a more lucrative specialty. This discrepancy was never planned, but it’s no accident either. Under the fee-for-service system, payment is for piecework. Doctors are paid for patient visits. Specialists are able to charge more than primary caregivers.

Revenue can be increased by shortening visits and cramming more of them into a day. But that shortchanges patients. By its nature, good primary care requires intimate knowledge of the patient, something that can’t be adequately accomplished in 15-minute increments.

In addition, specialists are paid for sophisticated tests and procedures that may require little of their time but can be very lucrative. It is much easier to maximize the number of tests and procedures than the number of visits.

In the past, this differential in income may have been justified because specialists required much more training than primary care doctors. That’s no longer the case. Primary care doctors now receive about as much training as many specialists. Yet the differential has stubbornly persisted despite serious efforts to level the playing field, due largely to the wealth and political clout of specialists and their corporate allies. Tweaks to the way we pay doctors will not solve this problem.

A few years ago, I was asked to help a group of young physicians-in-training understand why it seemed so hard to become a primary care doctor. After I ran through the list of barriers, I asked them why anyone would want to go into primary care. Their indignant answer: “Because we went to medical school to be doctors!”

Most people don’t become doctors primarily for the money. They don’t object to being well compensated (who would?), but that’s not what drives them. Most are motivated by wanting to help people and being good at it. But the health care system works against such altruism.

What makes primary caregivers so valuable? Let’s take another example. If you were to build a house but decided to use only subcontractors and you had no general contractor or overall budget, you might end up with a collection of superb parts. But the house could be very expensive and may not work very well.

Primary caregivers are much like general contractors. Ideally, they possess a deep understanding of their patients and their values, and a broad knowledge of illness and its causes. They also decide which treatments to prescribe, and which, if any, specialists to call in. They provide services directly and they manage and optimize expensive specialty resources. In doing so, they save more than they cost and often produce a better result.

Primary care doctors are on the path to extinction. If we are to provide health care for everyone, we have to find ways to reverse this trend. In my next column, I’ll suggest some of them.

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