I just received my JAMA in the mail today. There it was. "Unintended Consequences of Resource-Based Relative Value Scale Reimbursement". Commentary by Dr John D. Goodson, MD, Department of Medicine, Harvard Medical School.
I can assure you I did not go to Harvard. But the unintended consequences of health care reform are a constant. And you can get that thought provoking truth here at The Happy Hospitalist. And my blog is free. And if you have been reading anything in the last month, you will see I have been blogging continuously about the inequalities on so many levels. Striking inequalities called Medicare Part B. The inequalities that trickle through Part A and now Part D with disastrous financial consequences.
Almost word for word, every single point of interest I have brought up in the last month was so eloquently displayed across the pages of the prestigious JAMA. By an Ivory Tower Doc. The doc that travels. Gives speeches. Talks to Congress. Sells books. Writes chapters in medical books. Writes commentary to JAMA.
Climbs the academia ladder filled with similarly enlarged egos, each feeding on each other to see who can publish more often, more funding, more research, more pats on the back.
And again, my blog is free. The ending commentary was a shot across the bow of the single payer fanatics. You can't have primary care for all if you don't have primary care docs for all. It is an impossible feat. The same government that gives us the ridiculous RVU system with all its engrained faults, creating the inequalities among physicians and causing us the death of primary care. This is the same government that would run the single payer health care for all. Access for all, but no where to go. Welcome to the new Medicare. It is an impossible feat. It will never happen in the current state of access, education, cost and incentive systems.
His quote:
Without a robust, well-supported, appropriately compensated and self-sustaining generalist workforce, the majority of the US population will not be able to benefit from the powerfully effective interventions for the asymptomatic patients whose only contact with the health care system is through generalists. Furthermore, broad and affordable universal access to health care will not be possible without a solid base of generalists who can deliver care and organize appropriate referrals.
Let me give you some more free commentary of my own, free of academia ego.
If primary care is walking out of the system set up by our government, currently 50% of the system, the government that would control primary care, how does any one believe that primary care would stay in it with 100% financing, single payer for all.
Let me answer you. They wouldn't. And they aren't now. Less than 15%. Startling. Bravo Dr Goodson. One million kudos to bringing this, which is obvious to me, into the major print of the Ivory Tower medicine. Maybe the forces that create disastrous policies will believe you of the academia broth. The Harvards of the world. My commentary is free, from the trenches and oh so real. I see the results of this failed Medicare policy every day by way of out of control diseases, when specialists must get involved to whack off limbs, cut chest cavities and place feeding tubes for massive strokes.
Stuff that could be prevented if only primary care could survive and thrive. And was given time to cogitate. The current state of primary care is dead. It is Oh so sad.
They'll just hire "Physician extenders" to fill in the blank. There is a bumper crop of doctor wannabees. The state of TN actually now has a "doctorate" level course in one of it univesities, so nurse practitioners can be a "doctor" for real.
ReplyDeletefree of academia ego.
ReplyDeleteThis, sir, is also generalization. I'm not academic, but I sure met SOME reasonable faculty. But that was a while ago.
I would like you to carefully evaluate your assumption that a single payer system would screw primary care. Lots of countries with single payer systems compensate primary care well, and deliver quality.
The balance between quality and access is not a guarantee the market will provide. Neither does a single payer system.
I thought some about your big money experiment. I would make consumers frugal with their first health care dollars, but the usless/harmfull bone marrow transplants after surgery, radiation, chemo would be, "What the heck? It's on the government." (Kinda like now)
I think you are trying to reinstill personal responsibility in the health care system(both consumers, docs). Good for you. But any system will have drawbacks and the balance will need to be drawn on a policy level. So who will set the policy?
Happy TGving.
You have a lot more faith in the Government than I do. I believe you completely when you say that Internal Medicine "...is by far one of the most cognitively challenging fields which carries with it the need to understand how chronic illness interacts, on so many fronts."
ReplyDeleteBut that won't stop Big Brother from trying to replace docs with FNP's. They only think about what is politically expediant, and not about the ultimate ends.
why would physician extenders consider primary care? it sucks for them the same as for everyone else. they will go into the more lucrative fields as well. or they will be hospitalists rather than clinic providers.
ReplyDeletebut the usless/harmfull bone marrow transplants after surgery, radiation, chemo would be..
ReplyDelete"sir" speaking of a generalization...you just made a big one. This isn't the 90's. BMT is not done on breast cancer patients anymore. Why don't you review the present indications for BMT and the survival rates (and cure rates) for what otherwise would be a death sentance. You would be surprised.
HH:
I too began my medical life as a clinic PCP. PE's have their place but anybody wqho thinks a PE is the same thing as a board-certified IM or FP is fooling themselves. I can't tell you the number of times I have seen a PE get in over their head without even realizing they were over their head. Along those lines is the idea that a PE can easily be a hospitalist. As an ex-hospitalist we have had to let go of several PE's for the simple fact that they didn't know their limits and call for help. There is a place for PE's in the hospital (straightforward ortho post op c/s etc), but thinking that a PE can take care of patients with multi-system organ dysfunction as well as an experienced doc is simply foolish.