Health Care Reform Center

From the Publishers of the New England Journal of Medicine

Eliminating a Viable Primary Care Workforce — A Primary Care Perspective

Posted by NEJM • November 18th, 2009 • Printer-friendly

When physicians or health policy experts propose that the United States move to a single-payer health care system, with all doctors on salary,1 I find it disheartening: I am hoping for a practical, ethical, financially sound solution that would correct (at least partially) the problems in our system and preserve its strengths. We need a solution that recognizes our culture, our rapidly growing elderly population, the rejection of capitated health care by so many Americans, and the damage that our government’s Medicare program has done to primary health care for the elderly.

I could not spend the amount of time necessary to provide appropriate care to my general internal medicine patients if I depended on Medicare fees. And sadly, the care that I provide to dying patients on my palliative care service is essentially pro bono if the patient is on Medicaid or another government health care program for the indigent.

A single-payer system completely controlled by the government would be a variant of the slowly failing systems in the United Kingdom and Canada. It seems appropriate to recall the aphorism “those who do not learn from history are doomed to repeat it.” We have learned from history. I believe that the majority of my colleagues would agree that, though it was initially fair, Medicare is now driving medical students away from primary care through foolishly unfair reimbursement.

The sustainable growth rate (SGR) formula, which is scheduled to reduce Medicare’s physician fees by 21.5% one week after Christmas, will (because the overhead percentage for family practice physicians and general internists is, on average, 55 to 60%2) result in a cut in net income of at least 43%. The SGR is illustrative of what we could expect under a single-payer system. Given our required yearly attempts to repeal this absurd denial of the economic realities of medical practice, I find that my students have little interest in primary care. And indeed repeated studies have shown a dramatic decline in the proportion of students who choose careers in primary care.3,4 Tragically, since we depend on internists and family practitioners to provide the increasing number of palliative care specialists that our aging population requires, that specialty will be the next domino to fall.

The citizens of Britain and Canada are increasingly dissatisfied with their single-payer systems and are straining, with some success, to break the bonds of their tightly regulated, government-controlled health care. Grafting the British single-payer system with salaried doctors onto our current system is the wrong answer to a serious problem and is doomed to be rejected by U.S. physicians and patients; we should instead devote our energies to finding the right answer.

Melvyn L. Sterling, M.D.
1310 West Stewart Dr.
Orange, CA


Dr. Sterling reports receiving lecture fees from Wyeth. No other potential conflict of interest relevant to this article was reported.

This article (10.1056/NEJMopv0909479) was published on November 18, 2009, at NEJM.org.

References

  1. Relman AS. Doctors as the key to health care reform. N Engl J Med 2009;361:1225-1227. [Free Full Text]
  2. Medical Group Management Association. MGMA cost survey: 2009 report, based on 2008 data. Englewood, CO: MGMA, 2009.
  3. Bodenheimer T, Grumbach K, Berenson RA. A lifeline for primary care. N Engl J Med 2009;360:2693-2696. [Free Full Text]
  4. Colwill JM, Cultice J, Kruse RL. Will generalist physician supply meet demands of an increasing and aging population? Health Aff (Millwood) 2008;27:w232-w241. [Free Full Text]