Opinion: It’s time our primary thought is primary care

WLFI File Photo
WLFI File Photo

Editor’s note: Jonathan Staloff is a senior at Brown University studying community health. While at Brown, he was president of CareFree Clinic, an undergraduate student group that connects Rhode Island’s uninsured population with free primary care.

(CNN) — Coming home from school for the holidays has its perks: cable television, home-cooked meals, not having mice as roommates — the holy triumvirate of luxurious living.

Still, it has its drawbacks. Among the most exhausting parts of being home, particularly as a college senior applying to medical school, is the conversation I find myself in with every relative, family friend and minor acquaintance I’ve ever known.

I’ve become pretty efficient in these conversations, as they frequently center on the same question: What kind of doctor do I want to be?

The true answer is: I don’t know. However, while my answer is as uninteresting as it is brief, the response it elicits time and time again never fails to fascinate me: “Whatever you do, make sure you specialize. Don’t go into primary care.”

On the surface, I understand their advice. Why spend hundreds of thousands of dollars on eight years of schooling only to make $200,000 as a primary care doctor, when I can make almost triple that amount as a specialist and give my mom the joy of talking about her son, the cardiothoracic surgeon?

Still, for the life of me I cannot remember the name of that neurologist I once saw when I had those annoying headaches or that endocrinologist I went to when I was afraid I was too short.

Yet without hesitation, I’ll affectionately tell you the name of the doctor who has cared for me for the past 21 years.

Medical specialists enjoy an unparalleled prestige in this country, and a paycheck to match.

Our health care system centers itself around specialty care and belittles the care provided by “regular doctors.”

Primary care accounts for roughly half our visits to the doctor, and yet only 30% of payments to doctors’ offices.

Surprisingly, our disproportionate investment in specialty care isn’t delivering the expected results. In one Health Affairs study of 99.9% of America’s counties, investigators found that counties dominated by specialists had higher mortality rates from heart disease, cancer, and neonatal death than those with more primary care physicians, not to mention higher surgical rates and overall health care costs.

Doctor shortage, increased demand could crash health care system

Our primary care shortage is not limited to just a few counties. The need is national, and its consequences severe.

The Centers for Disease Control and Prevention reports that 133 million Americans are living with at least one chronic illness, accounting for more than 75% of all health care costs and 70% of annual deaths.

The tragic irony is that chronic illnesses, notably heart disease, certain cancers, and diabetes, are largely preventable. Maybe we’re so sick in this country because we prioritize treating sickness over maintaining health, fixing our problems instead of preventing them.

It’s time we realized that doctors can be our partners in health, not just reversers of illness. It’s time we valued the heart attack that never was as much as the heart attack patient narrowly saved. It’s time we placed a premium on primary care.

As health care reform takes full force, we must concern ourselves not only with how our health will be insured, but with how it will be delivered.

With tens of millions of Americans becoming insured for the first time, we need primary care doctors now more than ever.

Acknowledging this need, the Affordable Care Act is testing innovative new payment mechanisms to encourage and reward effective primary care, the most notable of which is the formation of Accountable Care Organizations.

Traditionally, primary care doctors have been paid on a “fee for service” basis, meaning that physicians are reimbursed predetermined amounts for the particular service they provided. This payment mechanism gave primary care doctors an incentive to provide a long list of services, whether necessary or not, just to scrape by.

In the new model, spearheaded by Medicare, doctors are encouraged to form Accountable Care Organizations where doctors will be rewarded not just for services provided, but also for value added to the patient.

Appreciating that quality primary care has the power to prevent expensive hospitalizations and trips to the emergency room, physicians participating in an ACO can receive a portion of the money that insurance companies save as a result of their services.

This new model, if successful, has the potential to both reemphasize our health system around primary care and curb the rising cost of health care.

Doctors working in fast-food restaurants

Despite Obamacare’s best efforts, a career in primary care still lacks the same allure as specialization. One recent study in the Journal of the American Medical Association indicated that only 22% of internal medicine residents aim to practice primary care. Why is it sexier to treat organs in the United States than it is to treat people?

If we are to secure a healthier America, we are going to need providers who know our names without having to look at a chart. No payment reform is going to build the army of primary care physicians we need; only a culture shift can do that.

It’s still true that I don’t know if I want to be part of that army. The next time I come home for the holidays, however, I sure hope someone tells me I should.

The opinions expressed in this article are solely those of Jonathan Staloff.

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