Kevin Pho has a good op-ed in USA Today about ER overcrowding. He correctly points out that much of the problem can be attributed to the increasing difficulty patients have accessing primary care:
A recent study in JAMA showed that patients with health insurance were primarily responsible for the increase of emergency services over the past decade. Lack of access to an available doctor is the major reason.
So, why has access to primary care physicians constricted so much in the last couple of decades?
Even though primary care physicians can treat many emergency department cases, their numbers are decreasing because of wide salary and lifestyle disparities when compared with their specialist counterparts.
These salary disparities are the direct result of government price controls. The payment amount doctors receive for Medicare and Medicaid patients is arbitrarily set at absurdly low levels by CMS.
This also depresses the payment physicians receive from commercial insurers because many of these carriers base their payment schedules on those arbitrary CMS rates.
The result is that primary care physicians can’t afford to take new patients if they have Medicare, Medicaid or any insurance plan whose payment schedule is based on the CMS model.
These price controls also reduce the number of medical students willing to go into primary care. They just aren’t willing to endure medical school, residency, and crushing debt for the privilege of working for a pittance.
Price controls always (always) produce shortages. In this case, they have created a shortage of primary care physicians which has in turn created the increasingly serious problem of ER overcrowding.
Naturally, those boneheads who now control Congress plan to “fix” this situation with (you guessed it) more heavy-handed government meddling in the health care marketplace.
The solution to the ER overcrowding situation, as I have pointed out many times before, is to get rid of the price controls. Let PCPs charge what the market will bear, and the problem will be gone in less than a decade.
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Great post. As someone who is starting medical school next year (changing careers), I’m not even considering primary care (unless I bomb Step 1, of course). The debt incurred is just too great not to specialize. One of the private schools I interviewed at listed their total cost of attendance at $264,000. If you borrow all of that, interest is running on most of that throughout all of medical school and residency. This means you’re looking at over 300 grand to pay back. Try going up against that millstone on a pediatrician’s salary while supporting a family, mortgage, etc.
I’m actually going to a much cheaper state school and am lucky enough to be paying for most of it out-of-pocket. I still won’t consider primary care because it’s just not worth the years of abuse for barely more than my crappy IT jobs have paid.
Posted 03 Dec 2008 at 11:11 pm ¶‘This also depresses the payment physicians receive from commercial insurers because many of these carriers base their payment schedules on those arbitrary CMS rates.’
Sorry - if market forces were working the obvious demand for primary care would see private insurers funneling cash into the sector. I agree that your government needs to make higher investment in primary care but it has to be planned to ensure that the workforce and geographical coverage are in place. For a superb model of primary care practitioners, where individuals or groups are private contractors to the government, look no further than the UK where anyone can see a doctor free of charge the same day for any urgent appointment.
Posted 04 Dec 2008 at 6:00 am ¶Marc,
So we can all basically assume that you’re an NHS fonctionnaire? Are you high up in the organization?
Posted 04 Dec 2008 at 10:14 am ¶‘So we can all basically assume that you’re an NHS fonctionnaire?’
No, just an ordinary citizen with my family registered with a local primary care practice, although I do some consultancy work with various health organisations around Europe. Believe it or not, the NHS is highly valued by the vast majority of Britons, not least because of general practitioners (GPs) instantly accessible with no fee in every locality by everyone, poor or rich. Filling a prescription is free to many, such as children, and in any case the flat rate for any drug prescribed by a GP is about $10. You do understand this value I take it?
Posted 04 Dec 2008 at 1:03 pm ¶Marc, none of your examples are “free” or “no fee.” Nor is anything else in your system.
Brits their pockets vacuumed every pay period to pay for it.
Posted 04 Dec 2008 at 1:41 pm ¶‘none of your examples are “free” or “no fee.” Nor is anything else in your system. ‘
Of course not - it’s free at the point of use, which means that unlike millions of Americans we don’t live day to day with fear we can’t pay health bills. And the overall tax take per head is about half the health spend per head in the US. And if you don’t pay tax - say you’re a child - it’s entirely free.
Posted 04 Dec 2008 at 2:16 pm ¶“we don’t live day to day with fear we can’t pay health bills”
You only have to live in fear that you’ll die while languishing on a waiting list, or be denied some cancer drug because the apparatchiks at NICE won’t pony up, or get some infection from your rat-infested hospitals, or die in the parking lot of the ER because your ambulance has been stacked there to manipulate the wait time stats, or be forced to pull your own tooth because you can’t get at a dentist, or any number of other horrors associated with your ramshackle health care system.
Posted 04 Dec 2008 at 3:10 pm ¶You’re picking again on the outliers you get from our right wing press and which are just as or more prevalent in the US. Let’s have a look.
Waiting lists have come down drastically under our Labour government - all cancer referrals are made in a maximum two week window now for example. In the US, as we know from studies such as the latest Commonwealth Fund, millions go without care at all.
The drug issue - this is interesting now as the NICE model is being picked up by many other countries and it will apply in the US in some form (and already does of course - cost-effectiveness of marginally effective/unproven drugs are being taken into account). There was a good article in the NYT the other day about NICE and how it is pioneering tough decision making for other countries, including the US See http://www.nytimes.com/2008/12/03/health/03nice.html
“To arrest this trend, the United States needs to adopt at least some of NICE’s methods, said Dr. Mark McClellan and Dr. Sean Tunis, who served earlier in the Bush administration as, respectively, administrator and chief medical officer of the Center for Medicare and Medicaid Services.”
The rate of hospital acquired infections is higher in the US.
There are no ER parking lot waits. That was an isolated example. In the US, you keep telling us that ERs are overcrowded.
Dental - yes, our NHS system is not good, mainly because the government messed up the pay formula and many dentists went private (unlike with primary care docs, who got a great deal). But in the US, there are millions without any dental care and who are pulling their own teeth as we speak.
Posted 04 Dec 2008 at 3:54 pm ¶“But in the US, there are millions without any dental care and who are pulling their own teeth as we speak.”
How many more times are you going to keep asserting things like this without providing even one example?
Posted 07 Dec 2008 at 7:07 am ¶Paul, with respect, but do you actually live in the US? I find it hard to believe you don’t know that more that 100 million Americans do not have dental insurance; that according to your Centers for Disease Control and Prevention. in 2003 and 2004, 27 percent of children and 29 percent of adults had cavities going untreated; and one in three children aged 2 through 18 in Medicaid have untreated tooth decay, some 6.5 million children. As for an example, surely you know about the case last year of 12-year-old Deamonte Driver of Maryland, who died following an untreated toothache.
Posted 07 Dec 2008 at 4:34 pm ¶“You’re picking again on the outliers”
“As for an example, surely you know about the case last year of 12-year-old Deamonte Driver of Maryland, who died following an untreated toothache.”
Posted 09 Dec 2008 at 1:05 pm ¶“As for an example, surely you know about the case last year of 12-year-old Deamonte Driver of Maryland, who died following an untreated toothache.”
Joseph, he asked for ‘one example’. After providing broad figures, I cited one that made the news. Actually, it wasn’t the only recent death of a child because of an easily treatable tooth condition in your country. But surely you can see that while shocking deaths like this do make headlines, it’s even more shocking that the 100 million without dental insurance do not raise hardly any media interest, and neither does the huge burden of dental ill-health.
Posted 09 Dec 2008 at 3:49 pm ¶Joseph, Paul and Catron, he is killing you guys. You are flailing and failing in your arguments. I am not in favor of completely govt run health care but all of your arguments really are worthless in the face of the statistics. I have family in Canada who would have been bankrupted in the US with our healthcare system. He was taken care of competently and in the same way it would have been handled here in the US. Meanwhile, yesterday, a cardiologist in my hospital put in a pacemaker into a 89 yr old demented patient with private health insurance….
Posted 18 Dec 2008 at 12:30 pm ¶Post a Comment