All Physicians Are Not Created Equal: How to Fix Medicine's Two-Party System

Imagine there is a committee of politicians made up of 24 republicans and 5 democrats. Their job is to decide a politician's salary—for democrats and republicans—and decisions are made by majority rule. Which party do you think would have the highest salary?

Much like American politics, doctors have a two-party system. It's the Primary Care Party versus the Specialist Party. For the past 20 years, the specialists have been pummeling the primary cares. In 1991, the AMA formed an expert committee called the RUC in response to a Congressional mandate to provide recommendations to the Center for Medicare & Medicaid Services (CMS) on the worth of every visit and procedure a doctor can perform. CMS then accepts, rejects, or modifies these recommendations and effectively places a dollar amount on the thousands of codes doctors use to get reimbursed. CMS sets the standard. Private insurers then use these standards to decide how much they reimburse physicians in their own networks.

At the tip of this convoluted payment pyramid lies the RUC, composed of 29 physicians, each representing the 29 specialties. Five of them are primary care doctors. Majority rules. It is the reason our nation's doctors practice quantity medicine, not quality medicine.

Our current health-care malaise is the result of the federal government making policy around recommendations from specialists who are looking out for their own, while ignoring the needs of a highly functioning system. The backbone of an efficient, cost-effective health-care system relies upon a strong primary care workforce to manage the common problems and refer for help in managing complex and rare problems. Other countries in the world that rank far better than the U.S. in medical services have about 75% generalists and 25% specialists. The U.S. is exactly opposite: 75% of our doctors are specialists. And about 94% of graduating physicians in America chose a specialty over primary care last year.

Med students, while inexperienced, aren't dumb. They follow the money and the lifestyle. There are two vastly different worlds available to them: Start at $80,000, work 60 hours a week on the eight-minute visit hamster wheel, drive a Toyota, and play on the public golf course; Or specialize, and start at $250,000, work 40 hours a week, spend 30 minutes with each patient, and enjoy the newest BMW and country club membership.

The primary care docs in America have been virtually eliminated by the Specialist majority. We, as a nation, are just starting to feel the hurt this is causing. The feds may soon mandate insurance coverage for us all, but there are so few primary care docs around that we won't be able to use our new insurance. Most of these new insurance plans will be micro-managed primary care gatekeeper-type policies. The ERs will be flooded because primary care won't be available. The cost of health care will skyrocket. And the waits to see a doctor will trump Massachusetts' 52-day wait.

The Obama administration has three proposals—increase the number of medical students, use more physician's assistants and nurse practitioners, and expand the National Health Service Corps. None of these will work. They are all band-aids that won't stick for more than 30 seconds. Increasing the number of med students will simply increase the number of specialists driving BMWs. The American public still wants to see doctors, not PAs and NPs. The National Health Service Corp will offer generalists another low-paying option to practice in areas where no docs want to practice.

Reversing the effects of the RUC will take 20 years, and a new generation of physicians. The first policy change needed to solve the primary care crisis is to remove the conflict of interest within the RUC. It should either be staffed with health policy experts, or with 75% generalists and 25% specialists. If that happened today, twenty years from now our actual physician workforce would reflect what's needed. Unfortunately, this would also be the beginning of the health-care war. We'll see lobbyists for specialists teamed up with the hospitals who profit massively from specialist care versus the lonely 25% of doctors who represent primary care fighting for equal pay, lifestyle, and a strong health-care system. I have a hunch which party is going to win this one. What are your thoughts, Hillary? Remember 1993?

Jay Parkinson is a physician who lives in Brooklyn, and the Chief Concept Officer at Myca. He saw that patients and doctors communicate very differently from how the health-care industry does, using the Internet and their iPhones. He soon had a functioning practice, incorporating his Web site and house calls with email, IM, SMS, video chat, and PayPal. This system was developed into an application wrapping up all of those empowering technologies into one powerful system—Hello Health. Parkinson and Hello Health were profiled in the Fast Company magazine article "The Doctor of the Future."

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  • Jay Parkinson

    Hi Ryan...
    It's really difficult to track much of anything in healthcare when so few doctors use computer systems that are able to track outcomes. So many of the systems focus so much on billing that they can't really offer much in terms of helping you be a better doctor. Since we are free from this insurance fiasco, we can dedicate lots of our resources to helping doctors be better doctors by tracking outcomes, making them aware they're following standard of care, making sure the documentation is done using meaningful data points that ensure our platform gets smarter and smarter the more doctors and patients use it.
    So yes, definitely, quality measures, patient outcomes, and patient satisfaction are at our core.

  • Ryan Smith

    Jay - Good article. There are a lot of brilliant specialist and primary care doctors. For those us in the industry there seems to be a stigma attached to primary care docs as not being as important or successful as specialist(many of us know the opposite is true). I am sure money has a lot to do with it but in order to get medical students thinking differently we have to attach the same level of importance to being a primary care physician as being a specialist.

    What are your thoughts on comparative effectiveness research and are there any plans to use the Myca system to track patient outcomes?

  • Soo Kim

    Thanks for great article Jay. Your article helps me clarify what I am doing and makes me to want to leave some comments. I am a general practitioner and a owner of the one of famous cafe in South Korea. We ( include me and other two doctors, all of us are primary physicians) are doing our "Doctor" business and cafe business in same place. Is it possible? Yes we've been doing this for last two years and we are regarded as a unique and successful example of new form of providing medical service for better communication between doctor and patient. We've had excellent review from public so far. The reason why I started the " General Doctor"( our clinic + cafe title) is an inevitable choice when I graduated. The medical situation in Korea is nothing much different to the States. Most of medical students choose to be a specialist instead of being a general practitioner for the sake of money. Also, there are unavoidable cultural conception about "doctor = specialist" even if most people just need to see their primary physician instead of spending tones of money and time for just seeing "1 minute" interview with so called Guru specialist.
    I can say that me and my colleagues are leading a remarkable experimental movement in Korea for the better and friendly medical service, not as a cliche which commonly used in doctor's advertisement. Even if I still have to solve lots issues, I strongly believe I am and we are doing some devotion for new paradigm of medical service which it ought to be.
    Best wished for you and your collegues working hard for the future and thanks again for your article.
    Hope to talk to you in the future if I can go to Health 2.0 in this year or next year.
    If you want to know more about " General Doctor ( doctor's office+cafe), you can check our website. .

  • Jason Reichel

    Jay, thanks for the excellent article. While I completely agree that the system is fundamentally flawed, I don't think we can easily pass it off to turf wars. The assertion that, "The American public still wants to see doctors, not PAs and NPs" is slightly skewed. People want competent healthcare professionals that can confidently and quickly get them on the road to recovery. Ultimately, primary care and specialists need to work more harmoniously to combat the issues that prevent the accessibility and affordability of quality healthcare (allopathic, homeopathic and everything in-between included). I don't want my primary care MD reading my MRI and I would prefer to have access to a cardiologist when and if the need arises. But for 90% of our health needs, primary care MDs are the first and best source of care.

    The healthcare system in this country is not a sinking ship but more a like behemoth aircraft carrier that cannot be rerouted easily or quickly. I have high hopes that Hello Health and Myca platform are the first real attempts to change tack. Thanks again for working to get this ship back on course.

  • Jay Parkinson

    I agree Peter. There are some solutions that you mention that could possibly work, but the politics of making them work will likely make the solutions ineffectual. Hence, my remark about Hillary. Even though the issues are different, those who profit from our healthcare system won't go down without a deep-pocketed fight. When the cost of medical education can be made up in one year's salary for being a radiologist or dermatologist, primary care will suffer. NPs and PAs are becoming more accepted. I agree. However, again, few NPs and PAs want to do primary care because the pay is so bad and the work so grueling. It's going to be interesting, but it's also going to be a bitter political fight for the solutions you and I know need to happen. Thanks for the comment.

  • Peter Lucash

    Other than the widely accepted idea that primary care docs are underpaid, I'm not sure what your point is. The snide remark about Sen. Clinton is irrelevant at best. The Clinton plan is far, far different from the discussion today.

    Primary care supply can be impacted quickly in a number of ways. Pumping up the reimbursement - and away from specialists - may see some specialties handle some primary care issues that they are perfectly qualified to handle (as some in primary care will handle some "specialty" work for their patients). Supply of specialists can be controlled by reducing the numnber of residency slots - it's worked before, if I recall, and can do so again. CMS can impose a pay shift - I would hope by tranisitioning over several years.

    You are flat out wrong about the acceptance of NPs and PAs. Mid-level practioners are widely accepted by patients, and more so as patiens (and physicians) gain experience with their capabilities. These clinicians can relieve much of the demand pressure, have a shorter and faster training route, and offer a different career route for nurses.

    Finally, there are other ways to boost primary care supply. One is to forgive medical school loans for going into a primary care practice. Another is to raise Medicaid fees in states which pay poorly (other states are closer to Medicare).

    FYI: I've worked in healthcare for some 30 years as a hospital and medical practice administrator, consultant, blogger and college instructor (the latter more in business than pure health care).