Arnold Kassanoff: The backbone of health care is crumbling

I have practiced internal medicine and clinical cardiology in Dallas for 44 years. My wife and I have reared and educated three children and have lived a comfortable life, commensurate with my education and the demands of my profession. I have always felt privileged to be a physician.

I chose a primary-care field because it represented the cornerstone of traditional medicine in taking care of patients. I have been a medical advocate, yielding a challenging and satisfying career. My specialty is diagnostic. I find out what’s wrong, and then, only when necessary, refer the patient to a specialist. I follow problems (heart disease, diabetes, hypertension) over a long period and promote preventive measures. A special bond is created, resulting in patient trust and security.

In recent years, since the advent of a federal health care system and managed care, my colleagues and I have observed that this backbone of the heath care system is collapsing. Because of Medicare and managed care’s diminishing reimbursements to primary-care physicians, fewer medical school graduates are going into primary care (internal medicine, family practice, pediatrics, obstetrics/gynecology). Idealistic new physicians frequently enter practice with educational debt, and they, too, must support and educate their families.

Compared with other fields, such as cosmetic surgery, radiology, orthopedic surgery, anesthesiology, or some of the medical subspecialties such as gastroenterology or interventional cardiology, primary-care income is much lower. For example, an orthopedic surgeon or an ophthalmologist may make $350,000 to $400,000 annually; an internist or family practitioner usually earns $100,000 to $125,000 and has to huff and puff to reach that level. Is there any wonder medical students choose the more lucrative fields?

Medicare reimbursements are roughly 30 cents on the charged dollar, resulting in rushed visits and the need for high volume. Still, primary-care physicians have trouble meeting overhead.

As a result, as recent studies in the New England Journal of Medicine have shown, there is a 51 percent decrease in graduates going into family practice, an 18 percent decrease in those going into internal medicine (most of these become hospitalists, without a practice of their own), and a 16 percent decrease for obstetrics/gynecology. The percentage of third-year residents in internal medicine planning to become general internists, not hospitalists, has dramatically dropped – from 50 percent in 1998 to 27 percent in 2003, and the trend continues.

Fewer and fewer physicians will be around to take care of the aging population.

Morale has declined among existing primary-care physicians. Many take second jobs to bolster their incomes in doing exams for insurance companies or taking administrative jobs. The once challenging and satisfying career of caring for patients is nearing extinction, especially as older clinicians retire.

Our present health care system is large and dysfunctional, with little chance that it will be fixed soon. Our lawmakers are only vaguely aware of the increasing demands and only recently approved a 5 percent increase in Medicare reimbursements for primary care. In the meantime, my rent has increased by 25 percent, and to a lesser degree so has equipment, supplies and utilities. I recently had to reduce my office manager’s hours to half-time.

My practice is a large, primarily Medicare practice, crowded with acute and chronic illnesses. I, like many of my colleagues, continue to practice only because I consider it my calling.

The demise of the primary-care physician cannot continue. The reimbursement system needs radical change. By increasing the income of the primary-care physician, more young physicians will be drawn into this specialty. This increase will necessitate fewer expensive subspecialists, resulting in a decrease of the total health cost and a more cost-effective system.

Some think it’s best for society to relinquish the days of Marcus Welby, M.D. and embrace the world of large, impersonal groups and computer-driven managed care. Hippocrates would disagree, and so do I.

Dr. Arnold Kassanoff is a board-certified internal medicine physician and a fellow of the American College of Physicians in Dallas.

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