"The times they are a changin'."
This classic lyric by Bob Dylan is as prophetic today as it was 55 years ago. The field of medicine is changing rapidly and in ways we can only begin to imagine. Technology is just part of it; other changes could shake the foundation of health care itself.
In the future, we may see computers reading X-rays, DNA analysis guiding individual medicine, and more and better treatments coming for everything from coronary artery disease to severe degenerative hip arthritis. Those changes are exciting and welcome. The change that concerns me is more fundamental. It is simply the answer to one question: Why are we in medicine?
As I see it, the answer can lead us in one of two directions. One direction would move us toward maximizing the system's financial revenue. The other would focus us on taking care of our population. To put this on an individual level, I ask, Why did you go into medicine? Was it to make the most money you can or was it to take care of people?
I believe the majority of family physicians went into medicine to take care of people. As I travel around the country, I hear the issues facing us all. Sure, we want payment reform because we know the facts of "no margin, no mission." Many family physicians are small-business people. They are struggling to pay employees and provide them with health insurance and other benefits, as well as to pay the rent, malpractice insurance, utilities, taxes and a myriad of other expenses before they pay themselves. Family physicians deserve a decent wage, loan forgiveness and economic stability.
To get that, we have to give something back. What we give are our skills learned through years of study, residency and practice in our communities. We teach others the art of family medicine so our children and our children's children will have family physicians to take care of them.
On the other side is a system that is increasingly out to capitalize on the illness, frailty and bad habits of our population. Maximizing profit is why we have for-profit groups in health care. Not-for-profit-groups have had to fall in line with the for-profit groups to compete for patients. Hospitals have had to redesign facilities to make them more appealing to compete for patients. With grandeur comes expense.
"Paying patients" used to mean those with insurance (including Medicare). Nonpaying patients were those who did not have insurance or were on Medicaid. But what about those patients who have nothing? No health insurance. There are millions more of them today. As parts of the Patient Protection and Affordable Care Act have been slowly chipped away, the call to look for other ways to give everyone health care has begun. That call, including from advocates of a single-payer system, is getting louder.
As with all issues of this magnitude, it is not just a simple this or that. "I don't want insurance companies telling me how to practice medicine," and "I don't want the government telling me how to practice medicine" are two sides of the same coin. Right now, there are multiple entities telling us how to practice medicine.
Looking at how things are right now, I would have a tough time if I were just beginning my practice. Most likely, I would choose direct primary care. It would be an ethical dilemma for me because I have never turned anybody away from my office for inability to pay. That is why I now work at the Free Clinic of Rome in Rome, Ga. I am happy not to be bothered with collections. On the other hand, I am constantly looking for ways to help finance the limited services we offer.
One suggestion I have heard involves providing a "primary care benefit" to all those who have insurance. It would allow anyone with any health insurance, including catastrophic plans, up to four primary care visits per year without copay. Preventive medicine, we know, is the best money spent in health care. If we can prevent a heart attack, we will save the system money. As long as the system relies on things such as the hospitalization of heart attack patients, and on the stent placement or bypass surgery that results, we will not see an increase in primary care spending.
The emphasis is in the wrong place when the system, driven by the need for increased revenue, relies on this type of income. The cost of health care is rapidly approaching 20 percent of our GDP. Many have said 20 percent is the breakpoint at which we can no longer afford the system we have. How do we stem this tide?
I am not convinced that single-payer is a solution the current political climate will tolerate. I may be wrong, but it seems like too heavy a lift at this point. Maybe there is a compromise.
Consider this: How about guaranteed primary care for everyone? Call it "single-payer primary care," if you will. If everyone in the country could access affordable primary care and prevent complications of heart disease, lung disease, stroke and diabetes, we likely could save billions of dollars.
The CDC Foundation estimates that cardiovascular disease alone costs our country more than $320 billion a year in health care costs and lost productivity. By 2030, that figure is expected to eclipse $1 trillion.
Similarly, the cost of care and lost productivity for patients with diagnosed diabetes increased 26 percent from 2012 to 2017, rising to $327 billion. Costs related to COPD are expected to reach $49 billion next year, up from $32.1 billion in 2010. And the direct health care costs for cancer in 2015 were estimated at $80.2 billion
What if we had the workforce needed to improve access to care? What if that care was affordable so patients received recommended primary, preventive care rather than more costly care after the fact?
How much money could we save?
More importantly, how many lives?
The financial savings would not be immediate, of course, because we need to continue to treat those with existing conditions. But consider the future. If we invested in primary care -- in a system run by doctors, not for-profit administrators -- consider the potential savings. Consider the increased productivity of a populace no longer held back physically and financially by health care concerns or costs.
Insurance would remain a profitable industry because it would still be needed to cover hospitalization and subspecialist services. This would be a two-tiered system in which everyone would be covered by primary care in hopes of keeping the population healthy alongside another tier to cover accidents and subspecialty needs.
This will be unthinkable to many. I can hear the objections that only the rich could afford health care. My answer to that is we already have that problem, and this is a compromise that might help millions.
No one likes change, but change will come.
"Come senators, congressmen,
Please heed the call.
Don't stand in the doorway,
Don't block up the hall.
For he that gets hurt
Will be he who has stalled.
There's a battle outside
And it is ragin'.
It'll soon shake your windows
And rattle your walls,
For the times they are a-changin'."
We need to change -- for our profession, for our country and most of all for our patients.
Leonard Reeves, M.D., is a member of the AAFP Board of Directors.