Real change
Toolbox
Published: June 30, 2009
In the last few months several local doctors have decided to move away, and worried patients with nowhere else to turn have sent up an outcry about the lack of care options in the Rutland region.
But it is not just Rutland. A story in the Herald on Sunday described how a shortage of primary care physicians across the country stands as a real impediment to health care reform. It turns out that the problems in our health care system are deeply imbedded, and it will take time to achieve the kind of change needed to provide true health care security.
It is not an uncommon occurrence for someone to move to an area, and then, when they try to make an appointment with a doctor, there are no doctors to see. But you don't have to be new to an area. Rutland residents left behind when their doctors moved away are in the same predicament. Well-established practices often tell callers seeking help that they aren't accepting new patients. It's even harder for Medicaid or Medicare patients to find a doctor because low reimbursement rates cause many doctors limit the number of such patients they see.
President Obama's proposals for health care reform are significant and necessary, but the shortage of primary care physicians in the Rutland region demonstrates that the problems we are facing go beyond that of providing coverage. Coverage is not useful if patients can't find a doctor or if the only doctor available is in the emergency room.
The shortage of primary care physicians is due in part to the higher earnings that specialists can expect to gain. Specialists earn more because they are in the business of performing many high-cost procedures or treatments; and the more procedures and treatments they perform, the more money they make.
With the proliferation of for-profit practices and hospitals in recent decades, the health care system has devoted an excess of resources to providing an abundance of sometimes unnecessary care, while the crucial care provided by primary care physicians goes wanting.
Part of the problem is the enormous debt amassed by medical students. They need to earn at a high level just to pay off their debts and to make a decent living, or at least they think they do.
It has become a cliché to say that turning around our medical system is like turning around a battleship. It only happens slowly, but the turning has to start somewhere, and it needs to continue steadily.
Obama's reform proposal is one place to start. By providing access to care for millions who now lack it, the plan taking shape in Congress would increase demand, now unmet, for primary care physicians. Expanding programs to promote primary care as a favored choice among medical students — by helping pay off medical school debts, for example — would help meet that demand.
Somehow channeling federal money toward practices with a business model based less on profit and more on patient care would also be helpful. Of course, we could expect that if that happens, profit-making practices that believe they are not being adequately recompensed would no doubt howl that government bureaucrats were coming between them and their patients.
In the meantime, Vermont now has nine federally qualified health care centers and 34 satellite offices covering most of the state. These centers are designed to provide care to people who are otherwise left without options. Sen. Bernard Sanders has championed this federal program, working to bring new centers to Vermont and promoting their expansion nationally. He has said 126 new centers will be established this year across the country.
Among the many changes that must happen to reform our health care system, one of the most fundamental is a cultural and societal change. Once patients and providers all agree that health care is primarily a service and secondarily a business, then real change will be possible. An attitudinal change of this sort is beginning to happen, and as the system becomes increasingly tattered — as it has with the loss of doctors in Rutland — that change will inevitably take hold more firmly.
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