We need more generalist physicians. And a new health system so that they can be effective.

We don’t have enough primary care physicians in the US to properly (or, often and in many places, even improperly) care for our people. We all need a primary care doctor, and some of us need specialists. But rarely does a specialist have the time, interest, or expertise to manage all of your problems, and also do the recommended preventive work. Unfortunately, primary care physicians rarely do either, especially when it involves managing the care delivered by many different specialists, who can be unaware of what treatments the other is recommending and of how it might conflict with treatment they are giving. Doing this properly takes a lot of work and time.

For example, you mention to your cardiologist that you have knee pain. They say “I don’t do knees; here’s a referral to an orthopedist”. They’re done. If you go to your primary care doctor, they will examine you, try to figure it out and maybe treat it. But if they refer you to an orthopedist, they will follow up, read the report, look at the x-rays, read the recommendation, and try to explain to you what it all means. In short, a specialist referring to another specialist saves time and work; a primary care doctor referring to a specialist generates more work for themselves.

But there are not enough primary care doctors to do this, and those that exist are not given sufficient time by their employers (most are employed by hospital systems or large groups, often owned by private equity) to do it right. Because – and this is the most important thing – these hospital systems and especially private equity are, like insurance and pharma companies, in the business of making money, and only incidentally providing health care. Yes, many doctors are also interested in making money, but this is not their only or primary concern.

So, because most doctors are employed, and because primary care doctors may work much more for much less money, we have a dramatic shortage of primary care doctors in the US. A recent issue of Your Local Epidemiologist describes this in some depth.

One approach to primary care is that which Sweden has adopted, as documented here by the Commonwealth Fund.

Sweden is aligning primary care access goals with physician workforce policy more explicitly. Rather than treating physician training as separate from care delivery, Sweden is using workforce policy as a tool to strengthen continuity, accessibility, and person-centered primary care. To support this goal, the Swedish National Board of Health and Welfare analyzed primary care workload and physician capacity, established a benchmark of one primary care physician per 1,100 residents, and issued recommendations to guide regional workforce planning toward that target.

The Commonwealth Fund notes that

The United States faces a similar problem. Although physician training strongly influences where physicians ultimately practice and what specialties they choose, federal graduate medical education (GME) financing remains largely tied to algorithms based on hospital funding patterns established decades ago. The Centers for Medicare and Medicaid Services lacks authority to measure workforce outcomes associated with the nearly $21 million in Medicare funding that supports physician training. The result is a system that often produces workforce outcomes misaligned with patient needs, specifically not enough primary care physicians, general surgeons, and psychiatrists.

Commonwealth adds “Sweden’s recent reforms suggest a different model: define national access goals first, then align workforce policy around them.”

What a novel idea! Imagine figuring out what you are trying to achieve and then designing a system of achieve it! This is completely different from how health policy, including (or perhaps especially) physician supply and makeup is done in the US. (Well, except for for-profit companies who know what their goal is – make more money by any means necessary, which is never providing you with the best, most comprehensive and effective, or accessible, healthcare.) The system we use is to … do the same old thing. Pay subspecialists more, allow students to choose which specialty they want, and expect that somehow enough will choose primary care, despite the fact that they will make far less and often (not always, depending on the other specialty) works more, will almost be always employed by a large hospital system or group practice owned by private equity, and be on a hamster wheel of “productivity”, which means they cannot see enough patients, cannot deliver adequate care to the people they do see, and for themselves achieve limited professional satisfaction in having the control necessary to influence positively the health of their patients. 

As I have written before (e.g., Changes in the RUC: None.. How come we let a bunch of self-interested doctors decide what they get paid?, July 21, 2013; Pay primary care more: Kennedy may be getting this one right!, July 23, 2025 ), there is no mystery on how to change the income levels of primary care physicians relative to subspecialists. The Medicare payment “pie” is divided up between specialties mostly on the recommendations of an AMA-appointed group of physicians called the “RUC”, which is dominated by subspecialists. CMS, whichadministers Medicare, doesn’t have to follow the RUC’s recommendations, but usually does. And the RUC’s makeup of about 15% primary care physicians guarantees that primary care will be underpaid by Medicare. And, since almost all insurance company reimbursements are based on multiples of Medicare payment, this translates to the whole system. CMS could set up, or require the AMA to set up, a RUC that was, say, half primary care doctors!     

A word on the term “primary care”. While it has become the standard phrase in the US, and we can’t get away from it, it is not a great one. It was popularized by internists (adult medicine doctors) to distinguish those more properly called “general internists” from their internal medicine brethren who did mostly hospital work (“secondary care”) including intensive care (“tertiary care”), and then expanded to include general pediatricians and family physicians. Of course, family physicians are mostly all (90%) in what is now called “primary care”, and they (or the also commonly used “general practitioners”) are the mainstay of outpatient care physicians for the populations of most countries. Family physicians differ from other “primary care” physicians in that they are trained to provide comprehensive care for people of all ages, with all problems (referring when necessary) across the lifespan, including caring for children, old people, delivering babies, caring for folks in the hospital, in nursing homes, and doing lots of different procedures.

Unsurprisingly, it is hard to find even family physicians doing all these things now, except sometimes in rural areas where there are fewer physicians in other specialties. It has always been true that the privileges granted to family physicians have been largely determined by how much other physicians can make doing that work; many will be “first assistant” surgeons (fairly well paid) except when their communities have a glut of surgeons who “need” the work = income. Many years ago, it was discovered that only about 10-15% of graduating family medicine residents in Texas were interested in delivering babies in rural Texas; however, this was compared to 0% of OB-Gyn residents!

So let’s start with identifying what we want to achieve: enough primary care physicians, distributed broadly enough across the country in rural and urban areas, for every single person to have one. For those primary care (or family, or generalist) physicians to be paid enough relative to subspecialists that students are attracted to the field. For them to have enough time budgeted to manage complex problems and even more complex interactions between patients and other doctors. This is especially a need for older adults, who are most likely to be seeing multiple specialists for multiple problems. Relying on ERs or Urgent Care is a very poor and inadequate alternative.

That requires a complete reworking of how our health system functions. Covering everyone, such as by the improved and expanded Medicare for All system called for by the S. 1506 and HR 3069 bills, is an absolutely necessary part of this, but is not alone sufficient. We also need to restructure physician payment to encourage enough primary care that people can easily access it and it can be effective, implementing completely Starfield Four Pillars of Primary Care: [first] Contact, Continuity, Comprehensiveness, and Coordination (Starfield B. Primary Care: Concept, Evaluation, and Policy. New York, NY: Oxford University Press; 1992). If ANY of these are missing or incomplete, we have an inadequate health system – as we in fact do.

No messing about at the edges. No "reforms" that reform little. No saying we cannot afford universal health care, something every other developed country does, because our insurance companies need to make huge profits. No denying the need for an immediate steps to ensure an adequate primary care workforce because we don’t want to pay subspecialists less.

This must happen now, happen yesterday. There is no morally acceptable alternative.

 

                                       

Pay primary care more: Kennedy may be getting this one right!

I have recently written strong criticisms of Secretary of Health and Human Services Robert F. Kennedy, Jr. and his positions on a number of issues, including most importantly vaccines (see RFK, Jr.: The Secretary of Health and Human Services is Dangerous to Your Health!). Not only is he wrong about vaccines being dangerous, he is in fact creating major danger by discouraging their use. The polio vaccine essentially eliminated a disease that was a major scourge in the US as well as the rest of the world, as did the measles vaccine. Many other vaccines protect our children – and adults – from other serious viral diseases like influenza, COVID, mumps, chicken pox, rubella, shingles, and human papillomavirus (HPV) which causes cervical cancer, as well as bacterial diseases including diphtheria, tetanus, pertussis, and Hemophilus influenza b. The last is something most people have not heard of, but early in my career was a major cause of morbidity and death in infants and young children from meningitis, pneumonia, and epiglottitis, which caused their throats to swell rapidly and choke off their breathing. Many others have articulately expressed this concern, including the pediatrician Perri Klass in the New York Times. While these diseases affected people of all social classes, they were more prevalent among the poor and minority groups such as the people I cared for at Chicago’s Cook County Hospital. Indeed, research has demonstrated tremendous benefits from vaccines on the health of children and other populations that go far beyond just the decrease in the specific diseases that they target to decreasing all-cause mortality!

Kennedy is wrong about many other things, if not all of as of such immediate potential danger as urging people to not get vaccinated. These include nonsense like suggesting that people who eat right and exercise won’t get disease, that raw (unpasteurized) milk is better for you, and that “natural” is always better (which, even if we could agree on a definition of “natural”, it isn’t). One recent example is his arguing for Coke to use “natural” cane sugar rather that high-fructose corn syrup, both of which are sugar and have calories and in large amounts are bad for you.

But there turns out to be one area where Kennedy and I seem to agree, which is the need to take concrete action to increase the number of primary care physicians. Lots of people, including politicians, healthcare providers, and health policy experts, express concern about the shortage of primary care, but have done nothing to address the real cause of this problem – that primary care physicians (and the nurse practitioners and physician’s assistants working with them) get paid a lot less than do physicians in other specialties. Kennedy appears to be doing something other than wringing his hands. On several occasions I have written about the RUC, the AMA committee that decides how to divide up the pie of Medicare dollars among specialists by deciding how much each thing doctors do is worth relative to other things that they do. (Changes in the RUC: None.. How come we let a bunch of self-interested doctors decide what they get paid? July 21, 2013, Doctors' incomes and patient coverage: both need to be more equal July 26, 2014, and most recently, Not enough primary physicians OR Nurse Practitioners: It's the money, stupid!, June 27, 2024).

Not to get too technical, there is a set amount of Medicare dollars and the RUC decides (or recommends to CMS, which almost always accepts those recommendations) how many physical exams, say, are equivalent to one gall bladder surgery, considering (theoretically) both difficulty and time. This makes a tremendous difference in physician income and, I would argue, specialty choice by medical students. And, over the years, the amount of time it takes for doctors to do some things, particularly procedures, changes. Colonoscopies used to be estimated to take an hour and a quarter, but now are routinely done in 30 minutes. Cataract surgeries take a fraction of the time that they once did. This can result in physicians billing for more procedures than the model assesses as possible in a day. In contrast, the time it takes for a physical exam, or to listen to an interpret a person’s story, hasn’t changed significantly. The composition of the RUC, according to the AMA, represents all specialties, but its membership has a low proportion of primary care doctors – five of the 32 seats. Unsurprisingly, then, specialist-performed procedures are valued more highly than cognitive work. And, very important, these rates (relative value units) do not affect only Medicare payments – virtually all insurers pay based upon Medicare rates, so it is the whole health system! Prior to this new regulation, alternative models for allocating payment have been developed, such as this 2025 publication from the National Academies of Science, Engineering, and Medicine (NASEM).

So, now, maybe, a change. The NY Times reports that, buried in an 1800-page HHS regulation, are proposed changes in the RUC methodology that would benefit primary care. This would be real action! In addition to reassessing these relative values, the action would also look at the current practice of reimbursing more for the same procedures done in a hospital than in a doctor’s office, a major way that hospitals make money. And, for those who think “of course it costs more to do something in a hospital”, this is a technicality; it simply means that the hospital owns the practice or clinic. So two, say, skin biopsies performed in similar doctor’s offices across the street from each other are now reimbursed at very different rates if one is owned by a hospital. This is absurd and inequitable, and getting rid of it makes terrific sense!

The diffusion of medical services to people and communities is primarily driven not by the health needs of the populations in different areas but by the potential to make the most money for health care providers. These are largely, and increasingly, hospitals and health systems, as well as enormous insurance-company and private-equity owned practices rather than individual or small group physician-owned practices. So, we get enormous hospital campuses and medical facilities in major cities and wealthy suburbs and little or nothing in poor neighborhoods and rural areas. This should change. The only reason for decisions about what healthcare services to provide and where to provide them should be the health needs of people, and not on how much profit can be made.

The new HHS regulation will be a big step in this direction if it redirects Medicare (and thus all insurer) funds to primary care, and does not preferentially favor hospital-owned practices. To the extent that he is responsible for it, Kennedy should be congratulated. However, while it is a big step, it is not a solution. The next, necessary, step is a universal health insurance program where every single person is covered and covered by the same system, and where establishment (and closure) of health facilities, and the services that they provide or do not, is entirely based on the health needs of the people. Of course, there will be a lot of resistance – highly paid specialists will resist the proposed HHS reimbursement changes, and the institutionalized powerful insurance companies and other big players who are making lots of money from “healthcare” will oppose more comprehensive changes. Indeed, they already are, with highly funded social media campaigns against universal health care.

We are glad for this first step, but we need to keep fighting to get a comprehensive health program – like those of every other wealthy country!

Privatizing Medicare through "Medicare Advantage" and REACH: The Wrong Way to Go!

The things to remember about “Medicare Advantage” plans is that 1) they are not Medicare, and 2) they may offer little or no advantage. They are a form of private insurance, cost Medicare a lot of money, and in some situations (especially when you are sick) can indeed hurt you.

Let’s get to the first. Medicare was created in 1965 to provide universal health care to senior and disabled people. It was a tremendous victory for those who had fought for decades to have a universal health insurance system in the US. It was also strongly opposed by those who thought their pocketbooks might be hurt, specifically the AMA, as well as other right-wing forces that just opposed everything that might actually help most people (and thus most Great Society, and even New Deal, programs). The supporters never envisioned that Medicare would be the end of the road, especially when, in the same year, Congress passed Medicaid, a federal-state collaborative program that was aimed at helping the poor access health care. They assumed that it would be expanded to finally include all Americans.

Of course, many of the opponents of Medicare didn’t give up either. The AMA, while never contrite, shut up about it after it became clear that rather than hurting physicians’ incomes, Medicare was a bonanza for them, ensuring payment for services had often previously been unable to collect for. Those who hate programs that benefit people, of course, are still around. But the most insidious and dangerous threat is from those who see any government program as a way to make lots of money, especially if it can be privatized without much risk to the private sector investors. This is really how Medicare (and many other public programs) have been most insidiously and effectively attacked -- by privatizing its programs to guarantee lots of money for the profit of the private companies, and largely insulate them from risk.

Enter Medicare Advantage (MA).  MA plans are largely run by insurance companies (and sometimes by venture capital groups) and are called “Part C” of the Medicare program, but they essentially take people out of Medicare and put them in a private managed care program. These companies then get the money that would have gone to the Medicare program (we’ll call it Traditional Medicare, or TM) for you. Plus they get extra money. Why do private companies caring for you under MA get more money than TM allocates for you? Because they do, right. Because the pro-for-profit “caucus” (PFPC) of the Congress, from both parties, wanted to increase the portion of people in Medicare entering MA. So these companies could make more money. And contribute more to the members of the PFPC.

Remember the old phrase “feeding at the government trough”? That is what these companies do, very well. Virtually no public function that is privatized becomes more effective at delivering service, since the amount of profit generated is increased by providing less service. To the extent that it sometimes seems to look better, it is almost always because of 2 things: that the public services were starved for funding in the first place, making them look bad and justifying the call to privatize them, and that private companies’ inefficiency, corruption, and overall bad acting is harder to ferret out than government agencies’.

How do MA plans make more money? In the traditional HMO manner, they limit access to a “panel” of doctors and hospitals. These are not necessarily the worst ones in your area, but they are the ones that the plans have negotiated the best deals with, for which they pay the least. They attract members with some perks like vision care, hearing care, etc., which can be useful if one is generally healthy. And of course, MA plans vary in quality and in performance; some of those covering state employees by contract have performed better possibly because of having a more educated, informed, and influential client base. But this is not always the case; see the example of city workers’ resistance to Mayor Eric Adams of NYC trying to push retirees into MA.  

And do not consider for a moment that the goal of any of these programs is to provide excellent health care: it is to make money. And that they make money is demonstrated by the aggressive marketing that Medicare-eligible people get from these companies, not to mention television advertising. The Commonwealth Fund recently published a piece called “The Role of Marketing in Medicare Beneficiaries’ Coverage Choices”, which describes this in detail. ‘Soaring private plan enrollment has led to a sharp increase in marketing and sales efforts, some misleading and inaccurate.’ It goes on to explain in how MA works and how they market. It also notes that about 1/3 of Medicare beneficiaries used an insurance broker; a boon to that private sector industry as well. MA plans can keep 15% of the money they get for profit and overhead, having to spend only 85% on actually delivering care (which they call the “medical loss ratio”!)

The way that MA plans make money is enrolling lots of people, many of whom are healthy (Wow! Free gym membership!) and don’t cost them much, and then submitting bills that make their patients look like they are as sick as possible thus inflating their bills (called “upcoding”). At best this an effort to maximize revenue from Medicare, which there is no incentive to do in TM. Plus, if they can get certain poor people enrolled, they can collect an additional $350 for each one regardless of whether they actually provide any care! This was implemented with the theoretical idea of increasing equity by incenting the enrollment of poor people, but really has the opposite effect since those folks now have their care restricted when they are sick by the private insurance company, while under TM it would not be. And, of course, they make money by fraudulently overbilling Medicare for billions of dollars, winning the Lown Institute’s 2022 “Shkreli Award” for bad behavior by corporations!

 

MA is not the only way Medicare is being privatized. As I have written before ("Private Equity": Profiteers in nursing homes, Medicare Advantage, DCEs, and all of healthcare, Sept 16, 2022; Direct Contracting Entities: Scamming Medicare and you and bad for your health!, Feb 7, 2022), the Center for Medicare and Medicaid Services Innovation Center (CMMI) implemented Direct-Contracting Entities (DCE), which was renamed REACH as of January 2023 (without any other significant change). REACH has allowed the creation of mostly investor-owned companies that contract with primary care practices (often already owned by corporations, not owned by the doctors) and voilà, all of those doctors' patients are in their REACH group, which then gets the money that Medicare would have paid for you. What is really tricky is that, unlike MA, you didn’t have to choose it; they choose for you by contracting with the group (often corporate) that owns your primary care practice! And your doctor may not even know that s/he is in one! You can only get out if you can find another doctor who is not in one – particularly difficult in rural or urban underserved areas where even finding a doctor is hard. Not to mention that REACH is even more lucrative than MA, as it allows the private company to keep 40% of its take as profit and overhead, spending only 60% on patient care!

The effort to privatize Medicare is absolutely the wrong way to go. The way to go is to keep the structure of Traditional Medicare, where anyone can use any doctor or hospital, where there is no profit taken out, and overhead is about 2%. And then increasing its benefits so that it covers 100% (not 80%) of approved charges so people don’t have to get a Supplement Plan, as well as cover dental, vision, hearing, etc. This is affordable, since it could be funded by money now used to generate huge profits for private investors, but could actually be used to improve our healthcare. While we still need to address access in terms of geography and specialty distribution, eliminating the profit motive will make major steps toward access and improved quality.

Then we can have Healthcare for All.