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I cannot disagree with anything Dr. Grumbach says here, except for being more pessimistic that taking more activist approach and working with instead of fighting against our allies in primary care has a chance of changing the sorry state of affairs. I did not imagine, at the start of my career in family medicine, that at the point I am at now, having just (mostly) retired, we would still have a system that excluded so many from coverage and yielded such poor outcomes at such high costs. But the continued discrepancies in payment for cognitive vs. procedural services do not seem to be going away. We continue with our quasi-religious belief in the value of "competition" among insurers. Having just spent a week trying to figure out my options for enrolling in Medicare, as someone who understands the issues likely better than 99.9% of Americans, I was stunned at how difficult it try to make an "informed" choice. And why should costs of Medigap plans from different insurers that, by law, have to have exactly the same coverage, vary by as much as $30-$40/month? Clearly, insurers understand that most Americans cannot sort through this and make ill-informed choices that will cost them more and yield higher profits. The clinic where my wife and I received primary care was bought by an arm of a for-profit insurer and it is no longer possible to reach a human by phone. I tried to reach the urologist on call for our hospital about an acute patient issue several weeks ago. He worked for that clinic. As a physician trying to reach another physician, I spent over an hour on hold and never got to a live person.
Private equity firms are taking a larger and larger role in practice ownership. Their goal is extraction of maximum profit, not improving patient care. Many of our large, non-profit health care systems, as highlighted recently in a series of articles in the New York Times, may not be distributing profits to shareholders, but are accumulating large funds being used as venture capital and pursuing payment from people who cannot afford to pay as well as paying their executives handsomely. Many Americans, disproportionately minorities and the poor, are mired in medical debt. Tinkering with the RBRVS is unlikely to either dramatically change how valued primary care is in our system nor how attractive it is as a career choice to trainees.
Insurance companies add huge overhead costs to our system for no added value. Those I work with and I have wasted untold hours dealing with inappropriate denials of care (with physicians employed by insurance companies denying hundreds of thousands of claims without even looking at them [e.g., https://ctmirror.org/2023/03/25/how-ct-based-cigna-saves-millions-doctor...), multiple and often unknowable formularies/copays/exclusions for medications, etc. Medicare Advantage, rather than decreasing costs via competition, is costing us more than traditional Medicare would. In my entire career, I can think of exactly once where "input" from an insurer actually improved care. A single-payer, capitated system of care would instantly save the U.S. a huge amount of money by eliminating not just their overhead but ours as well for dealing with them. Yes, such a system would also have problems, but they would be far less wasteful and discriminatory than the system we have now.
Alas, I think it will take far more than the type of activism and new alliances Dr. Grumbach proposes to bring about meaningful change of the type he advocates and we so desperately need. I wish I had a good solution to suggest, but we seem no more able to address this sensibly than other foreseeable catastrophes that could be avoided with major systemic change, such as global climate change and the likelihood of more pandemics. . In a country where politicians in 10 states who refuse to expand Medicaid coverage when the federal government will pay at least 90% of the cost do not get ridden out of town on a rail, true reform of of the medical-industrial complex will likely require much stronger political action than somewhat broader alliances and patient testimonials. Nationwide primary care stoppages? Discharging politicians opposed to reforms from practices and telling them they can go to the ED if they need care? We need to get more creative in addition to the very sensible measures Dr. Grumbach suggests.