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I agree with Dr. Stange's diagnosis - our health care system is seriously ill and in need of radical treatment. I also agree with Dr. Hays that the recommended treatment is unlikely to succeed. Family physicians, or all primary care clinicians, are unlikely to be willing or able to start refusing to care for substantial numbers of patients in need in order to force action on a crisis in access to primary care. Were we somehow to precipitate such a crisis, we should also be cognizant that it takes far less time to produce nurse practitioners and physician assistants than board-certified primary care physicians.
A smaller proportion of physicians are in private practice now than in the past; employed physicians typically have little or no control over their scheduling/workload. The growing role of private equity firms in owning medical practices should not be overlooked, either - their goal is to extract money, not improve health care.
This problem cannot be fixed without addressing a major cause of the dysfunction in our health care system - private health insurance and fee-for-service payment. We cannot continue to ignore the huge direct and indirect costs driven by this dysfunctional system. It is more of a blue whale than a mere elephant in the room. Direct Primary Care may offer a better way for some clinicians to provide high quality, personalized care for patients and make a good living while working sane hours, but it is not an option for many patients, nor something that clinicians like me in America's health care safety net, can contemplate. Tinkering with wRVU values continues to fail to address the overvaluing of procedural vs. cognitive services as conversion factors are adjusted to avoid decreasing specialist payment or increasing overall payment.
I think the only way we could get to a substantially more functional system is to start with moving to a single-payer health care system, giving us substantial, immediate savings and eliminate huge amounts of practice overhead. If the system were capitated and primary care clinicianswere responsible for reasonable, risk-adjusted patient panels, we would then have the flexibility to address patient needs in whatever manner was most appropriate - office visits, video visits, telephone calls, patient portal messages, etc. Not worrying about "billable visits" would allow formation of provider teams that could better provide needed services more efficiently and cost-effectively.
Alas, I never expected when I started my career that, near the end of it, we would have made so little progress toward a more sensible, efficient, and patient-centered system. We probably cannot get there without major action to force change in our dysfunctional system. But I don't think the actions suggested by Dr. Stange will happen or, if they did, be enough to create the change we need. I doubt we could ever get agreement on a system-wide strike of primary care (and hopefully other) clinicians, but I suspect that nothing less than that would lead to meaningful change.