Americans are constantly being told they need a primary care physician. Supposedly the key to good health is having a close relationship with your family doctor. According to a research paper from Stanford and Harvard medical schools we live longer in areas with high concentrations of primary care physicians:
On average, the researchers found, for every 10 additional primary care doctors per 100,000 people, a community experiences a 51.5-day rise in life expectancy.
Your family physician is also the gateway to specialty care. I’ve talked to some specialists who won’t see patients without a referral. Years ago, a former neighbor complained to me that his wife’s primary care doctor treated nothing. She merely referred every health complaint to a specialist. Visits were short because they just involved a referral. He suspected that was the doctor’s strategy to bill Medicare for more patients. Instead of taking time to treat them just move them down the assembly line of specialty providers. Indeed, others have also wondered why some primary care physicians tend to refer patients rather than treat them. In an article for MEL magazine writer Chris Bourn asked:
What’s the Point of a Primary Care Doctor?
They seem to exist entirely to funnel patients to more expensive specialists—but it may be the consumer, not the healthcare industry, who’s really to blame for this, and we’re suffering as a result.
By contrast, in Britain it’s not straightforward to see a specialist. In Britain your GP acts as a gatekeeper to specialty care.
[H]ow primary care is managed in both places reveals a stark divergence in cultures. In the U.S. at least one in three visits to a primary care physician (PCP) results in a referral to a specialist (which is twice as many referrals as G.P.s make in the U.K.) — a trigger-happy trend that’s been on the rise since at least the late 1990s.
According to the Health Care Cost Institute, office visits to PCPs declined by 18 percent between 2012 and 2016…
Against an apparent backdrop of decline in both patient demand and doctor enthusiasm for end-to-end treatment within primary practice, you might wonder why you’re still being shunted through their waiting rooms, when it’s a specialist you really want to see. You might also wonder, since you’re in a diagnosing frame of mind, where all this pressure for referrals and over-treatment is really coming from.
Most physicians will tell you the financial incentive to refer patients is not very strong. Federal antikickback laws prohibit direct financial rewards. However, one physician has a theory why some referrals occur:
Here, unnecessary treatment might emerge from a culture of professional courtesy, rather than out-and-out grift: “It is hard not to view a referral as an overture from another physician, and it is equally hard not to return the favor.”
However, patients often welcome referrals with the attitude more care is better care. I recall reading an article that for seniors living in Florida going to the doctor was something of a social activity. Sitting in the waiting room allowed seniors to meet other seniors, who would compare physicians and recommend their favorite doctors and specialists. Seniors would often schedule additional appointments based on those interactions and recommendations.
Some of the undertow is coming from the patients themselves — from a consumer-culture approach to healthcare (Exhibit A: Walgreens), from a “misperception that more is better,” from “the notion that additional information can’t hurt…”
And then there is defensive medicine. Physicians are often worried about the liability of getting sued for missing something. I saw a urologist who told me he was 90% sure my condition was very minor and would clear up on its own within a few days. However, if I wanted to be 100% sure then I would need an MRI and some other test that I have since forgotten. The best cash price I could find was an additional $800 on top of the $200 I had already paid. I decided to forgo the additional tests since I was paying the bill out of pocket. According to a 2017 Medscape survey of primary care:
Just under half (49 percent) of the physicians who responded had been named in a lawsuit, and a fifth of those had been implicated for wrongful death. Of the primary care doctors who had been involved in lawsuits, 28 percent said they “no longer trust patients and now treat them differently,” while 39 percent “indicated that the threat of malpractice influences their actions all or most of the time.”
To sum it all up, excessive referrals and less primary care treatment is a complex problem with many causes.
Legal anxiety, plus consumer whims, plus physician attrition — it’s a powerful combination of forces all pulling decisive treatment away from the doctor’s offices and into the specialist clinics, operating rooms and hospitals. And it’s leaving a trail of infernally complex billing, contested claims, wasted money and misapplied resources in its wake.
In countries such as Britain GPs act as gatekeepers to specialty care. They too worry about being sued. In a recent survey 80% responded they had ordered needless tests or made unnecessary referrals due to worry about lawsuits. About half that proportion had prescribed medications that they didn’t believe were clinically necessary to keep patients happy. American physicians sometimes do the same. I once read that a physician picking up their prescription pad was their sign the visit was over and the prescription was tangible evidence of the medical service provided.
King James Bible — And Jesus answering said unto them, They that are whole need not a physician; but they that are sick.
New Living Translation — Jesus answered them, “Healthy people don’t need a doctor—sick people do.
So — do healthy people need to see a doctor?
A lot of doctors say don’t come in unless you’re sick. My dad adopted that belief. I doubt if he had been to see a doctor in 20 years when he suffered an aneurysm. Of course, it’s unlikely a doctor would have caught it unless he went to one of those Life Line Wellness screening vans.
Not a huge item, but that Medscape survey on doctors being sued seems fishy. The survey implies that ten percent of primary care physicians have been involved in a wrongful death suit.
That would translate I believe to millions of lawsuits– far more than our legal system could handle, and I bet far more than actually occur.
I wonder if it’s a case where a doctor was accused of a wrongful death but never proven. I can believe that one-in-ten primary care physicians at some point in their career had a patient die and the offspring were disgruntled and blamed the doctor without evidence. Maybe they threatened to sue but it got nowhere or didn’t sue. It’s sort of like in the case of my father’s death. Let say he had gone to the doctor for something it’s unlikely his aneurysm would have been detected unless they were looking for it. Even after he went to the hospital in an ambulance they suspected but could be know for sure what it was.
Devon, I think Dr. Goodman is wrong wanting the same tax credit to purchase insurance. John suggests $2,500 for a single and $10,000 for a family in 2017. Admit it Devon, that is thinking like a Socialist. One size fits all mentality. Here are current numbers, rates for Trump’s high-quality low-cost STM in Detroit City, for January 1st, 2023. A 30 year-old-male is $160 a month for a $10,000 deductible in the 48202 zip code. Obamacare costs $209 a month for a Blue Cross HMO with a $9,100 deductible.
With Goodman’s $2,500 the tax credit pays 100% of Trump’s STM plus $580 is deposited into the 30-year-old’s HSA at the bank. The tax credit is $8 short in paying for Blue Cross.
For a 64-year-old Trump’s STM is $6,384 per year. Obamacare is $6,648 per year. Obviously Goodman’s $2,500 credit just drops the price some, people will be upset if they are older. Goodman’s “SMALL” $2,500 tax credit needs adjustment for 2025 when we control the White House. ALSO, FYI I am using Detroit because these premiums are about average in the USA for Trump’s STM which is in more states than any competitor. Otherwise, people in Dallas will want larger credits than Nebraska with their low rates.
I suggest the credit remains the same for each age in all states. This way Nebraska has an advantage over Florida because health insurance is less in Nebraska. That’s life. However, I suggest the credit should be in 2025 voting to be adding (2) ZEROs to the individual’s age. For example, if someone is 38 the tax credit is $3,800. A child is $2,000 a year credit, the floor, and the credit increases to $6,400 for a 64-year-old.
The age-based tax credit should increase annually with the CPI. Devon, Dallas is the MOST expensive zip codes in America with Trump’s STM. If you and your lovely wife are 55-years-old and your tax credit was $5,500 X 2 + $11,000. A 55 year old couple’s premium, in Dallas zip code 75001, is $10,884 a year so the Federal Government will pay for your health insurance PLUS deposit $16 every year into your HSA. (Even in the most expensive zip code the credit is enough to cover 100% of the premium.)
Now the State of Texas doesn’t have to pay for the States’ employee health insurance and the cost of Medicaid will plummet. When we strip out the high cost of employer-based benefits out of products and services their prices will decline for the American consumer.
I don’t see a need to let the Federal Government tax EVERY single dollar saved for retirement so again Goodman is wrong wanted to start taxing HSAs, what a clown! BUT, we do need to increase the maximum HSA deposit to $10,000 for singles under 55-years-old. Family’s maximum deposit is double or $20,000.
This tax credit helps young people big-time and targets PROSPERITY to the poor! Imagine a 30-year-old couple with $20,000 annually going into their HSA. At 65-years-old this couple might expect their MSA balance to be significant when they are 100 years old. That’s the goal right? People will be saving today for medical procedures that may be invented in 60 years from now. Your grandchildren might be getting brain transplants in 2325 Devon. Sounds expensive.
Also, if someone wants to produce more future taxpayers the credit is $2,000 per child with no limits. Devon, If you are healthy you are not going to hit a $10,000 deductible so if you raise your deductible to $25,000, because you have $250,000 in your HSA, your premium drops to $8,316 so your HSA deposit would increase to $2,684 per year if you wanted to stay in the VERY expensive Lone Star State.
FYI – these tax credits help young people because we need to help the young, we need their vote in 2024 to save America. FYI – a 30-year-old couple in Charlotte, NC 28201 with 2 children get $10,000 in age-based tax credits which pays 100% of the premium plus deposits $5,560 every year in their tax-free HSA. In fly over country my age-based tax credits will pay for the family’s health insurance plus deposits $5,000 in the family’s HSA. Even in high priced Texas my credits pay 100% of a 55-year-old couple’s premiums in Texas! Everybody else will get larger tax credits in America. I am not talking about far-left Democrat states like NY or CA.
I appreciate your work on the numbers, Ron.
My question about the Goodman tax credits was always how the gov’t was going to finance them.
Let’s say that there are 60 million individuals and 40 million families in the non-Medicare, non-Medicaid population. (this may be low)
So the total outlay for tax credits would be about $550 billion a year.
Where does that come from? By my estimate, converting all of today’s employer payments into taxable income would only yield about $200 billion in new tax revenues..
Comments welcome..