I went to my physical therapist yesterday for knee treatment and we talked about the fact that Blue Cross is cutting their reimbursement to the point that the cost of providing care will not even be covered. All I could do was lament with him and listen.

One insurer even told him (the owner of the business) to just “make the sessions shorter and don’t give as much care.”

Clearly the insurance intermediaries, who never actually see a patient or deliver any care, haven’t got a clue how this whole health thing works. They are happy with mediocre doctors that cut time and care. Those doctors (and physical therapists) run mills, but the insurance companies are happy with them. Quality and quantity of time are not rewarded, and in fact are punished in the health care environment we have.

He asked me if primary care had any problems like that. I felt like screaming, “Aren’t you reading my blog?”. Or more to the point, why doesn’t the entire population know that access to a primary care physician will become as rare as swimming with dolphins. It will depend upon how much money you have to buy concierge/retainer medicine.

Where you live will play a role. If your community has a large multispecialty clinic, like Kaiser or Sutter Palo Alto Medical Group, you may have access.

Doctors in training are flooding away from general Internal Medicine, Pediatrics and Family Medicine in droves. Only 2% of medical students plan to go into primary care. It used to be over 50%. A recent Jim Lehrer report discussed the reasons. We’ve been talking about it for years but things have only gotten worse, not better.

The whole premise of health care reform ensures that everyone has access to good quality care. Every nation that provides good, quality access has a strong primary care base that is the foundation. Primary care is valued by the government, the payers, the population and even by the physicians.

We have it all backward. It is time to revamp the system from the bottom up. Frankly I don’t care if we get one more multimillion dollar robot to assist in a rare surgical procedure or one more new “next generation” imaging scanner until we can rationalize how we pay for care.

We have not yet begun the hard work to bring costs under control because there are too many pigs at the trough. One of my favorite teachers said “you can’t clear the swamp until you get the pigs out of the way”.

We have a lot of pigs to move aside so more people can get to the water.

Tony Brayer is an internal medicine physician who blogs at EverythingHealth.

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