Welcome John Geyman, M.D., and Host Wendell Potter (author, Deadly Spin)

[As a courtesy to our Guests, please keep comments to the book and be respectful of dissenting opinions. Please take other conversations to a previous thread. - bev]

Breaking Point – How the Primary Care Crisis Endangers the Lives of Americans

Host, Wendell Potter:

Just last week, the 34-nation Organization for Economic Cooperation Development (OECD) released the results of its most recent study of the health care systems in the 40 counties considered to be “developed.” It came as no surprise to see that the U.S. health care system—if we can even call it a system—is still by far the most expensive on the planet.

We spend two-and-a-half times more on health care per person than the OECD average. The average expenditure per person in the U.S. is $7,960. The OECD average, by comparison, is just $3,233. Yet we rank 29th in the number of hospital beds per person and 29th in the average length of a stay in the hospital. We have high rates of avoidable hospital admissions for people with asthma, lung disease, diabetes, hypertension and other common illnesses, and we lag behind many other countries on other measures of quality and accessibility.

And when it comes to access to physicians, we’re considerably closer to the bottom than the top. We rank 26th in the number of physicians, especially primary care doctors, per 1,000 people.

All of the bad news for the U.S. in the OECD report is troubling if not shocking, but that last data point—that 25 countries have more physicians per capita than we do—even caught me by surprise.

But after reading Dr. John Geyman’s latest book, Breaking Point—How the Primary Care Crisis Endangers the Lives of Americans, I now understand why and how we have sunk so low. Not only does Geyman explain what has happened to our primary care infrastructure over the past several decades, he makes the most compelling case I’ve read anywhere about the urgency of rebuilding it. He also suggests ways we can do it.

If you’re not acquainted with Geyman, you should be. He is one of the wisest and most prolific writers about health care in America. Breaking Point is his 12th book and follows another must-read: Hijacked: The Road to Single Payer in the Aftermath of Stolen Health Care Reform.

As you can tell by the title of that book, Geyman is not a big fan of the Affordable Care Act, a.k.a. Obamacare. While he notes that the reform law will expand access over the next several years, “it will not make a dent in the primary care crisis.”

In fact, he goes on, “the 32 million Americans who gain some kind of insurance coverage between now and 2019 will find it more difficult than ever to find a primary care physician. Insurance without a physician—how much of a gain is that?

A former Republican country doctor, Geyman writes that when he graduated from medical school in 1960, there already was a growing shortage of general practitioners, but not nearly as severe as today. In 1960, 18 percent of U.S. doctors were in general practice. By 2000, the number had fallen to 12 percent, and it continues to spiral downward because of the many disincentives in the U.S. for medical students to go into primary care.

Those disincentives have led to primary care physicians becoming an endangered species.

“Specialization, subspecialization and sub-subspecialization are increasingly taking over the physician workforce,” he writes. “The reasons for these changes have much to do with money and the business of medicine. The decline in generalist medicine and primary care is inexorable with present policies in health care, and present trends signal a disaster unfolding.”

That disaster is indeed unfolding, although you’d hardly know it from the politicians and pundits who are more interested in ideology and the gamesmanship of reform than truly addressing the problems with workable solutions. And while the far-reaching reforms that are needed have so far been beyond the ability of lawmakers to enact—also having to do with money and the business of medicine—the disaster that is unfolding is increasingly being felt by American families.

Because of increases in population and the dwindling supply of general practitioners, more and more Americans are unable to find a personal primary care physician for themselves or their family. As a result, Geyman writes, their care has become increasingly expensive and fragmented.

Why does primary care matter? Geyman lists several reasons. Patients with regular access to primary care doctors receive more preventive services, and they have fewer preventable emergency room visits and hospital admissions. Because they get to know their patients well over time, primary care doctors order fewer tests than specialists, and they help protect their patients from inappropriate, unnecessary and expensive overutilization of specialist services. Having primary care leads to earlier diagnosis and treatment of illnesses, enhancing quality and outcomes of care. Primary care doctors are also ideally suited to coordinate care for patients who need multiple specialists. And studies have shown that patients with an ongoing relationship with a primary care doctor are more compliant with treatment.

Geyman believes, and I agree, that primary care must be at the heart of a transformed U.S. health care system—and it ultimately will be transformed because the status quo is not sustainable. And, like me, he is an optimist—transformation not only is possible, it is inevitable. Toward the end Breaking Point, Geyman provides us with “ten lessons for primary care and health policy” that every reform advocate and every lawmaker truly interested in reform should read. Only someone with Geyman’s knowledge as a physician in private practice for decades and a renowned scholar of health care systems around the world could develop what essentially is a roadmap out of our unfolding disaster.

The last of those ten lessons is especially important for advocates who were disheartened and disillusioned when Congress passed the Affordable Care Act because of its shortcomings and the fact that it gives the insurance industry a renewed lease on life. Lesson #10: “The fight for sustainable and accountable health care can be a long one, but it can be won in the end by those prepared to keep at it.”

Breaking Point is worth reading not only to get a better understanding of the value of primary care but also Geyman’s wise counsel, reality-based optimism and challenge for us to stay in the fight and never give up. “We can all make a difference if we choose to do so,” he concludes. “Let’s go for it!”

Indeed. It’s time for all of us to rally, especially with the fate of the Senate and White House at stake.

124 Responses to “FDL Book Salon Welcomes John Geyman, Breaking Point – How the Primary Care Crisis Endangers the Lives of Americans”

BevW November 27th, 2011 at 1:56 pm

John, Wendell, Welcome back to the Lake.

Wendell, Thank you for Hosting today’s Book Salon.

RevBev November 27th, 2011 at 1:59 pm

Would you report some of the other 10 Lessons, or ways we can make a difference? Thanks for being here.

Wendell Potter November 27th, 2011 at 2:01 pm
In response to BevW @ 1

Thanks, Bev. And hello, John. Welcome–and thanks for writing a terrific and very valuable book.

tjbs November 27th, 2011 at 2:02 pm

Let me share a story about my precious daughter, now 28.

Five years ago she was struck with unbelievable cramps, enough to force her to the emergency room at 10;00 at night, primary care. She was between jobs with no insurance. It cost $2,200 for two hours of observation and a couple of Mytol tablets.

Then she started her new job with an HMO . Though in constant discomfort, last New Eve she was stricken again and was given a sonogram but the attendant was hot to trot to her very important New Years Eve party and said there was nothing to be concerned about.

Then her office switched to NYBCBS and she went to see the doctors that treated her in her first Job insurance plan, they did an MRI and found the spot which now consumes half an ovary. She will be operated on in 2 weeks probably losing it.

We do not have the greatest health care system in the world but rather the greatest PROFIT driven, amoral health care system the world has ever seen and it’s degusting and as far from the Hippocratic as possible !

Elliott November 27th, 2011 at 2:02 pm

Hi, welcome to the Lake

It just frustrates me that the opportunity to re-form our health care system was cravenly squandered. Having said that, I hope your book sells well and influences many.

Wendell Potter November 27th, 2011 at 2:03 pm

John, you wrote that money and the business of medicine are at the heart of the primary care crisis. Would you elaborate?

John Geyman November 27th, 2011 at 2:03 pm

Hi, I’m hear and thank you for your interest in this book. John Geyman

Elliott November 27th, 2011 at 2:04 pm
In response to tjbs @ 4

(((tjbs fille)))

eCAHNomics November 27th, 2011 at 2:07 pm

The U.S. medical industry does not have primary care docs bc it can, i.e. bc there is no monitor on the industry to behave in any way other than to cater to the wealthy. And the rich need only expensive specialists. It’s surprising it’s taking so long for docs to figure that out.

John Geyman November 27th, 2011 at 2:08 pm
In response to RevBev @ 2

There are a number of lessons that we can draw from the primary care crisis. We can flesh some of them out as we go along on this Book Salon, but for openers, the biggest cause of the crisis is Money, the Business of Medicine, which acts as a continuing barrier to having enough primary care physicians and retaining them in practice. The biggest problems are educational and political, but they all revolve around money.

John Geyman November 27th, 2011 at 2:10 pm
In response to Wendell Potter @ 3

Thanks, Wendell, and thanks for your writing your terrific book, Deadly Spin.A courageous book and a breakthrough in our understanding of how the insurance industry really works. John

Wendell Potter November 27th, 2011 at 2:12 pm

Can you describe the role money–and the business of medicine–play in thwarting efforts to reform our health care system and, specifically, to improve primary care in this country?

Mauimom November 27th, 2011 at 2:12 pm

Dr. Geyman, thank you for this book. It’s wonderful: both analysis of where we are, and a prescription for getting better.

Now, if we could only get the public and politicians to read it!!!

I find it discouraging that so many think PPACA was “progress,” unaware, as you say “that its provisions will fail to contain costs, provide universal coverage or significantsly reverse financial incentive throughout our market-based system.”

Wendell Potter November 27th, 2011 at 2:13 pm

Thanks, John. I’m honored and flattered that you mentioned and quoted from Deadly Spin in Breaking Point.

John Geyman November 27th, 2011 at 2:14 pm
In response to tjbs @ 4

Yes, you are right on! We do have an amoral “system” based on money and ability to pay, not medical need. As such, we are an uncivilized country compared to most advanced countries, which see health care as a right. Very sorry to hear of your daughter’s bad experience—unfortunately all too common— but a symptom of not having enough primary care docs available to see us over years, to be available whenever we get sick, and who care!

John Geyman November 27th, 2011 at 2:16 pm
In response to Elliott @ 5

I hope this book will get out there to help with the political problems. It will be sent shortly to every member of Congress (if they or their staffs can read!)

Wendell Potter November 27th, 2011 at 2:18 pm

As you noted in the book, “the government has been missing in action over the past several decades in planning, implementing and monitoring the evolving primary care needs of this country.” Why has there not been a vocal champion for primary care in Washington? And is there one now?

Mauimom November 27th, 2011 at 2:21 pm

Dr. Geyman, one question that kept recurring for me as I progressed through your book was, “where are the doctors with regard to this situation?”

I’m old enough [let's just say I'm on social security] to recall that every past proposal to move on “universal care” or some reform to bring to the US something like the British or Canadian or French system would be met with AMA howls of “socialized medicine.”

Have doctors come to realize both that the system is broken [not only for their patients, but for them] and that the insurance companies and drug manufacturers are NOT their friends?

It seems to me if we could get the doctors on the side of “reform,” it would become inevitable.

John Geyman November 27th, 2011 at 2:22 pm
In response to Wendell Potter @ 6

Yes, money and the business “ethic” are at the heart of the problem, as you well know from your experience in the insurance industry.A long story (and the subject of my last book now in progress) that will show the many ways that the free market doesn’t work in health care. Besides most insurers, most hospitals,nursing homes, dialysis centers, hospices, are for-profit (many investor-owned), plus of course, the drug, medical device and medical supply industries. Then there are physicians, especially specialists with their over-compensated services, who make more money by doing more, whether inappropriate, unnecessary, or not. All tied together in a deregulated “system”.

eCAHNomics November 27th, 2011 at 2:22 pm
In response to Mauimom @ 13

The politicians’ only interest in medical care is to make sure their donors get all they want. Pols have NO interest in the kind of medical care real people get.

tjbs November 27th, 2011 at 2:22 pm
In response to John Geyman @ 15

I remember growing up in a small town in the 50′s where the primary care physician came to our house, to treat my brother’s rheumatic fever. How far we have fallen.

Kathryn in MA November 27th, 2011 at 2:24 pm

Welcome, Wendell! Thank you for hosting and that clear introduction. And thanks for all you have done to raise awareness and turn things around. Now to settle in and read the comments.

John Geyman November 27th, 2011 at 2:26 pm
In response to eCAHNomics @ 9

Yes, that’s true. We have a specialist dominated physician workforce because the specialists make so much higher incomes than primary care in a more limited range of practice and with more comfortable lifestyles. The shift is dramatic. We had 18 percent of U.S. physicians in general practice when I came into medicine 50 some years ago; now only 7 percent of medical school graduates go into family medicine and only 2 percent of those entering internal medicine become general internists.

OldFatGuy November 27th, 2011 at 2:26 pm

Been looking forward to this just so I could say:

THANK YOU Dr. Geyman for a great book. I’m now interested in reading your older ones I missed!!!!

greenharper November 27th, 2011 at 2:27 pm
In response to John Geyman @ 16

This is a good idea! Thanks to whomever thought of it and is financing it.

Mauimom November 27th, 2011 at 2:27 pm
In response to tjbs @ 21

And I think many of us would be willing to pay — in increased medical training in primary care, and other ways — to bring this model back.

i know it infuriates me to think of the percentage of my “medical dollars” going to the insurance companies, who basically do NOTHING other than turn down claims.

Wendell Potter November 27th, 2011 at 2:28 pm
In response to Kathryn in MA @ 22

Thanks, Kathryn. John is one of my heroes. Every one of his books have been remarkably informative and inspiring. I have learned much from him and am delighted to hear he is at work on yet another book.

John Geyman November 27th, 2011 at 2:28 pm
In response to Mauimom @ 13

Agree completely. The PPACA just won’t work; it’s really a gift to the medical industrial complex. Unfortunately it will take a few years before people will realize that it’s just another policy failure.

RevBev November 27th, 2011 at 2:30 pm

This may be off topic, but relevant. Is it from the Docs. or pharma that Medicare has so many restrictions about drugs…even things the drs. order?

Mauimom November 27th, 2011 at 2:31 pm
In response to John Geyman @ 28

Well those were YOUR WORDS I was quoting!!!!!

A “high five” for our agreement on that issue. I think you’ll find most folks at FDL share that view.

eCAHNomics November 27th, 2011 at 2:31 pm
In response to John Geyman @ 19

The industry is part of the mafia of the intelligentsia (the other two MoI industries being law & higher ed). Known in the economics field as information asymmetry market imperfection. It is the knowledge gap between buyer & seller that gives the industry pricing power, and additional pricing power comes from the fact that the customer is vulnerable, namely sick. As a final fillip, third party payment has made the customer indifferent to what the price is.

What part of the industry will benefit most from this depends on power various segments of the industry have. Since PhRMA & insurance have the $$$ to make the biggest political contributions, they benefit most. Rich docs also fall within that exalted circle, but to become rich, a doc must specialize to have rich patients, who are also big pol contributors.

Etc.

Soon in the oligarch U.S. the wealthy will have personal docs, the way royalty used to, and there will be no one in the ind who cares about anyone else.

OldFatGuy November 27th, 2011 at 2:31 pm
In response to eCAHNomics @ 20

I soo love your ability to get down to the basic, bottom line truth, in so few keystrokes. That’s a gift. :)

eCAHNomics November 27th, 2011 at 2:32 pm
In response to tjbs @ 21

Curiously, it takes docs a long time to figure out where the $$$ are.

John Geyman November 27th, 2011 at 2:32 pm
In response to Wendell Potter @ 17

Right, Wendell. The government has been missing in action on primary care. What physician workforce planning groups that we have had have been dominated by the non-primary care specialties. And primary care is not well represented in organized medicine. There are about 145 specialty and subspecialty groups within the AMA. Quite a contrast with other countries: in England, for example, where a sizable majority of physicians are in general practice, that group has the most political power within the profession and with the government.

Wendell Potter November 27th, 2011 at 2:32 pm

Speaking of PPACA, you noted that it allocates a few million dollars to train 500 primary care doctors but, as you wrote, it and other actions “are just a few buckets of water in response to a fire that is raging in primary care.” Do you know if there were proposals before Congress during the debate on reform to do more for primary care?

eCAHNomics November 27th, 2011 at 2:33 pm
In response to OldFatGuy @ 32

I’ve been writing/talking about this issue for 20 years.

BevW November 27th, 2011 at 2:33 pm

Wendell, Comment #9 (below) – Your thoughts – is this how the Health Care Industry “plans” care?

The U.S. medical industry does not have primary care docs bc it can, i.e. bc there is no monitor on the industry to behave in any way other than to cater to the wealthy. And the rich need only expensive specialists. It’s surprising it’s taking so long for docs to figure th

at out.

Mauimom November 27th, 2011 at 2:34 pm

I am wondering about the question I posed: where are the doctors?

Is your answer [as suggested in your comment @ 23] that they’ve all migrated to the higher paying specialties, so they just don’t care about primary care?

Does everything work so well for them in their “universe” that they just don’t see the problem?

eCAHNomics November 27th, 2011 at 2:34 pm
In response to Wendell Potter @ 35

Don’t know anything about PPACA, but whatever drop in the bucket it is, what’s to prevent these docs from further training to become specialists? If it’s a time period, like X years, they’ll just fulfill the contract, then switch.

John Geyman November 27th, 2011 at 2:37 pm
In response to Mauimom @ 18

Good question and observation. Little known is that a majority of U.S. physicians (59 percent) in a big national survey of all specialties several years ago support single-payer national health insurance, the single-most effective way to start real reform. And a few years previously, almost six of ten medical school deans also did. But their influence is drowned out by the vested interests in organized medicine as well as the various corporate stakeholders in the medical industrial complex.

fatster November 27th, 2011 at 2:37 pm

It’s all about the money. Primary care in the public sector struggles, too. As a result of lack of adequate funding, patients with no means to pay who seek primary health care at the county level must meet very stringent poverty requirements. And if patients aren’t quite poor enough to qualify for county-provided primary (specialty, too) care, but don’t meet Medicaid eligibility requirements, and charity-based care is not available–well, they just join the ranks of the millions who go without. Of course, the price of that situation escalates exponentially once the ill-health condition they have worsens or is exacerbated to the point that they have no recourse but to show up in the ER. It is a shame and a scandal as my southern grandmother used to say.

Thank you so much for this forum and the privilege to interact with Dr. Geyman.

eCAHNomics November 27th, 2011 at 2:38 pm
In response to Mauimom @ 30

Yet another implication of information asymmetry market imperfection is that any govt program directed toward industry will be captured by the ind itself, rather than by the ind’s customers.

Mauimom November 27th, 2011 at 2:39 pm
In response to John Geyman @ 40

Little known is that a majority of U.S. physicians (59 percent) in a big national survey of all specialties several years ago support single-payer national health insurance, the single-most effective way to start real reform.

Wow!!! How do we mobilize that?????

ffein November 27th, 2011 at 2:40 pm

My dad was a “general practitioner” (family practice) in a small town which he started after he came home from WWII. He had a small office, made house calls, delivered babies, set broken bones, etc. He retired before he should have but mostly because his malpractice insurance was too high (even tho he had never been sued). I talked to a resident at the VA about ten years ago who wanted to set up her own practice in an area where there weren’t physicians but she was already in debt for $100,000 in student loans so her only option was to join a corporate group of physicians. It’s too costly to go to school, and the insurance industry has helped this along. Very sad.

John Geyman November 27th, 2011 at 2:40 pm
In response to tjbs @ 21

You’re right. We have fallen a long way, and it will take a long time (maybe a couple of generations) to rebuild our primary care infrastructure. But is CAN be done. We will figure it out eventually: as Winston Churchill famously said: the Americans will do the right thing, but first they will exhaust all the alternatives! And I like the economist Herbert Stein’s observation: If things can’t go on forever, they will stop!

John Geyman November 27th, 2011 at 2:42 pm
In response to OldFatGuy @ 24

Thank you, but I may be older than you,and I still feel young (and my wife of 55 years reminds me how immature I still am!

Kathryn in MA November 27th, 2011 at 2:43 pm

Gentlemen, let me pose a rather daring question – If research showed cannabis to be a cure for cancer, could you imagine the Money behind Big Pharma and Big Medicine squelching the research and lobbying for a double down on The War on Drugs?

OldFatGuy November 27th, 2011 at 2:44 pm
In response to Mauimom @ 38

I think that’s sort of the answer.

Those in it for the money and prestige, i.e. shallow, will migrate to the specialties. Thus it’s no surprise that these types of folks don’t/can’t think of anything beyond their small world. (Not to say ALL specialists are shallow, but all who enter for money/prestige do migrate to specialties).

The few now who become primary care docs do so out of a genuine sense of caring, and making a difference, it seems to me.

Then they get into practice, and the way the insurance/compensation works forces them into running an assembly line mill to see enough patients to make a living wears a lot of them down to the point that a lot of them get out of primary care.

It’s a vicious cycle. The pediatric office I managed has four primary care docs, and every one of them were caring, decent, and principled people. Yet they too would get ground down from all the pressure to increase patients per hour or reduce costs here or there that they would sometimes ask whether it was worth it.

Primary care is now seen as the bottom of the barrel in their careers.

John Geyman November 27th, 2011 at 2:44 pm
In response to greenharper @ 25

Yes, this is a joint effort with Physicians for a National Health Program (PNHP). the best organization in medicine. We did this also with my last book Hijacked; I share the costs of getting them to 535 Congress people with PNHP.

eCAHNomics November 27th, 2011 at 2:44 pm
In response to ffein @ 44

Heh. Two members of the MoI (comment 31) jousting for which one will benefit most. Would be fun to watch (in a gallows humor way) if it weren’t for the ruined lives.

Wendell Potter November 27th, 2011 at 2:45 pm
In response to BevW @ 37

There is no real planning, except planning to meet short-term profit goals. That is one of the big problems. Because so many of the health care players, not just insurers but drug companies, hospitals, medical device manufacturers, etc., are for-profit companies, they care first and foremost about meeting shareholders’ short-term earnings expectations. They will do whatever it takes to be able to please those shareholders and Wall Street analysts every three months when they announce quarterly earnings. For insurers, that means to avoid insuring people who really need coverage, if at all possible, and refusing to pay claims. For drug companies, it is charging outrageous prices for new pharmaceuticals. Whenever you try to reform our profit-obsessed health care industry (which is a much better word than system to describe what we have in the US), you will be proposing to alter some doctors’ incomes and some companies’ profits. And they will fight to keep that from happening.

John Geyman November 27th, 2011 at 2:47 pm
In response to Mauimom @ 26

Agree. Such a lot of waste with our multi-payer system of some 1,300 insurers, mostly in the business of making money and avoiding sicker people. The currency of their realm is the “medical loss ratio”, what they have to “lose” on paying for actual care.

Mauimom November 27th, 2011 at 2:47 pm

Dr. Geyman, could any part of this problem be solved by training additional primary care doctors? {Something better than Obama’s weak tea.]

Could there be a program, like there used to be, and perhaps still is for teachers, whereby a percentage of one’s medical student debt was forgiven if one practiced in an area “of need”?

Are there any ways that individual states [I'm thinking Vermont] can set up their own single payer systems?

Just trying to think of some things short of mobilizing for political action.

greenharper November 27th, 2011 at 2:48 pm

P.S. Do you think that this essential book might get more attention if sent to the principal district office of each member of Congress?

When I went with a group to lobby our Congressman about single-payer Medicare for all, he seemed to have more time for us since it was in his largest district office.

John Geyman November 27th, 2011 at 2:49 pm
In response to Wendell Potter @ 27

Thanks, Wendell, and YOU are one of my heroes! Takes real character to tell us how it really is within the industry you spent so many years in. You have demonstrated how much difference one person can make in exposing the problems.

RevBev November 27th, 2011 at 2:51 pm
In response to Wendell Potter @ 51

I guess that’s the answer to my question above about Medicare & drugs: rules & limited coverage.

eCAHNomics November 27th, 2011 at 2:51 pm
In response to Wendell Potter @ 51

Shareholders are irrelevant for the most part, since they are passive. The information asymmetry market imperfection also contaminates the relationship bet CEOs and shareholders.

As I understand it, in Europe they have meetings with “stakeholders” which involve some representation of medical ind customers, that have meetings, resulting agreements about prices/quantities.

Of course, with the oligarchs taking over Western Europe, expect that cooperative environment to end and the European medical ind to become more like the U.S. one (I.E. catering to the wealthy only), rather than the reverse, (i.e., U.S. ind becoming more like western Europe/Canadian inds used to be).

John Geyman November 27th, 2011 at 2:53 pm
In response to RevBev @ 29

Mostly a problem with the drug industry, which has resisted any price controls all along the way, as well as importing drugs from other countries. The won in 2003 with the Medicare prescription drug legislation,which handed off that drug benefit to industry without price controls. The drug industry greatly exaggerates what they spend on bringing new drugs to market (and most of them aren’t really new). The government does negotiate drug prices for the VA and Medicaid down to about 58 percent of what we pay, so we know it could be done.

OldFatGuy November 27th, 2011 at 2:54 pm
In response to John Geyman @ 55

Yes!!!

Want to second that with my personal thanks too Mr. Potter!

You’re viewed as a hero by many too!! Rightly so, too.

John Geyman November 27th, 2011 at 2:54 pm
In response to Mauimom @ 30

Thanks a lot!

OldFatGuy November 27th, 2011 at 2:59 pm
In response to John Geyman @ 28

The PPACA just won’t work; it’s really a gift to the medical industrial complex. Unfortunately it will take a few years before people will realize that it’s just another policy failure.

Unfortunately, I’m afraid it’s actually more than just a policy failure, IMO it’s actually made things worse by making the insurance companies even bigger and more powerful by mandating the entire country be their customers. I fear this failure not only won’t help, but will make real progress even harder in the future.

I really do wish it would be repealed. Or struck down.

Wendell Potter November 27th, 2011 at 2:59 pm
In response to eCAHNomics @ 57

The big institutional investors that own the majority of shares in all big companies are not what I would characterize as passive. CEOs definitely pay a lot of attention to the investment goals of institutional investors and do whatever they can to make sure they are “enhancing shareholder value.” If those investors are disappointed in a quarterly earnings report, they will sell their shares, which, if they own a lot, will lead to a drop in share price. When that happens, the value of the CEO’s stock options go down. Trust me, they do not want that to happen and will do whatever they can to make sure it doesn’t.

John Geyman November 27th, 2011 at 2:59 pm
In response to eCAHNomics @ 31

Yes, all true. One more new twist is the feeding frenzy we are seeing among hospitals, insurers and physician group practices in preparation for the accountable care organizations (ACOs) called for in last year’s health care “reform” bill. As one example, reported today in a St. Louis paper: a 3 minute visit to dermatologist for a wart cost the patient $538, including a facility fee at the dermatologist’s office: sign of things to come!

Wendell Potter November 27th, 2011 at 3:00 pm
In response to OldFatGuy @ 59

Thank you. I really appreciate your kind comments.

AitchD November 27th, 2011 at 3:00 pm

30 years ago a total cholesterol level of 240 wasn’t considered risky. Then the statins were developed (and were very expensive until the generics came online). Soon the risky levels around 300 came down, so the bell curve changed, and ‘normal’ became under 240, so more patients were advised to begin statin therapy, which further altered the bell curve with a 200 level being the new upper-limit for risk. And still no one knows anything about cholesterol and health, except for a few people who know that the brain requires cholesterol (and as likely as not regulates the organism’s level as long as the host doesn’t insanely abuse itself).

DWBartoo November 27th, 2011 at 3:00 pm

A most superb Book Salon!!!

Thank you, John, Wendell …and Firedogs!

If it will take “several generations” before things may be made sane and rational, then considerable damage, with real human costs will occur.

When combined with the other failures, as eCAHN, among others, has pointed out, a decade or more of continuing greed and intentional failure, especially if the US continues to pursue “endless” war, will bankrupt this nation morally as well as economically … and the accounting, when, or if, it comes will be historic in its measure … that is assuming the rest of the world does not tire of America’s “exceptionalism” and terrorism and decide that both must end.

Just a wee concern …

DW

eCAHNomics November 27th, 2011 at 3:02 pm
In response to John Geyman @ 63

Heh. In my day we soaked our feet & dug warts out ourselves.

One tea-insy part of MoI is convincing everyone that every minor problem requires “medical” care.

John Geyman November 27th, 2011 at 3:03 pm
In response to Wendell Potter @ 35

No, Wendell. There wasn’t a lot to do with primary care in the 20 pound, 2000-plus page bill. Some provisions that fall way short of the needs, however, include more funding for the National Health Service Corps and community health centers, as well as a 10 percent bonus for primary care physicians (for just two years!).

AitchD November 27th, 2011 at 3:03 pm
In response to John Geyman @ 63

3 minutes?

OldFatGuy November 27th, 2011 at 3:04 pm
In response to Mauimom @ 53

Here’s an idea, how about college educations being free just like high school???

I know, I know, soshalizm!!!!!

John Geyman November 27th, 2011 at 3:05 pm
In response to Mauimom @ 38

Yes, they have overwhelmingly migrated to the non-primary care specialties. We have less than 30 percent of our physician workforce in the three primary care specialties of family medicine, general internal medicine and general pediatrics, many are nearing retirement age, and they are not being replaced.Moreover, many physicians are now in part-time practice.

eCAHNomics November 27th, 2011 at 3:06 pm
In response to OldFatGuy @ 70

Reductio ad absurdum. Free med school allows docs to make even MORE $$ by catering to wealthy patients without having to pay off anything to U.S. taxpayers. Part of looting, not part of solution.

clambake November 27th, 2011 at 3:07 pm

Is more preventative care always better? I just finished reading a couple of books that question this assumption: Dr. Nortin Hadler’s Rethinking Aging and H. Gilbert Welch’s Overdiagnosed. They discuss various cancer screenings, treatment of mild hypertension, tight glycemic control of type 2 diabetes, etc.
On the other hand– I guess you could say that both books could present a powerful argument for more primary care physicians– giving PCPs the time to discuss costs and benefits to various treatments and screenings.
And both books do lay bare the profit motive behind many treatment guidelines. Hadler is particularly withering in his critique of contract research organizations.

Wendell Potter November 27th, 2011 at 3:07 pm
In response to John Geyman @ 63

You also expressed skepticism that accountable care organizations ACOs) as proposed under PPACA will succeed. Can you explain your concern and skepticism about ACOs?

OldFatGuy November 27th, 2011 at 3:11 pm
In response to eCAHNomics @ 72

Well, I was talking about the first four years of college, not med school, but still I see your point.

Guess I was hoping if the financial disincentives of education were out of the way, more folks might attempt to be docs.

Although that wouldn’t work if the number of docs is being tightly monitored and controlled by the AMA, which is what many claim.

John Geyman November 27th, 2011 at 3:12 pm
In response to fatster @ 41

Yes, the public sector is greatly underfunded, and our safety net falls apart more every year. Now only 42 percent of the 350-plus acute care visits in the country are to personal physicians; 29 percent are to ERs and 20 percent are to specialists. Access to real primary care is becoming the exception, and ER docs are having more and more difficulty in arranging ongoing care for their patients. We have enough money in the overall system, we just need to reorganize the system, get health care more on a service ethic and re-allocate where the money goes. A big political challenge!

marymccurnin November 27th, 2011 at 3:13 pm
In response to eCAHNomics @ 72

I disagree. If medical school was free then we would have a broader range of docs. As it stands, only the rich and the indebted get through the process. The catering to the wealthy is an overall cultural issue that we need to address.

marymccurnin November 27th, 2011 at 3:14 pm
In response to John Geyman @ 76

Perhaps using P.A.’s and others for primary care could help bridge the gap.

John Geyman November 27th, 2011 at 3:16 pm
In response to Mauimom @ 43

That’s the $64 question! We need a movement across the country. Perhaps the movement for national health insurance can become part of the 99 percent movement as it sorts out in coming months and years. Michael Moore offered a ten-point agenda several days ago, which I think is great; national health insurance is #7 on that proposal. My Hijacked book has more detail on that question.

OldFatGuy November 27th, 2011 at 3:17 pm
In response to marymccurnin @ 77

Yeah, that’s kind of where I was coming from, but I wasn’t even sure whether med school and/or law school should also be free.

Is it in Europe??? I dunno.

Most of me says all education should be free, but I haven’t thought through all the consequences of that so I’ll stick to at least 4 years of college for now. But I’m with you in spirit on med school!!!!

OldFatGuy November 27th, 2011 at 3:18 pm
In response to John Geyman @ 79

Are you sure you were a former Republican????

LOL, sure don’t sound like any Republican I’ve ever heard.

fatster November 27th, 2011 at 3:19 pm
In response to John Geyman @ 79

With the homeless flocking to the OCCUPY sites, and given that the homeless heavily rely on county-provided primary care, I suspect that item will achieve greater recognition, promptly.

John Geyman November 27th, 2011 at 3:20 pm
In response to ffein @ 44

I wish we could clone 100,000 of your grandfather! Yes, student debt is a big problem these days: medical school graduates average more than $125,000 in debt from many schools; we need more government assist with loan repayment, especially for those graduates headed for primary care. And the malpractice insurance costs could likewise be helped—that’s a complicated area,and its costs of total health care spending is actually exaggerated: it’s no more than about 3 percent of health care costs.

Wendell Potter November 27th, 2011 at 3:20 pm
In response to John Geyman @ 79

That is the $64 question but the most important one. We really do have to have a movement. So far, we have not reached the tipping point, but we can get there if a movement is planned and led in a smart way.

John Geyman November 27th, 2011 at 3:21 pm
In response to Kathryn in MA @ 47

Yes, I can! If in doubt, just follow the money.

AitchD November 27th, 2011 at 3:23 pm
In response to marymccurnin @ 77

It has to be that way so US citizens who don’t qualify for US med schools have to go elsewhere, such as Grenada, which had to be invaded only to secure the safety of the US citizens attending the med school there. Tell me I’m wrong. Please.

John Geyman November 27th, 2011 at 3:25 pm
In response to Mauimom @ 53

Yes, an approach to training more primary care physicians is in the book, including changing how physicians are paid, how medical education is financed, setting a specialist-generalist goal (such as 50:5)), redesigning primary care with greater emphasis on team training, and establishing primary care departments in medical schools. All with a greater investment in primary care and revision of present reimbursement systems.

Kathryn in MA November 27th, 2011 at 3:26 pm
In response to John Geyman @ 85

Gosh. That’s just it – there is TONS of money in cancer treatment.

tjbs November 27th, 2011 at 3:26 pm
In response to John Geyman @ 85

That’s a big problem if the government, our government, refuses to allow research because it’s sooo bad.

John Geyman November 27th, 2011 at 3:27 pm
In response to greenharper @ 54

Yes, this is what we are doing.

BevW November 27th, 2011 at 3:28 pm
In response to John Geyman @ 79

Hijacked – The Road To Single Payer In The Aftermath Of Stolen Health Care Reform

The Patient Protection and Affordable Care Act of 2010 (PPACA) is being spun as the answer to our problems of health care access, costs and quality. But the dirty little secret is that the reform effort has been stolen by the very corporate interests that have perpetuated and profited from these problems for years. The result is a bailout of a failing insurance industry and a bonanza for Wall Street. Most Americans and Main Street lose once again. The need for real health care reform remains urgent. This well-documented book charts a path to that end.

fatster November 27th, 2011 at 3:31 pm
In response to John Geyman @ 87

Yes, sir, this is key: ” revision of present reimbursement systems”. We can produce all the primary care physicians imaginable, but if the means aren’t there to pay for that care, then millions upon millions of people will continue to go without care. (Again, I’m speaking from the perspective of county-funded and -delivered medical and health care.)

John Geyman November 27th, 2011 at 3:31 pm
In response to OldFatGuy @ 61

Yes, the insurance industry becomes even more of a barrier to health care reform as a result of the PPACA. Insurers are getting even more powerful through mergers,consolidation and diversification. They are going head to head with hospitals in organizing networks of physicians, and will become more involved in the actual delivery of care, including more market clout to negotiate prices in their own interest.

Wendell Potter November 27th, 2011 at 3:32 pm
In response to BevW @ 91

I agree, Bev. Hijacked is absolutely a must read. It would be a great holiday gift! Along with Breaking Point.

Kathryn in MA November 27th, 2011 at 3:33 pm
In response to John Geyman @ 90

Right – i think the DEA is congressionally bound to do research with only bad outcomes. I am following research done overseas, and with the real plant, not synthetic compounds. (edited)
Sorry! meant to answer to #89

AitchD November 27th, 2011 at 3:35 pm
In response to BevW @ 91

It’s not hard to imagine that soon enough a critical mass of ‘patients’ won’t be able to afford any kind of care, which will decimate (or worse) the funds for the medical ‘industry’, and particularly the for the physicians. That is when single-payer universal health care will become the only solution.

John Geyman November 27th, 2011 at 3:35 pm
In response to AitchD @ 65

Yes, that’s another part of the whole matter of increasing health care costs in a market-based system. As I’m going into this subject in my market book, one strategy supported by vested interests is to medicalize more of health care, including redefining the range of normal; statins and cholesterol level a good example, the lower threshold of “normal” greatly expanded statin markets.

John Geyman November 27th, 2011 at 3:36 pm
In response to DWBartoo @ 66

Yes, all big problems,and aren’t we tired of being so “exceptional” compared to other advanced countries—such an ill-informed and arrogant view.

John Geyman November 27th, 2011 at 3:40 pm
In response to clambake @ 73

Yes, both are good books, and more preventive care is not necessarily better.It can, of course, be very important, but it can lead to more testing and increased costs if tests are false-positive. And testing can be overdone when it doesn’t have supporting clinical evidence (e.g. PSAs over age 75, or a great example, full-body CT scans on a fishing trip for a problem in asymptomatic people.

eCAHNomics November 27th, 2011 at 3:42 pm
In response to John Geyman @ 98

“Exceptional” is code for ‘only the wealthy.’

John Geyman November 27th, 2011 at 3:46 pm
In response to Wendell Potter @ 74

ACOs will most likely make even more money for those in charge, whether expanded hospital systems or consolidated insurers with groups of physicians. There will be many opportunities to chase the dollar by cutting costs, limiting choice and services, and gaming the new system; some will be able to keep some of the “savings” that they make.ACO’s will try to avoid the sickest patients and game risk adjustment and quality measures, and our methods of measuring risks and quality are not up the task of preventing these games.

Wendell Potter November 27th, 2011 at 3:48 pm

John, in the book you equate the current state of our health care system to the housing and financial markets just before their collapse. You wrote, “We have seen the bubble burst in the housing market and Wall Street. The health care bubble will inevitably break when care becomes even more inaccessible for the growing tens of millions of people in need.” Do you think that bubble will burst within the next decade? And what will happen when it does?

John Geyman November 27th, 2011 at 3:49 pm
In response to marymccurnin @ 78

Yes, the training of more nurse practitioners and physician assistants are part of rebuilding primary care, with emphasis on team practice. But presently a majority of graduates of those programs go into specialty practice, where they find higher compensation. So both of those groups have much the same problem as physicians in opting for primary care.

tjbs November 27th, 2011 at 3:49 pm

Dreamer here, maybe there should be a law there will no talk of money or payments until treatment is complete.

It would be the exact opposite of the system we now where care is rationed by ability to pay.

Kathryn in MA November 27th, 2011 at 3:50 pm

i heard long ago (may be a myth) that ancient Chinese doctor was paid a stipend by citizenry and that they would cease paying the stipend if they fell ill, to resume paying once healed. That would encourage the doctor to do public health work, too.

John Geyman November 27th, 2011 at 3:51 pm
In response to OldFatGuy @ 81

Yes, though I’m shamed to admit it, I was a Republican until about 12 years ago, when I finally realized what that meant, just a slow learner!

eCAHNomics November 27th, 2011 at 3:51 pm
In response to John Geyman @ 101

As an aside, insurance is the ultimate moral hazard. All of the incentives are to collect premiums and deny claims. In the case of medical insurance, collect premiums and do your best to assure that the patient dies before any treatment is paid for.

BevW November 27th, 2011 at 3:53 pm

As we come to the end of this great Book Salon,

John, Thank you for stopping by the Lake and spending the afternoon with us discussing your new book and the Primary Care Crisis.

Wendell, Thank you very much for Hosting this great Book Salon.

Everyone, if you would like more information:

John’s website and book

Wendell’s website and book

Thanks all, Have a great week.

If you want to contact the FDL Book Salon: FiredoglakeBookSalon@gmail.com

John Geyman November 27th, 2011 at 3:54 pm
In response to fatster @ 82

I hope so, but it really is a large part of the 99 percent that are hurting in our present health care system. It takes more than $19,000 for a family of four to pay for insurance and health care; that out of a median family income of $50,000 is more than a hardship, and many are increasingly delaying or foregoing care.

tjbs November 27th, 2011 at 3:55 pm
In response to BevW @ 108

Yes, thank you both for such an informed discussion.

John Geyman November 27th, 2011 at 3:56 pm
In response to Wendell Potter @ 84

Yes, Wendell. That is our challenge and task ahead. We have succeeded with big movements in our past, such as womens’ suffrage and civil rights, so we can do this too!

Wendell Potter November 27th, 2011 at 3:56 pm

Thank you all, especially you, John.

eCAHNomics November 27th, 2011 at 3:57 pm
In response to John Geyman @ 109

It’s worse than that.

There’s no longer any incentive for docs to do anything to help patients. You show up in their offices, they send you out for a battery of tests that don’t diagnose anything and send you home, after a 5 min office face-to-face, with a prescription for antibiotics.

OldFatGuy November 27th, 2011 at 3:57 pm
In response to eCAHNomics @ 107

Exactly, and our new health care “reform” forces all of us into that ultimate moral hazard. I really hate that law. For the mandate, for it’s failures, and most of all for the biggest waste of the best opportunity in our history to make changes that would do some good.

So sad. But not a surprise I suppose. You probably bet on that outcome before the first hearings were held. Me, I was naive and hopeful. Then I learned.

John Geyman November 27th, 2011 at 3:57 pm
In response to BevW @ 108

Thanks to everyone for your interest and involvement in the primary care issue. All the best to you all. John Geyman

OldFatGuy November 27th, 2011 at 3:58 pm

Yes, thank you BOTH Dr. Geyman AND Mr. Potter.

Both of you are true American patriots.

DWBartoo November 27th, 2011 at 3:59 pm

A truly informative Book Salon.

John and Wendell, I thank you very much.

As always, Bev, I thank you.

And, Firedogs, I hope you will agree that John and Wendell are, very much, our kind of folks, and welcome to join us any old time?

My thnaks to all.

DW

eCAHNomics November 27th, 2011 at 4:00 pm
In response to OldFatGuy @ 114

I knew that when I read about O inviting PhRMA & insurance for secrud meetings in the WH, just like Cheney did for carbon ind execs.

Bluetoe2 November 27th, 2011 at 4:01 pm

Let’s be real. The Republican AND Democratic Parties threatens the lives of 99% of the American public. The 1%ers will be just fine.

fatster November 27th, 2011 at 4:05 pm

Many, many thanks for this forum. Very timely, and certainly top-notch!

Kathryn in MA November 27th, 2011 at 4:13 pm
In response to DWBartoo @ 117

Indeed, i hope they both are frequent visitors! Great guys.

heavyrunner November 27th, 2011 at 4:37 pm
In response to eCAHNomics @ 107

People so often talk about Medicare for All. It would be a lot better than the for profit mess we have now, but costs and outcomes argue favorably for what I support – an expansion of the VA system to cover everyone. All doctors would be salaried. If we need more primary caregivers, raise their pay. Keep specialist compensation under control. All health care would be universally available and free, much like it is in Great Britain.

Phoenix Woman November 27th, 2011 at 4:58 pm
In response to John Geyman @ 87

Indeed, medical school is extremely expensive, and primary-care docs are at the bottom of the totem pole in physician’s wages.

maa8722 November 28th, 2011 at 4:50 am

I’m wondering who are the supposed enemies of primary care physicians, enemies eager to stamp out every physician by any means possible.

I don’t think the importance of a robust primary care force hinges specifically on the fortunes of ACA, or even has anything to do with it. In any case, that issue is now out of our hands (and mostly so for the pols, too, for the time being). Until SCOTUS decides on the mandate, we won’t know where any of this is going next.

Even if the mandate is upheld there are serious flaws in ACA which will have to be fixed IF Congress decides to do so in lieu of reworking the whole thing. That seems doubtful unless the Dems get a trifecta a year hence.

Upending ACA may be reopen a path toward single payer down the road, ultimately followed by single payer / single source. Fits and starts may be the most we can expect that way, but it will be better than what faces us now.

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