Who’s the Boss of Primary-Care Doctors?
I’ve read the editorial several times, and it still isn’t clear to me how or why the Projo writers avoided mentioning the problem of liability insurance for primary-care doctors.
Shortly after I moved to Tiverton and found a nice local doctor to visit, he packed up and left the state for sunnier climes. My understanding is that the cost of insurance and the threat of being sued in Rhode Island were motivating factors. (It worked out, though, because it got me on the list of the practice’s senior doctor, who hadn’t been accepting patients when I inquired.)
Primary-care physicians seem to mirror a small-business model more than specialists do. People will travel farther for specialists, and their work is more likely to come to them via the referrals of other professionals. I’m sure there are other distinctions (such as the closeness of relationships with hospitals), but I don’t want to delve too deeply into guesswork. The point is that, as our society considers healthcare policy, we ought to think of primary-care providers in the same way that we think of other self-employed professionals.
Market and deregulatory incentives can encourage the occupation without bureaucracies meddling, as the Projo winds up suggesting:
Alan Sager, a health-policy expert at the Boston University School of Public Health, has suggested paying primary-care doctors $250,000 a year to work under a capitation system. The doctors would be earning considerably more than they do now. And because they would treat a set number of patients at a fixed yearly cost, adjusted for medical risks, the doctors would have no financial reason to offer more care than necessary.
Question number one is who will set and process the numbers of patients and income? By default, it would have to be the government, which means that doctors will no longer work for themselves, but for the folks who can give them raises and who can cut their pay or increase their work burden. I’d worry about the sorts of practitioners such an arrangement would attract, as well as the institutional focus that would shift to lobbying the authorities for more.
Question number two is what would provide incentive — given the rigid quota and salary deal — for doctors to resist the human urge to do as little as possible? If the five patients whom I have to see in an afternoon (hypothetically) don’t pay me and their return is not really my problem, I might just take the opportunity of a sunny day like today to rush through my itinerary and get out of the office. (Of course, for a reality check, I get to be outside all day anyway… digging post holes and mixing concrete.)
As I said, the editors don’t provide the “who,” but what they propose amounts to another increment of socialization, and in that respect, it provides another instance of the plain inadvisability of such a system.