Dear Editor,
I always wanted to be a real doctor. I first lived in Vermont when I was at medical school at Dartmouth, graduating at the top of my class before training to provide comprehensive family medicine. I returned to rural Vermont 10 years later with the dream of being a small-town family doctor, but I soon realized that role didn’t exist. Two years ago, I gave up and became a full-time hospitalist. I get paid more and I love my job, but it pains me to see my neighbors struggle under the financial strain of this system when I know we can do better and charge less.
Why are healthcare costs rising and primary care shrinking? Put simply, expensive medicine pays more. For individual physicians and health systems, the financial incentive is to meet medical needs in a way that provides healthier financial margins. When the Green Mountain Care Board limits hospital budgets, psychiatric floors and primary care clinics close while procedural clinics, imaging centers and labs expand. Primary care is marginalized precisely because it provides quality care at a lower cost.
Our last effort at shifting incentives to provide universal primary care, OneCare Vermont, tried to promote quality primary care by changing to a global payment. It failed because it added another layer of administration while having little to no impact on the way primary care was delivered on the ground, because it only applied to some patients. A better model looks more like direct primary care, where layers such as insurance, billing and additional administration are removed, and clinicians are paid directly for providing care that is accessible, continuous, comprehensive and coordinated with consultants when care is complex.
Beyond payment, we need a role that values physicians in primary care. Instead of pretending a physician is interchangeable with a nurse practitioner or physician assistant in primary care, we need to consider how to use each role in a way that maximizes value. Most people don’t need a physician most of the time, but all should have access to someone with the highest level of training on their primary care team.
We may not need physicians doing routine preventive care, low-risk acute care or structured chronic care. We do need physicians with focused expertise on high-risk areas such as hospital medicine, obstetrics, emergency care and specific organ systems. In urban areas, providing this expertise with physicians who limit their practice to subspecialties makes sense, but adopting that model in rural areas leaves us paying for expensive physician downtime with the inevitable fluctuations in volume in small local health systems. In rural Vermont we need more hospital-based and consultant physicians to also be a part of primary care teams to get the most out of our investment in physician time.
The value in primary care is in taking responsibility for our patients. You belong to them and they belong to you, even if they don’t show up to your clinic. This is the kind of relationship that is healing in and of itself. It is a relationship that can be an antidote to the pervasive feeling of our time that those with wealth and privilege, such as physicians, are out to extract as much as possible from the rest of society. We need this kind of medicine now more than ever, and we need real transformation to allow it to survive and thrive.
John Raser
St. Johnsbury, Vt.
