good reading on health care

[Azazello1313]

it's a few years old, but it really cuts right to the heart of the issue IMO. it would seem to me impossible to "fix health care" without really addressing this problem.

 

Question: How many American families have proper health insurance?

 

a) over 90 percent.

between 80 and 90 percent.

c) between 10 and 80 percent.

d) less than 10 percent.

 

Given that about 15 percent of American families do not have health insurance, the correct answer would appear to be (. However, in my opinion, the correct answer is (d).

 

The health coverage most Americans have is what I call “insulation,” not insurance. Rather than insuring them against risk, most families’ health plans insulate them from paying for most health care bills, large and small.

 

Real insurance, such as fire insurance, provides protection against rare, severe risk. Real insurance is characterized by:

 

– low premiums

– infrequent claims

– large claims

 

American health insurance—including employer-provided insurance and Medicare—is the opposite. Families typically are paid claims several times per year, often for small amounts. Premiums are high—the cost of providing insulation often exceeds $10,000 per year per family. However, most families pay these premiums only indirectly, through taxes and reduced take-home pay from employers.

 

Real insurance would pay for treatments that are unavoidable, prohibitively expensive, or for illnesses that occur relatively rarely. Instead, insulation reimburses even relatively low-cost services, such as a test for strep throat or a new pair of eyeglasses. Insulation pays for treatment even if it is commonplace or discretionary.

 

What is Wrong with Insulation?

For health care providers, insulation is a bonanza. Because consumers are not spending their own money, they accept doctors’ recommendations for services without questioning them and without concern for cost. Faced with an insured patient, a health care provider is like a restaurant catering to convention-goers with unlimited expense accounts. The customer will gladly take the most high-end recommendation and not worry about the price.

 

Consumers are happy as well. Insulation relieves the patient of the stress of making decisions about treatment. The patient also does not have to worry about shopping around for the best price.

 

The problem with insulation is that it is not a sustainable form of health care finance. Individuals, employers, and government are all under stress.

 

Families that are in the individual insurance market face sticker shock when they confront health insurance premiums. Many choose to remain uninsured.

 

Employers are finding health care expenses an increasing burden. A noticeable gap has arisen in the past twenty years between the growth of total employee compensation and the growth of wages. Take-home pay is stagnant or shrinking, as much of the growth in compensation is diverted to health care.

 

Medicaid has become the largest item in many state budgets. Medicare is responsible for America’s biggest long-term fiscal crisis, with a looming gap between promised benefits and expected tax revenues rising to several percent of GDP per year in the middle of this century.

 

From an economic standpoint, insulation is both inefficient and inequitable. It allocates too many resources to health care, and it includes regressive subsidies that flow up the income scale.

 

Insulation leads people to over-consume health care services. Americans make extravagant use of services that have high costs and low benefits. Many studies that compare groups with similar conditions show that those with the largest levels of health care spending fare no better in terms of outcomes than those that spend less.

 

Insulation is also inefficient because of the large taxes that it requires. Payroll taxes support Medicare. Income taxes support Medicaid. Moreover, income tax rates are higher than they would be otherwise, because employer-provided health insurance is a deductible expense for companies but is not taxable income to employees. Taken together, higher payroll and income taxes to support insulation discourage work and thrift, leading to what economists call a “deadweight loss” to the economy.

 

Insulation also is inequitable. Millionaires on Medicare have their treatments paid for by taxes on low-income workers. High-income earners derive relatively more benefit than low-wage workers from the tax exemption of employer-provided insulation from health expenses.

 

We Have Had Insulation for Several Decades. Why Is It a Problem Now?

Today, over 85 percent of our health care spending is paid for by third parties—either private health insurance or government programs. America has one of the highest rates of insulation in the world.

 

At the same time, and partly in response to the bonanza provided by insulation, medical specialization and medical technology have surged. In my book, Crisis of Abundance, I call this phenomenon premium medicine. Primarily because of premium medicine, the share of our income devoted to health care in this country has roughly doubled over the past 30 years, from about 8 percent of GDP to about 16 percent of GDP.

 

Sometimes our skilled specialists and advanced technology make a difference for patients, extending lives and alleviating suffering. Often, however, services are provided that make no difference. The MRI exam that I had when I hurt my back moving furniture was pointless—the treatment would have been rest and anti-inflammatories, whatever the exam showed. My doctor’s referring me to a nephrologist for microscopic hematuria (blood in a urine specimen not visible to the naked eye) was equally pointless—like many people, I have this symptom sometimes, and then it mysteriously goes away.

 

We have accumulated a dazzling array of human and physical capital, and we are developing a culture that insists on using it to the fullest extent. The use of medical services well beyond the point of diminishing returns is what is driving up our health care costs and making it difficult to finance individual insurance, employer-provided insurance, and our government programs.

 

Can We Solve Our Health Care Crisis by Being More Efficient?

By definition, our health care system would be more efficient if we could deliver the same health care services at less cost. While greater efficiency is certainly possible and desirable, it would not relieve the stress in health care finance.

 

For example, pundits such as New York Times columnist Paul Krugman claim that private health insurance is inefficient due to overhead. However, even if one eliminated all of the overhead in health insurance, this would reduce total health care spending by about 1 percent of GDP, still leaving us spending 15 percent of our GDP on health care, about 5 percentage points more than most other countries.

 

Moreover, any gain in efficiency would not slow the growth of health care spending, which is driven by the ever-increasing supply of premium medicine in the context of unchecked demand. The only reliable way to slow the growth of health care spending is to slow the rate of increase in consumption of premium medicine. We cannot address the problems caused by the extravagant use of health care services that have high costs and low benefits by trimming the overhead expense involved in delivering these unnecessary services.

 

Other countries spend less of their GDP on health care, with little apparent difference in health outcomes. (Note, however, that the standard measure of health care outcomes—average longevity—is a flawed indicator, because it ignores many benefits of health care and does not take into account other factors that influence lifespan.) This is because premium medicine is less available in those countries, and the constraints on supply limit the extravagant use of procedures with high costs and low benefits. For example, the use of colonoscopy to screen for colon cancer in healthy patients over 50, as recommended in the United States, is not possible in Canada, due to the scarcity of equipment and trained personnel. Yet this may make relatively little difference in average longevity, because colon cancer tends to emerge late and to move slowly, so that many of its victims die of other illnesses first.

 

How Would Real Health Insurance Work?

Real health insurance would pay claims to people who come down with expensive illnesses. Typically, these expenses accumulate over a period of years.

 

In Crisis of Abundance, what I have suggested is a health insurance policy that you buy this year, but reimburses you in five years, based on cumulative expenses. Such a policy might pay nothing if your total expenses over the next five years are less than $30,000. It might pay 100 percent of expenses thereafter.

 

For example, if I buy a policy in January of 2007 and my expenses from 2007 to 2011 total $35,000, I would be reimbursed for $5000. The policy that I buy in January of 2008 would reimburse me based on expenses that I incur from 2008 to 2012, so that if my expenses for that period were $33,000, then I would be reimbursed for $3000.

 

These overlapping five-year policies would provide a better safety net than the annual policies that we have today. The typical catastrophic illness does not stop requiring treatment on December 31.

 

However, there are other ways to implement real health insurance that are worth considering. For example, one could have a health insurance policy where you make a claim when you are diagnosed with an expensive condition. First-stage breast cancer might result in a $25,000 payment. A heart condition requiring major surgery might result in a $40,000 payment. And so on. Only major medical problems would trigger claims, and payments would be for fixed amounts, not for reimbursement for procedures.

 

Real health insurance would not require high premiums. Fewer people would be discouraged from obtaining insurance by sticker shock.

 

It is not just private health insurance that needs to be changed if we are to move to real health insurance. Medicare would have to change as well. Instead of the insulation of Medicare, real health insurance for the elderly might be what I call “Remaining Lifetime Care Insurance.”

 

Between age 65 and death, medical expenses average a total of $100,000 per person. However, even if an individual saves $100,000 by age 65, the individual still needs protection against unusually large expenses. At age 65, you might keep $75,000 to pay for expenses out of pocket, and then spend $25,000 on an insurance policy with a remaining lifetime deductible of $75,000. That insurance policy only pays when the expenses that you accumulate after age 65 exceed $75,000. However, it guarantees that your out-of-pocket medical expenses will not exceed $75,000.

 

With these sorts of policies, individuals would be protected from extreme financial loss. However, they would be insulated from much less of their health care expenses than they are today. In fact, some simulations I performed using the government’s Medical Expenditure Panel Survey showed how it might be possible to increase the share of out-of-pocket spending from 15 percent to over 50 percent, while still providing a safety net to the very poor and the very sick.

 

Having individuals pay for more of their own health care would be more efficient. It would reduce the disincentives to work and thrift caused by the collectivization of health care spending. It would also make individuals less inclined to undergo procedures that have high costs and low benefits. Consumers also would have the incentive to engage in comparison shopping when they encounter outrageously high charges from providers.

 

Can Consumers Make Reasonable Health-Care Decisions?

One common objection to real health insurance is that it is too burdensome for individual consumers to make health care decisions based on costs and benefits. The argument is that if we switch from insulation to insurance, then consumers will make bad decisions.

 

Harvard University health care economist David Cutler, in a conversation with economists at Cato, made such a point. He said that consumers do not really differentiate between necessary and unnecessary health care. As a result, he predicts that if consumers have to pay for more health care out of pocket, they will cut back proportionately on both cost-effective and cost-ineffective health care. Wasteful spending will decline, but so will useful spending. Ultimately, consumers’ health will suffer.

 

My view is that the solution to this potential problem is better information for consumers. I have endorsed the idea of a commission, perhaps with government funding, to study medical protocols in order to provide guidelines for what is typically cost effective.

 

How Would We Get There Institutionally?

Many government policies favor insulation rather than real health insurance. Changing these policies would help to encourage a transition to real health insurance.

 

State laws concerning health insurance tend to encourage comprehensive insurance. Lobbyists push for laws requiring insurance to cover treatments. These might include eye care, dental care, or fertility treatments. Such laws or regulations are inconsistent with insurance that is designed to protect against catastrophic illness.

 

Federal and state tax laws allow individuals to “launder” their health expenses through their employers in the form of comprehensive health insurance. We should reform the current system, in which employer-provided health insurance is deductible to companies but not included in individual compensation. One approach would be to count employer-paid premiums as compensation, or to put a cap on the amount of employer-paid premiums that would be tax exempt.

 

For people under 65, government should provide a safety net that is consistent with real health insurance. People who cannot afford to pay for health care will require government support, even to obtain basic services. People who have already been diagnosed with expensive illnesses probably will need a government subsidy in order to obtain real health insurance. Perhaps what some economists have called “catastrophic reinsurance,” in which government would pay all expenses above, say, $50,000 in a year, would enable the very sick to obtain health private health insurance. In any event, apart from the very poor and the very sick, government need not be involved in paying for health care.

 

Ultimately, people over 65 should be paying for health care out of savings. This means that Medicare ought to be phased out. I have proposed doing so by gradually raising the age of eligibility for Medicare. The age would stay the same for people currently on the verge of becoming eligible. It would rise somewhat for people in their 40s and early 50s. It would be raised considerably more for people now in their 30s, and Medicare would be phased out altogether for people under age 30.

 

How Would We Get There Culturally?

Today it is fairly deeply ingrained with most Americans that health care services are something that you should not have to pay for yourself. Insulation is the norm, and real health insurance as I would define it is almost nonexistent.

 

Suppose that we were to remove the tax benefits and other institutional supports for insulation. It is by no means certain that what would emerge instead would be real health insurance.

 

It could be that if health insurance were relatively unregulated and unsubsidized, then many people would opt to do without health insurance. This raises the issue of people “free riding” by doing without health insurance while healthy and then turning to government assistance when illness or injury occurs. It is to address this free-rider problem that some analysts propose making health insurance mandatory. This is a controversial idea, not well received at Cato. In any event, it is very difficult to justify a mandate for insulation, rather than a mandate for something closer to real health insurance.

 

Ultimately, I think we are headed for a collision of cultural values. We prefer insulation to real insurance. We expect services to be readily available, without the supply limitations or waiting lists that exist in countries where government is responsible for more health care funding. And yet we are growing increasingly concerned over the expansion of health care spending that takes place in a system that lacks constraints on either supply or demand.

 

Real health insurance may not be popular now. But when Americans see that the providers of insulation, including Medicare, have to turn to the rationing of health care services in order to meet budgetary constraints, real health insurance may start to look like a good alternative.

 

that's why what I think would make the most sense is:

1) eliminate the tax shelter for employer-paid health premiums, possibly replace it with a tax credit of $5K per person or something against money paid into either an individually procured OR employer sponsored program and maybe phase that credit out over time.

2) go ahead have the government provide universal coverage, but only for true catastrophic "insurance", like deductibles over $1000, etc. then if people want to "insulate", they can purchase that supplemental coverage on their own, or negotiate it with their employer (as long as there is no longer any tax advantage to the latter over the former). and perhaps the government continues providing more insulating coverage to the very poor and some of the elderly, but that needs to be seriously re-thought and pared back as well (probably by means-testing medicare coverage).

 

you can tinker on the edges and with the details, but that basic blueprint is the only thing I can see that might counteract the enormous upward pressure on health costs. which is frustrating, because all the democrats want to do is to basically get the government involved in buying MORE "insulation" for more people. that will exacerbate the underlying supply/demand problem, not "fix" it. you know, the democrats are trying to portray the situation as a binary power struggle -- either give more power to the government, or keep it with the insurance companies. that is just a false dichotomy -- the real issue is how much are individuals insulated from their own health care costs? give THEM the power, and let the insurers and providers respond to true market forces. and I do think progressives can get on board, if part of the whole idea IS to provide universal insurance against catastrophic costs.

[Chavez]

that's why what I think would make the most sense is:

1) eliminate the tax shelter for employer-paid health premiums, possibly replace it with a tax credit of $5K per person or something against money paid into either an individually procured OR employer sponsored program and maybe phase that credit out over time.

2) go ahead have the government provide universal coverage, but only for true catastrophic "insurance", like deductibles over $1000, etc. then if people want to "insulate", they can purchase that supplemental coverage on their own, or negotiate it with their employer (as long as there is no longer any tax advantage to the latter over the former). and perhaps the government continues providing more insulating coverage to the very poor and some of the elderly, but that needs to be seriously re-thought and pared back as well (probably by means-testing medicare coverage).

 

you can tinker on the edges and with the details, but that basic blueprint is the only thing I can see that might counteract the enormous upward pressure on health costs. which is frustrating, because all the democrats want to do is to basically get the government involved in buying MORE "insulation" for more people. that will exacerbate the underlying supply/demand problem, not "fix" it. you know, the democrats are trying to portray the situation as a binary power struggle -- either give more power to the government, or keep it with the insurance companies. that is just a false dichotomy -- the real issue is how much are individuals insulated from their own health care costs? give THEM the power, and let the insurers and providers respond to true market forces. and I do think progressives can get on board, if part of the whole idea IS to provide universal insurance against catastrophic costs.

 

I would certainly be on board with that. My GREATEST fear with the current system is that major illness for a middle class family in FAR too many cases equals bankruptcy.

 

Tangential to this, the mrs and I may be paying for our 2nd child's birth out of pocket - and our out-of-pocket costs will be comparable to what we'd be paying with our 80% "insulation" coverage, thanks to us informing ourselves.

[wirehairman]

This is the true crux of the problem with health care, IMO. Unfortuantely, noone in DC wants to acknowledge it or attempt to fix it. Instead, one side of the aisle wants to expand and force the use of a broken system, and the other side just wants to do nothing.

[CaP'N GRuNGe]

Brooks latest on the healthcare mess

[Ursa Majoris]

and I do think progressives can get on board, if part of the whole idea IS to provide universal insurance against catastrophic costs.

 

I agree completely.

 

I would certainly be on board with that. My GREATEST fear with the current system is that major illness for a middle class family in FAR too many cases equals bankruptcy.

Bingo. This is why the system needs blowing up and rebuilding now.

[bpwallace49]

Brooks latest on the healthcare mess

 

Deserves to be posted. Extremely well-written article.

 

Into the Mire

 

Published: February 22, 2010

Barack Obama came to Washington with the nation’s hope for change riding on his shoulders. He promised to reform the health care system. He hired many of the country’s top experts who had written brilliantly about how to do reform.

 

He immediately moved away from some of their ideas. This was understandable. America isn’t Plato’s Republic. It’s not a nation governed by experts. It’s a democracy. To get things passed, you’ve got to allow for political reality.

 

So President Obama promised to keep health insurance the same for most Americans. This meant it was going to be harder to bring down costs. This meant it wouldn’t be possible to replace the fraying employer-based insurance system. But these compromises could be justified.

 

Then the Congress began its deal-making. There were special favors put in for certain senators. There were special arrangements made for big Democratic donors, like the trial lawyers. These were compromises, too. They were ugly, and they soiled everybody involved. But, again, they could be justified for reasons of political expediency. The bill that emerged from the Senate was not to everybody’s liking. It wouldn’t reduce the nation’s overall health care spending.

 

But at least the Senate bill had some integrity. It would cover 30 million people without adding to the deficit. It did this in real ways. It included real Medicare cuts. Most importantly, it included an excise tax on luxury insurance plans.

 

The excise tax is one of those ideas health care economists of all stripes love. Currently, we have a perverse tax system that taxes salaries but not health benefits. This exclusion favors the rich over the middle class. It encourages extravagant health spending.

 

According to the Congressional Budget Office, taxing health benefits is one of the two most effective ways to bring down health care costs. Plus, it brings in a ton of revenue. According to the Lewin Group, a health care consulting firm, the excise tax in the Senate bill would bring in $957 billion between 2020 and 2029. This is what pays for expanding coverage. This is why the president could promise to veto any bill that adds a dime to the deficit.

 

But, alas, this is Washington, 2010. The muck rises. The compromises never stop.

 

As the year went on, health care reform grew more unpopular. If you average the last 10 polls, 38 percent of voters support the reform plans and 53 percent oppose. Obama’s reform is more unpopular than Bill Clinton’s was as it died.

 

As the political costs rose, members of Congress squealed louder. Congress is not a bastion of courage in the best of circumstances. When it is asked to actually pay for its expenditures, it verges on hysteria.

 

Some Republicans campaigned against the excise tax. John McCain had made replacing the tax exclusion a centerpiece of his reform plan. But Scott Brown of Massachusetts and others have now lobbied to preserve it.

 

Unions went next. They demanded a special deal so their members would be exempt from the tax. The Democrats caved and gave it to them.

 

Blood was now in the water. Everyone smelled weakness. If the White House hopes to pass something in this atmosphere, it needs every Democratic vote it can get. It needs to cater to every special-interest plea. Right now, the White House has no leverage.

 

Efforts to kill the tax mounted. On Jan. 27, Nancy Pelosi told a group of journalists, “The excise tax has no support, very little support, in our caucus.” The pollsters said it was a loser. That was a sign the Congressional leadership wanted it dead.

 

On Monday, the White House made another compromise. On the surface, it seems mundane. The imposition of the excise tax will be delayed until 2018, and the threshold at which the tax kicks in will be raised. In reality, the delay turns the tax into another Washington gimmick. Lord, give me virtue, but not yet.

 

The odds are high that the excise tax will never actually happen. There is no reason to think that the Congress of 2018 will be any braver than the Congress of today. It will probably get around the pay-go rules or whatever else might apply and it’ll postpone the tax again. The excise tax will turn into another “doc fix.” This is a mythical provision in which doctors are always about to get their reimbursements cut. But somehow they never do because the cuts are always pushed back, year after year.

 

So we’ve sunk another level in our tawdry tale. The White House, to its enormous credit, has tried to think about the long term. But it has been dragged ever lower into the mire by Congressional special interests that are parochial in the extreme.

 

This bill may be deficit-neutral on paper. But it has just become a fiscal time bomb. The revenue will never come. Compromises have to be made to keep it (barely) alive. But responsibility ebbs. Politics wins.

[CaP'N GRuNGe]

it's a few years old, but it really cuts right to the heart of the issue IMO. it would seem to me impossible to "fix health care" without really addressing this problem.

 

 

 

that's why what I think would make the most sense is:

1) eliminate the tax shelter for employer-paid health premiums, possibly replace it with a tax credit of $5K per person or something against money paid into either an individually procured OR employer sponsored program and maybe phase that credit out over time.

2) go ahead have the government provide universal coverage, but only for true catastrophic "insurance", like deductibles over $1000, etc. then if people want to "insulate", they can purchase that supplemental coverage on their own, or negotiate it with their employer (as long as there is no longer any tax advantage to the latter over the former). and perhaps the government continues providing more insulating coverage to the very poor and some of the elderly, but that needs to be seriously re-thought and pared back as well (probably by means-testing medicare coverage).

 

you can tinker on the edges and with the details, but that basic blueprint is the only thing I can see that might counteract the enormous upward pressure on health costs. which is frustrating, because all the democrats want to do is to basically get the government involved in buying MORE "insulation" for more people. that will exacerbate the underlying supply/demand problem, not "fix" it. you know, the democrats are trying to portray the situation as a binary power struggle -- either give more power to the government, or keep it with the insurance companies. that is just a false dichotomy -- the real issue is how much are individuals insulated from their own health care costs? give THEM the power, and let the insurers and providers respond to true market forces. and I do think progressives can get on board, if part of the whole idea IS to provide universal insurance against catastrophic costs.

 

Some good points here. Thanks for posting it.

 

I'm not so sure I'd want to go so aggressively against medicare though. If anything, i think i'd be more in favor of phasing out SS and requiring individuals to save for their retirement while redirecting a portion of those withholdings to strengthen medicare or a brand new program to replace it. Frankly when I retire years down the road, health and it's cost will be the biggest scariest unknown.

 

I do like the idea of covering everyone with catastrophic insurance and then making "insulation" an option to purchase.

[Azazello1313]

Some good points here. Thanks for posting it.

 

I'm not so sure I'd want to go so aggressively against medicare though. If anything, i think i'd be more in favor of phasing out SS and requiring individuals to save for their retirement while redirecting a portion of those withholdings to strengthen medicare or a brand new program to replace it. Frankly when I retire years down the road, health and it's cost will be the biggest scariest unknown.

 

I do like the idea of covering everyone with catastrophic insurance and then making "insulation" an option to purchase.

 

well the point is, old people are the ones who use the most health care, so that's where the insulation/insurance thing might really have some traction. you're not really going to dent health costs if anyone over 65 is still given government-sponsored "insulation". if they want to be more fully insulated, they can direct their resources in that direction. now I could see one argument being, the costs for "insulating" coverage for seniors would be prohibitive, so they would either have to pay out the ass for services or for their own insulation premiums. and that is a good point, but:

1) I don't think the cost difference b/w young and old would be THAT great if the really high costs are covered by the gov't, and

2) there are ways of giving them power over their own costs without making them broke. maybe seniors get a little larger tax credit against payments toward insulating coverage, something like that.

but just leaving medicare essentially the way it is, that's just leaving the biggest problem area in the whole deal alone to tinker on the edges. I don't think it will work.

Edited February 24, 2010 by Azazello1313

[Ursa Majoris]

but just leaving medicare essentially the way it is, that's just leaving the biggest problem area in the whole deal alone to tinker on the edges. I don't think it will work.

Exactly my point about the three hugh government spend areas. Fiddling about with the EPA and whatnot is fine but unless the elephants in the living room are addressed, it's all for naught.

[Azazello1313]

another money quote from arnold kling today:

 

There are certainly ways to improve efficiency, but there are no big free lunches out there. The only way to significantly slow the growth of health care spending is to make less use of procedures with high costs and low benefits.

 

There are two ways to approach reducing the use of high-cost, low-benefit procedures. You can have the government tell people what they can and cannot have. Or you can have individuals pay for a larger fraction of the medical procedures that they consume. It really comes down to those choices.

 

Advocating either one of those is political suicide, and talking about anything else is a waste of time.

[Ursa Majoris]

another money quote from arnold kling today:

 

Advocating either one of those is political suicide, and talking about anything else is a waste of time.

 

And there we have it.

[Chavez]

Wait, can we really have a discussion on health care without a "Have to agree here! TORT REFORM! DEATH PANELS!" post?

[bpwallace49]

10 Things Primary-Care Physicians Won't Say

by Jim Rendon and AnnaMaria Andriotis

Wednesday, February 24, 2010

provided by

 

Updated and adapted from the book 1,001 Things They Won't Tell You: An Insider's Guide to Spending, Saving, and Living Wisely, by Jonathan Dahl and the editors of SmartMoney.

 

1. 'Good Luck Getting an Appointment'

 

Patients feeling a cold creeping up shouldn't wait too long to call their primary-care physician since there's probably already a long line of patients waiting to see him or her.

 

 

A good primary-care doctor -- someone to coordinate your health care, help choose your specialists, and be the first to diagnose just about any problem -- is the key to good medical treatment. But they're getting harder to visit. Twenty-three percent of patients say they waited six or more days to see their physician the last time they were sick and needed to see a doctor, according to a 2008 survey by the Commonwealth Fund, a private foundation that promotes high-performing health-care systems. The longer wait in part is attributed to the slow-growing profession of primary-care physicians, which includes family medicine, general practice and internal medicine doctors. Currently, just a third of all doctors in the U.S., are primary care physicians, about 240,713 in total, up from 200,862 five years ago. "We're not really getting the best and brightest in primary care," says Kevin Pho, a Nashua, N.H., physician who writes the blog Kevin M.D. "And that's where they're needed."

 

2. 'I'm the Pauper of My Profession'

 

One big reason fewer medical students are specializing in primary care is simple economics. In 2009 primary-care doctors -- specifically those practicing family medicine and internal medicine -- earned an average of $201,548, according to Cejka Search, a physician and health-care executive search firm.

 

 

That might sound like a lot to most working people, but in the same year, dermatologists made $350,627, gynecological oncologists made $460,000 and doctors practicing neurological surgery made $548,186. "Students are not dummies," says Pho. "They graduate with $130,000 in debt; why should they go into primary care?"

 

When a primary-care doctor examines a patient with private health insurance, the doctor will get a payment on a scale that's similar to Medicare reimbursements, says Dr. Martin Shapiro, a professor of medicine and public health at the David Geffen School of Medicine at UCLA. It's even lower when they see Medicaid patients. "Reimbursement is a lot lower for primary-care physicians given the amount of time that a visit will take relative to the amount of time needed to do a procedure [for specialists]," he says. Reimbursements put a premium on volume, not on spending time with patients, he says.

 

3. 'You Asked to See a Doctor but You'll Likely See an Assistant'

 

These days it seems like a visit to the doctor involves little contact with an actual doctor. Instead, most of the time is spent explaining problems to assistants and having blood drawn by nurses. Many doctors have been beefing up their support staff -- physician assistants and nurse practitioners -- to help them squeeze in more patients, says Dr. Shapiro. "They need support staff; the primary-care doctor is dealing with patients all the time and they have to deal with emotional problems, their families' responses and doctors have to try to motivate patients to not get sick," he says.

 

While this system isn't inherently bad, it can have negative impacts for patients. Assistants may have a different philosophy from the doctor, leading them to treat problems differently. Communication can break down, causing confusion about medications, and a misdiagnosis by an assistant is always possible.

 

4. 'I Hawk for Big spam in My Spare Time'

 

Your physician relies on his best judgment when deciding what drugs to prescribe. And influencing that judgment is big business. IMS Health, a research and consulting services company for the health-care industry, found that the pharmaceutical industry spent $6.8 billion in 2008 targeting doctors with ads and sales representatives. "The introduction to pharmaceutical representatives starts as early as medical school, and it never really stops," says Pho.

 

The real amount is certainly much higher, since these figures include only journal advertising and salaries of sales reps, not their expenses. Drug reps give away pens, hats, and shirts, and buy office staff lunch, all in hopes of nabbing time with the doctor. Drug companies know doctors are more likely to take their cues from other doctors, so they sponsor weekend seminars at expensive resorts featuring presentations by physicians, says Pho. Drug companies pay these docs to give informative talks about medical conditions--for which the company's drug gets pitched as the best remedy.

 

5. 'Sore Throat? You Might Be Better Off Going to the Mall'

 

Walk-in clinics are springing up across the country. Currently, there are about 1,200, up from 850 in 2008 and 250 in 2007, according to the Convenient Care Association, a trade association for retail-based convenient care clinics.

 

They're run by hospitals, retailers like CVS and Walgreen, community health centers, or nursing schools who diagnose simple maladies, like strep throat or flu, and provide prescriptions, medical advice, or referrals if the problem is beyond their scope. These clinics have caught on in part because they don't require an appointment and tend to be less expensive than visiting the doctor or an emergency room visit. Some take insurance.

 

When visiting one, says Dr. Lori Helm, president of the American Academy of Family Physicians (AAFP), ask to have your records forwarded to your doctor, and be sure to tell him about any medication prescribed at the clinic. She says the organization doesn't recommend walk-in clinics for treatment of chronic medical problems.

 

6. 'I Hate Technology'

 

It's almost impossible to imagine anyone doing his job these days without a computer -- except your doctor. Although billing and other systems may be computerized, when it comes to medical records, some family physicians still prefer pen and paper. A 2009 AAFP survey found that just 53% of family physicians have adopted electronic medical records. New electronic medical-record systems can print out clear prescriptions that are cross-referenced with medical databases to avoid incorrect dosages or dangerous drug combinations; hospitals can access patient histories in case of emergency; and care can be better tracked over time.

 

For most patients the benefits of the technology are huge. It eliminates prescription errors due to illegible handwriting. It ensures that patients get the right dosage. Records won't get lost. It reminds doctors when they need to monitor their patients. And specialists can easily forward electronic records to your primary-care physician.

 

7. 'Your Insurance Company Is Calling the Shots'

 

These days, doctors have more freedom to send you to a specialist or order expensive tests than they once did under managed care. But that doesn't mean the system is mended. For starters, your insurance provider's pool of doctors may lack the subspecialist you need to see, says Helm. And with increased deductibles, it's often the patient who foots the bill for a referral or an expensive test.

 

Insurers also still wield the power when it comes to hospital stays, says Jerome Epplin, a geriatrician and clinical professor at the Southern Illinois University School of Medicine; he has recommended that a patient spend four days in the hospital only to have the insurance company overrule him, refusing to pay for the last day and sticking the patient with the bill. "We are powerless over it," Epplin says. Industry trade groups respond that patients have some recourse. "In most states, patients can appeal to an outside third party – generally it's a panel of physicians and the doctor always has the ability to talk to health plans," says Susan Pisano, a spokeswoman for the trade organization, America's Health Insurance Plans.

 

8. 'My Legal History Is None of Your Business'

 

Today's insurance plans give patients a wider range of doctors to choose from, but they don't necessarily give patients any more information to help them decide between doctors. To start, patients should call a doctor's office to find out what his or her specializations are, and if there's a certain age range of patients they primarily focus on.

 

Patients who want to dig around a bit more -- especially when it comes to a doctor's legal past like lawsuits -- can try the National Practitioner Data Bank, which state medical boards and hospitals use to do background checks; it includes information on disciplinary actions and malpractice payments.

 

In most cases, to find out if your doctor has been sued, you'll have to go down to the local courthouse, but if your doctor has moved around, you'll get only part of the picture. The best publicly available information is tracked by state medical boards, many of which publish this information on their web pages. If yours doesn't, you can pay a nominal fee for a report from DocInfo.org, a site run by the Federation of State Medical Boards.

 

9. 'If You're Over 65, I Don't Think I Can Help ...'

 

As troubling as things are in primary care, the situation is worse when it comes to treating elderly patients, especially those on Medicare. Doctors who specialize in geriatrics are certified by the American Board of either Family or Internal Medicine, and they're increasingly rare. Right now there is just one geriatrician in the U.S. for every 5,000 seniors, about half of what there should be, according to the American Geriatrics Society.

 

The problem is that fewer medical students are choosing this subspecialty: Last year only two-thirds of geriatric fellowship programs were filled. That's because treating older patients who have multiple, often complex problems is about the worst way a doctor can make a living. Medicare doesn't compensate much more for a 45-minute appointment with a patient with dementia, hearing loss and a half-dozen other maladies than it does for seeing someone for a simple checkup. "It is fiscal suicide to go out there and say, 'I am a geriatrician,'" says Dr. Bruce Robinson, who practices geriatric medicine and internal medicine in Sarasota, Fla. "You get the patients that require the most time that pay the worst."

 

10. '... Unless, of Course, You're Willing to Pay Extra'

 

Unfortunately, the shortage of geriatricians is worsening. As med students shy away from geriatrics, the number of people over 65 is set to grow faster than ever as boomers retire. The American Geriatrics Society estimates that by 2030, there will be a shortage of about 36,000 geriatricians in the U.S., up from 7,000 today.

 

Though the situation seems dire, there are ways to guarantee qualified care. One approach is to see a good primary-care doctor who is also a geriatrician long before you need one. Epplin says that in southern Illinois, not many doctors accept new Medicare patients, but when their existing patients go on Medicare, they keep them. Other approaches can be costly. In Sarasota, where Robinson practices, many doctors provide "concierge" service: Patients pay an annual retainer of about $6,000 in exchange for their doctor's cell number and upgraded access. Other physicians in Florida have begun asking patients to pay an annual administrative fee of about $200 or $300 to help them continue to provide individualized care. These pricey options aren't what most people have in mind when they think of health-care reform, but they may be the only way to maintain ready access to a good doctor.