Tag Archives: Affordable Care Act

The Politics of Medical Freedom

Winner of an Independent Publisher Books Award Bronze Medal for 2017, Paul Stepansky’s In the Hands of Doctors:  Touch and Trust in Medical Care is now available in paperback and as an eBook.  For the paperback edition, Stepansky has written a new preface, a stirring defense of Obamacare as a path to universal health care in America.  It is given here in its entirety in appreciation of the readers of “Medicine, Health, and History.”

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In the Hands of Doctors:  Touch and Trust in Medical Care

Preface to the Paperback Edition
Copyright © 2017 by Paul E. Stepansky.  All rights reserved.

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 In our time, political speech and writing are largely the defense of the indefensible.
                                         — George Orwell, “Politics and the English Language” (1946)

Now, less than a year after publication of In the Hands of Doctors, the Patient Protection and Affordable Care Act of 2010 (aka Obamacare), which I roundly endorse in this book, is gravely imperiled.  Congressional Republican legislators have joined a Republican President in a commitment to repeal the bill that has provided health insurance to over 20 million previously uninsured Americans.  The legislation thus far presented to replace it by the U.S. Senate  (the “Better Care Reconciliation Act of 2017”) would, according to the Congressional Budget Office, leave 15 million Americans uninsured in 2018 and 22 million by 2026.   Proposed cuts and caps to the Medicaid budget, which are part of the legislation, would, according to the CBO, decrease enrollment in the program by 16% over the next decade.  In brief, these cuts and caps would jeopardize the health and well-being of the one in five Americans and one in three American children dependent on the support provided by Medicaid.  Disabled and other special-needs children as well as elderly nursing home residents would suffer the most.  A Congressional vote simply to repeal Obamacare absent new legislation would have even more catastrophic consequences.
      Congressional opponents of the Affordable Care Act, no less than President Donald Trump, appear to live in a hermetically sealed bubble that makes only grazing contact with the socioeconomic ground below.  They share space in the bubble with colliding political abstractions that they grasp, one after the other, and radio back down to earth.  The political bubble dwellers offer us yet again the palliatives of context-free “medical choice” and “medical freedom” as remedies for the real-world suffering addressed by Obamacare.
     But these terms, as used by politicians, do not speak to the realties of American health care in  2017.  Rather, they hearken back to the era of the Founding Fathers, when issues of health, illness, freedom, and tyranny were much simpler.  Freedom, as the founders understood it, operated only in the intertwined realms of politics and religion.  How could it be otherwise?   Medical intervention did not affect the course of illness; it did not enable people to feel better and live longer and more productive lives.  With the exception of smallpox inoculation, which George Washington wisely made mandatory among colonial troops in the winter of 1777, governmental intrusion into the health of its citizenry was nonexistent, even non-sensical.
     Until roughly the eighth decade of the nineteenth century, you got sick, you recovered (often despite doctoring), you lingered on in sickness, or you died.  They were the options.  Medical freedom, enshrined during the Jacksonian era, meant being free to pick and choose your doctor without any state interference.  So liberty-loving Americans picked and chose among mercury-dosing, bloodletting “regulars,” homeopaths, herbalists, botanical practitioners, eclectics, hydropaths, phrenologists, Christian Scientists, folk healers, and faith healers.   State legislatures stood on the sidelines, rescinding or gutting medical licensing laws and applauding the new pluralism.  It was anarchy, but anarchy in the service of medical freedom of choice.
     Now, mercifully, our notion of medical freedom has been reconfigured by two centuries of medical progress.  We don’t just get sick and die.  We get sick and get medical help, and, mirabile dictu, the help actually helps.  In antebellum America, deaths of young people under 20 accounted for half the national death rate, which was more than three times the death rate today.  Now our children  don’t die of  small pox, cholera, yellow fever, dysentery, typhoid, and pulmonary and respiratory infections before they reach maturity.  When they get sick in early life, their parents take them to the doctor and they almost always get better.  Their parents, on the other hand, especially after reaching middle age, don’t always get better.  So they get ongoing medical attention to help them live longer and more comfortably with chronic conditions such as diabetes, coronary heart disease, inflammatory bowel disease, Parkinson’s, and many forms of cancer.
     When our framers drafted the Constitution, the idea of being free to live a productive and relatively comfortable life with long-term illness did not compute.  You died from diabetes, cancer, bowel obstruction, neurodegenerative disease, and major infections.  Among young women,  such infections included the uterine infection that routinely followed childbirth.  A major heart attack simply killed you.  You didn’t receive dialysis and possibly a kidney transplant when you entered kidney failure.  Major surgery, performed on the kitchen table if you were of means or in a bacteria-infested public hospital if you were not, was rarely attempted because it invariably resulted in massive blood loss, infection, and death.
     So, yes, our framers intended our citizenry to be free of government interference, including the Obamacare “mandate” that impinges on Americans who choose to opt out of the program.  But then, with the arguable exception of Benjamin Franklin, the framers never envisioned a world in which freedom could be extended by access to expert medical care that relieves suffering, often effects cure, and prolongs life.  But then, neither could they envision the enfranchisement of former slaves and women, the progressive income tax, compulsory vaccination, publicly supported health clinics, mass screening for TB, diabetes, and  syphilis, or Medicare and Medicaid.  Throughout the antebellum era, when physicians were reviled by the public and when neither regular medicine nor the rival alternative sects could stem the periodic waves of cholera, yellow fever, and malaria that decimated local populations, it mattered little who provided one’s doctoring.  Many, like the thousands who paid $20.00 for the right to practice Samuel Thomson’s do-it-yourself botanical system, chose to doctor themselves.
     Those who seek repeal of Obamacare without a credible legislative alternative that provides equal, preferably greater, health benefits to all Americans seem challenged by the very idea of medical progress.  Their use of terms like “choice” and “freedom” invokes an eighteenth-century political frame of reference to deprive Americans of a kind of freedom associated with a paradigm-shift that arose only in the final quarter of the nineteenth century.  It was only then that American medicine began its transition to what we think of as modern medicine.  Listerian antisepsis and asepsis; laboratory research in bacteriology, immunology, and pharmacology; laboratory development of specific remedies for specific illnesses; implementation of public health measures informed by bacteriology; modern medical education; and, yes, government regulation to safeguard the public from incompetent practitioners and toxic medications – all were part of the transition.  The Jacksonian impulse persisted into the early twentieth century, flaring up in organized opposition to compulsory childhood vaccination, and  finally petering out in the 1930s, by which time it was universally accepted that scientific medicine was, well, scientific, and, as such, something more than one medical sect among many.
     “We hold these truths to be self-evident,” Thomas Jefferson began the second paragraph of the Declaration of Independence, “that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness.”  What Jefferson did not stipulate, indeed what he could not stipulate in his time and place, were the hierarchical relationships among these rights.  Now, in the twenty-first century, we are able to go beyond an eighteenth-century mindset in which  “Life, Liberty, and the pursuit of Happiness” functioned as a noun phrase whose unitary import derived from the political tyrannies of King George III and the British parliament.  Now we can place life at the base of the pyramid and declare that quality of life is indelibly linked to liberty and the pursuit of happiness.  To the extent that quality of life is diminished through disease, liberty and the pursuit of happiness are necessarily compromised.  In the twenty-first century, health is life; it is life poised to exercise liberty and pursue happiness to the fullest.
     Why, then,  is it wrong to require all citizens to participate in a national health plan, either directly or through a mandate (i.e., a tax on those who opt out), that safeguards the right of people to  efficacious health care regardless of their financial circumstances, their employment status, and their preexisting medical conditions?  What is it about the Obamacare mandate that has proven so troubling to our legislators?  When you buy a house in this country, you pay local property taxes that support the local public schools.  These taxes function like the mandate:  They have a differential financial impact on people depending on whether they directly benefit from the  system sustained by the tax.  To wit, you pay the tax whether or not you choose to send your children to the public schools, indeed, whether or not you have children at all.  You are obligated to subsidize the public education of children other than your own because public education has been declared a public good by the polity of which you are a part.  The same goes for that portion of local taxes that provides police and fire protection.  We accept a mandate to support policemen and firefighters whether or not we will ever need them, in the knowledge that other members of the community assuredly will.  Similarly, those who opt out of Obamacare should pay a price, because they remain part of a society committed to health as a superordinate value without which liberty and the pursuit of happiness are enfeebled.
     It is inconceivable that the Founding Fathers would have found unconstitutional or unfair or governmentally oppressive a law that provided life-promoting health care that enabled more Americans to discharge the duties of citizenship and live more freely and productively in pursuit of happiness.  They declared that citizens – all of whom, be it noted, were white, propertied males – were entitled to life consistent with the demands and entitlements of representative democracy.  Their pledge, their declaration, was not in support of a compromised life that limited the ability to fulfill those demands and enjoy those entitlements.
     When, in our own time, the word “choice,” as used by Republican politicians, means that millions of Americans who rely on Obamacare will end up leading compromised lives, the word becomes semantically contorted and ethically bankrupt.  The absence of Obamacare does not, ipso facto, empower lower-income, assistance-dependent Americans to buy the comprehensive health insurance they need, especially when the tax credits under legislation proposed thus far provide far less support than the subsidization lower-income families now receive.  Freeing insurers from Obamacare regulations so that they can offer inadequate policies that lower-income Americans can afford to buy does nothing but maximize the medical risks of these financially choice-less Americans.  Here is a fact:  Economic circumstances wipe out the prerogative to make prudent choices in one’s own best interest.  For lower-income Americans, a panoply of inadequate choices is not the pathway to right-minded decision making.  With the Senate’s “Better Care Reconciliation Act,” unveiled in June and updated in July, 2017, millions of low-income Americans, especially those dependent on Obamacare subsidies and Medicaid, would have had an absence of credible and affordable choices for obtaining health care adequate to their needs.  The call simply to repeal the Affordable Care Act, which the Senate has rejected as of this writing, would take us back to a status quo ante when millions of Americans were either priced out of, or completely denied, health coverage.
     Of course, adult citizens may repudiate mainstream health care altogether on the basis of philosophical or religious  predilections.  Christian Scientists and Jehovah’s Witnesses, for example, hold theological beliefs that often lead them to refuse medical treatment.  Certainly, they are free to pursue health through spiritual healing or, in the manner of medieval Christians, to disavow corporeal health and earth-bound life altogether.  But by law they cannot deny their children, who deserve to live to maturity and make their own choices, the healing power of modern medicine, whether it comes in the form of insulin, antibiotics, blood transfusions, or surgery.  Nor should they be allowed to undermine social and political arrangements, codified in law, that support everyone else’s right to pursue life and happiness through twenty-first century medicine.  Those who, prior to the Affordable Care Act, had inadequate insurance or no insurance at all are not struggling to free themselves from the clutches of federal regulation; they are not crying out for new free market health plans through which they can exercise freedom of choice.  Rather, they are struggling to put food on the table and keep themselves and their families healthy.  To this end, they need to be free to avail themselves of what modern medicine has to offer, unencumbered by politically debased notions of freedom and choice.
     At this moment in history, in a fractionated society represented by a President and Congressional leaders whose daily missives bear out George Orwell’s acute observation about the corruption of language brought on by political orthodoxies, In the Hands of Doctors may have a wistful ring.  I hope not.  I am addressing the personal side of health care – the reality of a doctor and patient, alone in a consulting room, often surrounded by high-tech diagnostic aids but always containing those vital low-tech instruments with which one person reaches out to the other:  the physician’s eyes and hands and voice.  The human face of doctoring, which now includes the doctoring of nurse practitioners and physician assistants, remains essential to the success of any doctor-patient relationship, whatever the institutional arrangements that bring together this doctor and this patient, the former to help the latter.
     Endeavoring to understand the several aspects – and possibilities – of the doctor-patient relationship, I write about the nature of clinical caring; the relation between caring and patient trust; the need to recruit and train physicians who can bring this caring sensibility to their patients; the role of empathy in medical caring; and the obligation of medical educators to revivify primary care medicine to meet the critical shortage of frontline physicians within underserved American communities.  These issues will not go away, whatever the fate of Obamacare.
     When federal legislation, through the practical assistance it provides, extends the reach of trusting doctor-patient relationships to the most vulnerable  groups in society, it has a  function that is both binding and enabling.  It fortifies the webbing that underlies the increasingly disparate parts of our national mosaic.  Obamacare, the Children’s Health Insurance Program, Medicaid – these programs do not “bring us together” in a feel good way.  They do, however, prevent a free fall in which the subcommunities and interest groups into which society has decomposed land so far apart they are no longer in hailing distance of one another.  As to the enabling function, a comprehensive medical safety net for all Americans – let’s call it what it is: universal health care – revitalizes political democracy by extending to all Americans a greater possibility of life, liberty, and the pursuit of happiness.  In the everyday world, this pursuit boils down to the ability of more people to stay on the job or to work from home rather than not work at all.  Society benefits, since chronically ill people pursuing happiness under the umbrella of universal health care will better resist the complications and collateral illnesses that follow from their primary illness or illnesses.  Society also benefits by enabling healthier happiness-pursuers to avoid hospitalization and, among the elderly, to push back the time when nursing home care is required.  And finally, society benefits by seeing to it that all children, especially those who are disabled, receive every medical advantage as they traverse their own challenging paths to productive, choice-wielding citizenship.
     Obamacare is a far cry from universal health care, but for all its limitations and current financial straits, it has provided these binding and enabling functions for millions of Americans previously without a medical safety net.  Woe to politicians who shred it in the name of choice, a pleasing vacuity that evades the reality of disease and pain among many who are relieved to have a single avenue of subsidized care where none was previously available.
     Health care should be a national trust; everyone deserves what twenty-first century medicine has to offer, regardless of how much or how little choice can be worked into the offering.  Politicians who feel otherwise are enemies of the polity.  Jefferson, who as president helped set up the first smallpox vaccination clinics in the south and then, in retirement, planned a state-supported clinic to provide free medical care to those who could not afford it, would not have brooked the empty insistence that medical freedom and medical choice, unhinged from socioeconomic reality, trump access to medical care per se.  Nor, for that matter, does choice, whatever it may or may not mean, obviate our moral obligation as a society to see to it that best available treatment, whatever the pathway that leads to it, means treatment rendered by caring doctors willing to know their patients as people.

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In the Hands of Doctors:  Touch and Trust in Medical Care, 1st pbk ed

Paul E. Stepansky

978-0983080770        2016/2017pbk        348pp        $26.95pbk

Release date: September 12, 2017

Order now at Amazon.com

 

 

 

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Wanted: Primary Care Docs

“It will readily be seen that amid all these claimants for pathological territory there is scarcely standing-room left for the general practitioner.” – Andrew H. Smith, “The Family Physician (1888)

“The time when every family, rich or poor, had its own family physician, who knew the illnesses and health of its members and enjoyed the confidence of the upgrowing boys and girls during two or three generations, is gone.” – Abraham Jacobi, “Commercialized Medicine” (1910)

“More recent investigation shows that almost one-third of the towns of 1,000 or less throughout the United States which had physicians in 1914 had none in 1925. . . . it will be seen at a glance that the present generation of country doctors will have practically disappeared in another ten years.” – A. F. van Bibber, “The Swan Song of the Country Doctor” (1929)

“But complete medical care means more than the sum of the services provided by specialists, no matter how highly qualified.  It must include acceptance by one doctor of complete responsibility for the care of the patient and for the coordination of specialist, laboratory, and other services.  Within a generation, if the present situation continues, few Americans will have a personal physician do this for them.” – David D. Rutstein, “Do You Really Want a Family Doctor?” (1960)

“Whoever takes up the cause of primary care, one thing is clear: action is needed to calm the brewing storm before the levees break.” – Thomas Bodenheimer, “Primary Care – Will It Survive?” (2006)

“Potential access challenges”—that’s the current way of putting the growing shortage of primary care physicians (PCPs).  Euphemism melodious of care incommodious. Aggravated by the 33 million Americans shortly to receive health insurance through the Patient Protection and Affordable Care Act of 2010 – health insurance leads to increased use of physicians – the chronic shortage of primary care physicians is seen as a looming crisis capable of dragging us back into the medical dark ages.  Medical school graduates continue to veer away from the less remunerative primary care specialties, opting for the  well-fertilized and debt-annihilating verdure of the subspecialties.  Where then will we find the 51,880 additional primary care physicians that, according to the most recent published projections,[1] we will need by 2025 to keep up with an expanding, aging, and more universally insured American population?

Dire forecasts about the imminent disappearance of general practitioners or family practitioners or, more recently, primary care physicians have been part of the medical-cum-political landscape for more than a century.  Now the bleak scenarios are back in vogue, and they are more frightening than ever, foretelling a consumer purgatory of lengthy visits to emergency rooms for private primary care – or worse.  Dr. Lee Green, chair of Family Medicine at the University of Alberta, offers this bleak vision of a near future where patients are barely able to see primary care physicians at all:

Primary care will be past saturated with wait times longer and will not accept any new patients.  There will be an increase in hospitalizations and increase in death rates for basic preventable things like hypertension that was not managed adequately.[2]

I have no intention of minimizing the urgency of a problem that, by all measurable indices, has grown worse in recent decades. But I do think that Dr. Green’s vision is, shall we say, over the top.  It is premised on a traditional model of primary care in which a single physician assumes responsibility for a single patient.  As soon as we look past the traditional model and take into account structural changes in the provision of primary care over the past four decades, we are able to forecast a different, if still troubling, future.

Beginning in the 1970s, and picking up steam in the 1980s and 90s, primary care medicine was enlarged by mid-level providers (physician assistants, nurse practitioners, psychiatric nurses, and clinical social workers) who, in many locales, have absorbed the traditional functions of primary care physicians.  The role of these providers in American health care will only increase with implementation of the Patient Protection and Affordable Care Act and the innovative health delivery systems it promotes as solutions to the crisis in healthcare.

I refer specifically to the Act’s promotion of “Patient-Centered Medical Homes” (PCMHs) and “Accountable Care Organizations” (ACOs), both of which involve a collaborative melding of roles in the provision of primary care.  Both delivery systems seek to tilt the demographic and economic balance among medical providers back in the direction of primary care and, in the process, to render medical care more cost-effective through the use of electronic information systems, evidence-based care (especially the population-based management of chronic illnesses), and performance measurement and improvement.  To these ends, the new delivery systems equate primary care with “team-based care, in which physicians share responsibility with nurses, care coordinators, patient educators, clinical pharmacists, social workers, behavioral health specialists, and other team members.”[3]  The degree to which the overarching goals of these new models – reduced hospital admissions and readmissions and more integrated, cost-effective management of chronic illnesses – can be achieved will be seen in the years ahead.  But it is clear that these developments, propelled by the Accountable Care Act and the Obama administration’s investment of $19 billion to stimulate the use of information technology in medical practice, all point to the diminished role of the all-purpose primary care physician (PCP).

So we are entering a brave new world in which mid-level providers, all working under the supervision of generalist physicians in ever larger health systems, will assume an increasing role in primary care.  Indeed, PCMHs and ACOs, which attempt to redress the crisis in primary care, will probably have the paradoxical effect of relegating the traditional “caring” aspects of the doctor-patient relationship to nonphysician members of the health care team.  The trend away from patient-centered care on the part of physicians is already discernible in the technical quality objectives (like mammography rates) and financial goals of ACOs that increasingly pull primary care physicians away from relational caregiving.

The culprit here is time.  ACOs, for example, may direct PCPs to administer depression scales and fall risk assessments to all Medicare patients, the results of which must be recorded in the electronic record along with any “intervention” initiated.  In all but the largest health systems (think Kaiser Permanente), such tasks currently fall to the physician him- or herself.  The new delivery systems do not provide ancillary help for such tasks, which makes it harder still for overtaxed PCPs to keep on schedule and connect with their patients in more human, and less assessment-driven, ways.[4]

So, yes, we’re going to need many more primary care physicians, but perhaps not as many as Petterson and his colleagues project.  Their extrapolations from “utilization data” – the number of  PCPs we will will need to accommodate the number of office visits made by a growing, aging, and better insured American population at a future point in time – do not incorporate the growing reality of team-administered primary care.  The latter already includes patient visits to physician assistants, nurse practitioners, and clinical social workers and is poised to include electronic office “visits” via the Internet.   For health services researchers, this kind of  distributed care suggests the reasonableness of equating “continuity of care” with “site continuity” (the place where we receive care) rather than “provider continuity” (the personal physician who provides that care).

Of course, we are still left with the massive and to date intractable problem of the uneven distribution of primary care physicians (or primary care “teams”) across the population.  Since the 1990s, attempts to pull PCPs to those areas where they are most needed have concentrated on the well-documented financial disincentives associated with primary care, especially in underserved, mainly rural areas .  Unsurprisingly, these disincentives evoke financial solutions for newly trained physicians who agree to practice primary care for at least a few years in what the federal government’s Health Resources and Services Administration designates “Health Professional Shortage Areas” (HPSAs).  The benefit package currently in place includes medical school scholarships, loan repayment plans, and, beginning in 1987, a modest bonus payment program administered by Medicare Part B carriers.[5]

The most recent and elaborate proposal to persuade primary care physicians to go where they are most needed adopts a two-pronged approach.  It calls for creation of a National Residency Exchange that would determine the optimal number of  residencies in different medical specialties for each state, and then “optimally redistribute”  residency assignments state by state in the direction of underrepresented specialties, especially primary care specialties in underserved communities.  This would be teamed with a federally funded primary care loan repayment program, administered by Medicare, that would gradually repay participants’ loans over the course of their first eight years of post-residency primary care practice in an HPSA.[6]

But this and like-minded schemes will come to naught if medical students are not drawn to primary care medicine in the first place.  There was such a “draw” in the late 60s and early 70s; it followed the creation of “family practice” as a residency-based specialty and developed in tandem with social activist movements of the period.  But it did not last into the 80s and left many of its proponents disillusioned.  Despite the financial incentives already in place (including those provided by the federal government’s National Health Service Corps[7]) and the existence of “rural medicine” training programs,[8] there is no sense of gathering social forces that will pull a new generation of medical students into primary care.  Nor is there any reason to suppose that the dwindling number of medical students whose sense of calling leads to careers among the underserved will be drawn to the emerging world of primary care in which the PCP assumes an increasingly administrative (and data-driven) role as coordinator of a health care team.

In truth, I am skeptical that financial packages, even if greatly enlarged, can overcome the specialist mentality that emerged after World War II and is long-entrenched in American medicine.  Financial incentives assume that medical students would opt for primary care if not for financial disincentives that make it harder for them to do so.  Now recent literature suggests that financial realities do play an important role in the choice of specialty.[9]  But there is more to choice of specialty than debt management and long-term earning power.  Specialism is not simply a veering away from generalism; it is a pathway to medicine with its own intrinsic satisfactions, among which are prestige, authority, procedural competence, problem-solving acuity, and considerations of lifestyle. These satisfactions are at present vastly greater in specialty medicine than those inhering in primary care.  This is why primary care educators, health economists, and policy makers place us (yet again) on the brink of crisis.

Financial incentives associated with primary care are important and probably need to be enlarged far beyond the status quo.  But at the same time, we need to think outside the box in a number of ways.  To wit, we need to rethink the meaning of generalism and its role in medical practice (including specialty practice).  And we need to find and nurture (and financially support) more medical students who are drawn to primary care.  And finally, and perhaps most radically, we need to rethink the three current primary care specialties (pediatrics, general internal medicine, and family medicine) and the relationships among them.  Perhaps this long-established tripartite division is no longer the best way to conceptualize primary care and to draw a larger percentage of medical students to it.  I will offer my thoughts on these knotty issues in blog essays to follow.


[1] S. M. Petterson, et al., “Projecting US primary care physician workforce needs:  2010-2025,” Ann. Fam. Med., 10:503-509, 2012.

[2] Quoted in Nisha Nathan, “Doc Shortage Could Crash Health Care,” online at http://abcnews.go.com/Health/doctor-shortage-healthcare-crash/story?id=17708473.

[3] D. R. Rittenhouse & S. M. Shortell, “The patient-centered medical home:  will it stand the test of health reform?, JAMA, 301:22038-2040, 2009, at 2039.  Among recent commentaries, see further D. M. Berwick, “making good on ACOs’ promise – the final rule for the Medicare shared savings program,” New Engl. J. Med., 365:1753-1756, 2011; D. R. Rittenhouse, et al., “Primary care and accountable care – two essential elements of delivery-system reform,” New Engl. J. Med., 361:2301-2303, 2009, and E. Carrier, et al., “Medical homes:  challenges in translating theory into practice,” Med. Care, 47:714-722, 2009.

[4] I am grateful to my brother, David Stepansky, M.D., whose medical group participates in both PCMH and ACO entities, for these insights on the impact of participation on PCPs who are not part of relatively large health  systems.

[5]E.g., R. G. Petersdorf, “Financing medical education: a universal ‘Berry plan’  for medical students,” New Engl. J. Med., 328, 651, 1993;  K. M. Byrnes, “Is there a primary care doctor in the house? the legislation needed to address a national shortage,” Rutgers Law Journal, 25: 799, 806-808, 1994.  On the Medicare Incentive Payment Program for physicians practicing in designated HPSAs – and the inadequacy  of the 10% bonus system now in place – see L. R. Shugarman & D. O. Farley, “Shortcomings in Medicare bonus payments for physicians in underserved areas,” Health Affairs, 22:173-78, 2003 at 177 (online at http://content.healthaffairs.org/content/22/4/173.full.pdf+html) and S. Gunselman, “The Conrad ‘state-30’ program:  a temporary relief to the U.S. shortage of physicians or a contributor to the brain drain,”  J. Health & Biomed. Law, 5:91-115, 2009, at 107-108.

[6]G. Cheng, “The national residency exchange: a proposal to restore primary care in an age of microspecialization,” Amer. J. Law & Med., 38:158-195, 2012.

[7] The NHSC, founded in 1970, provides full scholarship support for medical students who agree to serve as PCPs in high-need, underserved locales, with one year of service for each year of support provided by the government.  For medical school graduates who have already accrued debt, the program provides student loan payment for physicians who commit to at least two years of service at an approved site. Descriptions of the scholarship and loan repayment program are available at http://nhsc.hrsa.gov/

[8] See the rationale for rural training programs set forth in a document of the Association of American Medical Colleges, “Rural medicine programs aim to reverse physician shortage in outlying regions,” online at http://www.aamc.org/newsroom/reporter/nov04/rural.htm.  One of the best such programs, Jefferson Medical College’s Physician Shortage Area Program, is described and its graduates profiled in H. K. Rabinowitz, Caring for the country:  family doctors in small rural towns (NY: Springer, 2004).

[9] See especially the 2003 white paper by the AMA’s taskforce on student debt, online at http://www.ama-assn.org/ama1/pub/upload/mm/15/debt_report.pdf and, more recently, P. A. Pugno, et al., “Results of the 2009 national resident matching program: family medicine,” Fam. Med., 41:567-577, 2009 and H. S. Teitelbaum, et al., “Factors affecting specialty choice among osteopathic medical students, Acad. Med., 84:718-723, 2009.

Copyright © 2012 by Paul E. Stepansky.  All rights reserved.