Posted by: notdeaddinosaur | April 6, 2010

Stating the Obvious

There’s a question that keeps popping up all over the place when the obvious mismatch between the dearth of physicians practicing primary care and the upcoming flood of newly insured patients thanks to the recently passed health INSURANCE bill:

What’s going to happen when all those people can’t find a primary care doctor to take care of them?

It is usually stated rhetorically. On the rare occasions when someone tries to answer it, they come up with something obvious:

People will go to Emergency Rooms.

Non-heathcare types may understand that ER care is far more expensive than that provided in doctors’ offices and clinics, but the downside to ER care for non-emergency problems goes beyond that. ER care is more expensive because the ER mindset (“Don’t miss anything,” as opposed to the primary care mindset, “Don’t miss anything important”) results in lots of unnecessary care: blood tests, CT scans and other x-rays, etc.

The other piece of this puzzle, rarely stated, is that many, many patients, perhaps the majority, will recognize that the ER is not the appropriate place to seek medical care for their longstanding problems even though they now have insurance. (ER docs won’t believe this, because they only see the people who come to the ER. It’s hard to believe that what you don’t see really exists, and I can vouch for the fact that there are lots of reasonable patients out there who do NOT think to rush to the ER for every little thing.)

The problem is that in the absence of sufficient numbers of primary care physicians — and with no mechanism to filter access to specialists — patients will self-refer to specialty care. Again, to non-healthcare types, this doesn’t seem to be much of a problem. The American perception is that specialty care is “better,” presumably because it’s “special”. And this is a huge mistake.

Specialty training is designed to focus on “not missing anything,” because in an ideal world, anyone who clearly has “nothing important” going on would never have darkened the specialists’ doors in the first place. When their comprehensive approach is applied to an unfiltered population, their extensive (and expensive) workups are not only useless and time-consuming, but dangerous to low-risk patients who have no need of exposure to the risks of useless testing.

What’s really going to happen when those 30 million newly insured patients can’t find Primary physicians is that the specialists offices will explode! Everyone walking in off the street will get the full workup of whatever that specialty office has to offer. Then, when no answer is forthcoming, they will get shuffled onto the next specialist, and the next, and the next. By the time they finally get into my office, multiple thousands of unnecessary dollars will have been spent to rule out everything I could have told them they didn’t have.

This is the real reason health care costs will explode under the new law.

What to do about it?

Perhaps if there were a requirement that newly insured patients’ first encounter with a non-primary-care physician be treated differently from an actual referral, we could find a way to get specialists to reign in their natural inclination to rule out everything under the sun (and then refer to their other specialty friends, to rule out everything else). I’m not sure precisely how this would work, but make no mistake: if something isn’t done to address this issue specifically, the unintended consequence of insurance coverage expansion will be a surge in health care expenditures of unimaginable proportions.


  1. Great post! We at hope to help alleviate some of the burden when it comes to the cost of healthcare testing! The medical community needs to ban together to keep healthcare affordable!

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