"The Physician's Influence in Controlling Costs" by Bruce S. Auerbach, M.D.

In all of the commentary written here and elsewhere on how to control health care costs, little attention has been given to the potential contributions that could be made by physicians – those at the center of the health care system.

But maybe the idea is beginning to catch on.

Two separate articles on the same day in two of the nation’s most respected publications have highlighted the role of the physician in containing health care costs.

Alan Sager and Deborah Socolar of Boston University, writing in The Boston Globe, boldly state that “doctors’ decisions essentially control almost 90 percent of health care spending…yet cost controls have ignored, marginalized, or sought to manipulate doctors instead of working with them.”

The pair, arguing that “a financial, legal, and clinical peace treaty between payers and doctors” is required to develop a health care system that covers everyone and eliminates waste, offered one approach: develop “small clusters of primary care doctors and other professionals that live within budgets, accepting capitation payments calibrated to patients’ health. Raising primary care doctors’ incomes by half would sharply increase their supply and their time to listen to patients and coordinate care.” [Italics added.]

Separately, in the business pages of The New York Times, economist Milt Freudenheim wrote about experiments around the country by federal and state governments and insurers to cut health costs by paying doctors more.

“The idea,” wrote Freudenheim, “is that by paying family physicians, internists and pediatricians to devote more time and attention to their patients, insurance and patients can save thousands of dollars downstream on unnecessary tests, visits to expensive specialist and avoidable trips to the hospital.” [Italics added.]

A key theme in both articles is the same: physicians, especially primary care physicians, can have a significant and critical impact on health care costs. What is needed is a greater recognition of the value of primary care and reestablishing the critical importance of the physician-patient relationship. Isn’t that the place, after all, where health care really takes place?

Thankfully, earlier this month Congress, led by the efforts of Senator Kennedy, overrode the veto of President Bush on the Medicare Improvements for Patients and Providers Act by a wide margin. While the focus of that bill was blocking a 10.6 percent cut in Medicare reimbursements to physicians, another key provision of the bill was a $100 million, three-year, Medicare pilot project to establish “medical homes” for patients. The program would pay primary care doctors more, as Freudenheim notes, “to keep better track” of patients. He cites existing programs in Philadelphia and Michigan, where Blue Cross Blue Shield of Michigan, with 4.7 million members, plans to spend $30 million this year to help primary care doctors offer these services.

Massachusetts, like the rest of the nation, is now struggling with its primary care crisis, and coalitions are forming to address the issue. Improved reimbursements for primary care (one reason why the Congressional vote on Medicare was so critical), solutions to the dilemma of defensive medicine, elimination of administrative hassles and duplication of paperwork are just some of the proposals for cost control that we physicians have been urging and are now being accepted by others.

In May I wrote the following in this space: “If we do not fix our primary care system, we will lose our ability for cost containment and control, and that will further jeopardize health care and health care reform. Around the country and around the world, the health care systems that are the most cost efficient and have the best outcomes are those with the most robust primary care networks.”

It’s still true, and it’s important – and gratifying – that others are beginning to recognize it as well.

Bruce S. Auerbach, M.D.
President, Massachusetts Medical Society