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A Family Physician Is…

What follows is an article that I wrote for NJAFP’s Perspectives: A View of Family Medicine in New Jersey recentlly.

While on vacation earlier this summer, as I sat on an idyllic beach setting with a good book, a cold beverage, and great jazz in my ears, the sky began to cloud over. With my peace disturbed at the thought of a less-than-perfect vacation day, I grumbled some words of dissatisfaction with Mother Nature – I thought this complaint was made in private, but not so. From about five feet away I heard a “local” say, “Don’t forget where you are. If you don’t like the weather just give it 10 minutes and it’ll change.” Since then I have been thinking about change quite a bit; the pace of change, how difficult change can be, the fact that change just “is,” it’s our reaction to the change that matters, and mostly how often the old axiom “the more things change, the more they stay the same” proves true. Consider these quotes from reports published in 1966 and 1967:

“The patient wants, and should have, someone of high competence and good judgment to take charge of the total situation, someone who can serve as coordinator of all of the medical resources that can help to solve his problem. He wants a company president who will make proper use of the skills and knowledge of more specialized members of the firm. He wants a quarterback who will diagnose the constantly changing situation, coordinate the whole team, and call on each member for the particular contributions that he is best able to make to the team effort.” 1

“Every individual should have a personal physician who is the central point for integration and continuity of all medical services to his patient. Such physician will emphasize the practice of preventive medicine… He will be aware of the many and varied social, emotional and environmental factors that influence the health of his patient and his family… His concern will be for the patient as a whole, and his relationship with the patient must be a continuity one.” 2

“The family physician is one who: 1) serves as the physician of first contact with the patient and provides a means of entry into the healthcare system; 2) evaluates the patient’s total health needs, provides personal medical care within one or more fields of medicine, and refers the patient when indicated to appropriate sources of care while preserving the continuity of his care; 3) assumes responsibility for the patient’s comprehensive and continuous health care and acts as leader or coordinator of the team that provides health services; and 4) accepts responsibility for the patient’s total health care within the context of his environment, including the community and the family or comparable social unit. The family physician is a personal physician, oriented to the whole patient…” 3

A while back, I asked a group of people to complete the sentence “a family physician is…”  Some of the people in that group were themselves family physicians, and some were non-physicians with strong ties to family medicine.  The answers were strikingly similar to those 50+ year old quotes.  

“Your one-stop shop for relationship-based, comprehensive, broad-scope care.”4

 “Someone who cares for the entire patient as a human being, who is on the front line of today’s complex medical care system who cares for newborns to the elderly and is usually someone who knows the patient best, like a good, trusted friend.”5

 “A family physician is someone who looks at the big picture, not just the medical conditions, but also their mental health and social/family situation and advises and supports the patient accordingly.”6

 On first glance, one might argue that it is only natural that the specialty would be defined, or define itself similarly from one generation to the next.  Accountants are still accountants, attorneys remain attorneys, and while the surrounding environment may change and grow more complex, the basis of a profession is likely to be consistent.  Still, the focus of so many conversations and articles (even this one) is how much change family physicians must endure and navigate.  I do not disagree with the premise, but I was also struck by the simplicity of the truth.  At the end of the day, through all the change, the basic nature of family medicine, the value of family physicians, and the role they play in their patients’ lives and in the healthcare economy are strikingly similar to the earliest visions of family medicine.  Family physicians are ultimately, as one respondent stated with eloquent simplicity, “your family’s healthcare partner for life.”  As family medicine travels the winding road that is healthcare in the 21st century, I maintain a hopeful perspective that this basic foundation of the quintessential primary care discipline will not change, and that my ability as a patient to have that life-long relationship with “the health professional [I] trust most to advise and guide [me] to be or stay healthy” will not be relegated to historical recollections of a reality long past. 

Unfortunately, not all similarities with the past are as positive.   

“We believe the cost of medical care can be reduced, the availability of medical care increased, and the quality of medical care improved, if the American people will accept the policy of each person turning to a general practitioner as his family doctor, personal medical guide, and health advisor.7 

Yes, it is far too simple to suggest that we have been saying the same thing for more than 60 years.  It is foolish to overlook the dramatic changes in our capabilities and understanding of science and medicine that have helped to drive cost over that time, and to merely suggest that we have been promoting a solid primary care foundation as the answer to skyrocketing costs with little success.  Still, the words were almost exactly the same in 1949 as they are today.  The call to embrace primary care is not a new one.  We’ve made progress, but perhaps not enough, and I am reminded of a potential version of the future included in the 2000 Keystone III report where Dr. Larry Green, then of the Graham Center, looked forward to the 2020 Keystone V Conference to discuss “why family medicine failed.”  While he suggested that this fictional group came to no consensus, there were four main points of view for the “failure” of family medicine. 

 The first was that the specialty didn’t fail, but rather abdicated.  

“In the specifics of specific places, it made sense to turn over the care of the dying, the newborn, the adolescent, the athlete, the discouraged, the pregnant, the bed-bound, the post-operative person – to someone else…but the ultimate result of these adaptations was the erosion of the functional domain until it lost its coherence, that essential totality that made it what it was.”8

 The second point of view was that “Family Medicine Went Down as a Part of the Old Paradigm.”  Here Dr. Green suggested that in addition to well discussed issues within organized medicine and the academic health centers, the demise of family medicine was hastened by the “nearly absent local family doctors” whose “near worship of their independence, lack of curiosity and solid contributions to better medicine, and focus on payment systems, resulted in their getting lost in their administrative methods and being ‘out-competed’ by others in the best execution of specific tasks…the idea of a healer-person was, at least for now, replaced by a healer-virtual, residing somewhere in the healthcare system as a whole.”8

 Additionally, Dr. Green suggested a third and fourth viewpoint; that family medicine failed because it “chose the wrong tasks” and “never became part of the culture.”  Both of these viewpoints offer equally chilling foreshadowing as we sit closer to the year 2020 that the paper envisioned than the year 2000 in which Dr. Green authored the paper.  The pessimist can look at this set of predictions and draw clear parallels to the reality of today. Many will suggest that the most dangerous crisis in family medicine today is the loss – or abdication – of comprehensiveness, which coupled with the inability or unwillingness of many family physicians to embrace change is not only killing, but in fact may have killed, the specialty.  Others will point to the same set of facts and suggest instead that it is rigidity coupled with a focus on integration, reporting, and validating at the expense of the traditional physician-patient relationship which is the core of the problem.  I understand both points of view, and while I have concerns, I still choose optimism for the future. 

I believe that the rumors of the demise of family medicine have been greatly exaggerated.  To be certain, there is great change all around us.  Today’s family physician is far different than the GP of 1949, the family doctor of 1966-67, and even the family physician of 2000.  

A family physician is more than a doctor of medicine.  A family physician can throw a curveball or change a diaper, watch his or her child play little league soccer or baseball and most importantly, provide care to the whole family and the whole person with a unique quality of care with caring, which is different than most other physicians.9 

Practice environments, patterns, and even the people practicing family medicine are changing.   Still the more they change, the more they remain the same.  Family physicians are still the centerpiece of a healthy healthcare system, they are still the best opportunity we have as a culture to “bend the cost curve” and by far the most well equipped to keep us and our children healthy now and in the future.  They are “the ultimate life coach – [working] tirelessly to care for the physical, mental and emotional health of their patients.”  And while I maintain my role as determined realist, I also remain boldly optimistic about the future – 2020 and beyond.

References

  1. The Graduate Education of Physicians: The Report of the Citizen’s Commission of Graduate Medical Education (Millis Commission). Chicago, American Medical Association, 1966
  2. Folsom MB, American Public Health Association and National Health Council. Health is a community affair. Report of the National Commission on Community Health Services. Boston, MA: Harvard University Press; 1967.
  3. American Medical Association. Ad Hoc Committee on Education for Family Practice. Council on Medical Education. Meeting the Challenge of Family Practice. Chicago: American Medical Association, 1966. (Also known as the “Willard Report”)
  4. Anonymous
  5. Ibid
  6. Ibid
  7. “G.P. Campaign Picks Up Speed,” Medical Economics, 1949
  8. Keystone III: The Role of Family Practice in a Changing Healthcare Environment. Washington D.C.: The Robert Graham Center, American Academy of Family Physicians, 2000
  9. Anonymous
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Why the “Doc Fix” debate matters to all of us

There is once again lots of discussion in the healthcare community over what we lovingly call the “Doc Fix.” The doc fix is that annual struggle in Congress to un-do the automatically triggered reduction in physician payment based on the entirely UN-sustainable “Sustainable Growth Rate” (SGR) formula. I am not the person to explain that formula, but feel free to read all about it on your own. My message today is less about formulae and policy, and more about what it means to you and me.
So, for those who are NOT regularly tuned in to healthcare issues beyond the fact that you or someone you know is occasionally a patient, google “doc fix” and read the most recent news — or just read the article at the link at the bottom of this page. Once you have read a bit on the topic, it will be easy to dismiss this as “rich” doctors complaining. That’s reasonable, but consider this: We KNOW (lots and lots of data support) that where there is a strong primary care infrastructure, where primary care docs are an integral part of the healthcare team (where patients have a “patient centered medical home”) healthcare costs go down and health outcomes improve (the system spends less to keep you healthier). Now consider that your son or daughter (or YOU) are considering going in to medicine, and really wants to be a family physician and deliver the kind of high quality primary care that our country so desperately needs. They (or you) can do that and all it will take is about $200k in debt – or the equivalent in personal wealth, willingness to work harder and less family-friendly hours than most of your physician colleagues, start the “earning” portion of their (or your) career in your 30s making barely enough to cover that debt…and never approach the salaries earned by your anesthesiologist, dermatologist, or almost any other “ologist” colleagues (in many cases earning 50% or more LESS) and have the additional pleasure of being told by the government that their (or your) pay will be arbitrarily reduced by 30% — and even if the self-important (er…I mean “well-intentioned”) politicians to whom we entrust our government DON’T do that, your paycheck is going to be held hostage for 10 days or so while those same “well-intentioned” Congressional representatives bicker over politics.
A person capable of being accepted in to medical school is clearly smart enough to be a doctor, or for that matter any other thing they may choose to be. So ask yourself, would you choose the path of a primary care physician? WHY would you want your son or daughter to choose that path?
If we want the kind of healthcare we deserve then this annual exercise of the “doc fix” must end once and for all with a new formula that replaces the SGR, and our system that rewards procedures at the expense of coordinated care MUST change. If not; if we don’t force our representatives to make difficult choices based on what is right rather than on how to keep all “voting blocs” happy, I fear that there will be no one left to provide the primary care that we deserve.
As always — and perhaps even more than always — these are my opinions and not necessarily the opinions of my employer (although I’d be willing to bet that most of my members agree).

The article I mentioned on the “doc-fix:” http://thehill.com/blogs/healthwatch/medicare/200513-gop-doctors-say-stand-alone-doc-fix-may-be-needed

Info on the PCMH: http://www.pcpcc.net/consumers-and-patients

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The Choice: Customer or Beneficiary

It’s been a long time since I blogged here. I had become concerned that I would be seen as speaking for the organization from which I draw a salary. I do that in other forums, willingly and with pride. So, while I would assume (hope) that many of the wonderful people for whom I advocate would agree with me here (or at least find what I say to be provacative enough to cause them to think), this blog does NOT express, nor is it endorsed by the NJAFP, the AAFP, or any of their members.

This morning I read an editorial by Paul Krugman of the NYT. While I agree with some of Mr. Krugman’s points, and disagree entirely with others, what jumped out at me today was that everyone who has something to say about our broken, fragmented healthcare “system” is able to clearly (and usually articulately) identify what they believe to be the source of the problem. Few however, offer solutions other than very typical, and usually partisan (a la Krugman) ideas that are often rejected by large portions of the electorate (and I’ve become convinced that this is all we are to most politicians…a measurable commodity on their march to power). Given that I am also long on problem and short on solution, maybe I am no different. That said, there is an 800 lb elephant in the middle of the room, and we need to begin as a society to talk about it.

The foundational problem is that our culture has become to quick to depend on “someone else” to take care of us. Greed and laziness are leading too many to NOT understand the consequences of “what they want.” The other day as a part of the budget debate, the president said (paraphrasing) “most Americans hate gov’t spending but like what it buys.” I disagree. I think that most Americans like what it buys THEM as long as they feel that some OTHER schmuck is doing the buying. This is the issue with healthcare. Most WANT their care to be the “commercial transaction” that Mr. Krugman eschews, as long as what that means is that such a transaction comes with all the protections and control that we gain as a paying customer…we just want someone else to pay the bill. Until we wrap our arms around that issue and make some tough decisions. The question that we need to ask ourselves with regard to our healthcare is “do we prefer to be customers, with all the rights, protectections AND RESPONSIBILITES that go along with being the person who pays the bill, or would we rather be “beneficiaries” — which by definition requires that we give up some control to those who pay the bill? I am well aware that in the commercial system as it currently exisits we are in many cases paying an “insurance company” who doesn’t treat us like a customer either. I am not debating the merits of a commercial system vs. a government funded system. I am however, suggesting that the root of our problem is, to borrow a phrase, “uniquely American.” We tell ourselves that we are the most fiercely independant culture on the planet. That is certainly a quality that has served us well throughout our rather young history. However, I fear that for many the interpretation of independance has conveniently eliminated the responsibility that is its prerequisite. Mr. Krugman is right. We can’t be “consumers” in a “commercial transaction” with the healthcare system if our neighbor is footing the bill. The flip side is that if we ARE consumers, there will be some who can “afford” more than others. Neither option is perfect.

Consumers or beneficiaries? I think we need to choose.

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EHR’s and Cost Savings – Not A Sure Bet

While there is increasingly less doubt that a system-wide revaluing and rebuilding of our primary care infrastructure will both reduce health care costs and improve health outcomes, there is less certainty with regard to the contributions of the high-tech elements of health reform. A recently released study by researchers out of Harvard Medical School scheduled for publication in the American Journal of Medicine suggests that despite Congressional support of more than $19 Billion, claims of increased efficiencies attributable to hospital computerization (EMR) “rest on scant data.” The study was based on a review of over 4,000 hospitals over a 5-year study period. The hospitals examined were at various stages of EMR implementation and capability, and ultimately even the “100 most wired hospitals” (as defined by an independent ranking of hospital computerization) are seeing neither cost savings nor significant increased administrative efficiencies. Additionally, the study found no appreciable difference between these “leaders” and the full study sample. In addition, researchers from Massachusetts General Hospital have also just released a study with a similar design and a conclusion that there was “little difference in the cost and quality of care” between those hospitals who had adopted EMR and those that had not.

While each of these studies can be challenged to some degree given the personal agendas of the authors, they leave me more convinced than ever of my previously held opinion that the jury is simply still out on EMR. There are clear advantages that should be obtained from the adoption of health information technology (HIT), but the entire enterprise is compromised by poor design. EMR’s are designed with the goals of the individual user, physicians and hospitals, as the focus. I think of this focus on management of individual patient records, coding technology, billing and the like as design based on micro level goals. Instead, the objective should be to meet the goals of the health system at the macro level. This is the functional equivalent of asking each airline to invest in separate, non-interoperable systems to control air traffic, and then expecting airline safety to improve. In fact, it is my opinion that the only way to control, and potentially reduce health care costs and improve outcomes at the system level through application of HIT is through the creation of a standardized, universal, completely interoperable system, or at the very least, the development of technology that allows the currently disparate systems to communicate as an interoperable information system.

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Wringing the Health Care Sponge

The following does not necessarily reflect the views or opinions of my employer…but then again maybe it does…you should probably check with them.

This will be a very short post for me. It’s more a question for discussion than a startling revelation. I hope that those of you who read this will share your thoughts on the subject. It seems that the discussion of health care (a.k.a. insurance) reform seems to have found some common ground, at least in a few areas. We seem to agree that the primary care infrastructure of our country needs to be rebuilt. We also have reached some degree of consensus with regard to the issue of the primary care work force. Essentially, we don’t have enough primary care physicians to meet the current need, much less the need that will be generated once we provide insurance to the majority of the currently uninsured in the USA, and the only way to improve that reality is to make the primary care practice environment more attractive to potential physicians and other clinicians. That, unfortunately, but realistically, means money. The conventional wisdom is that we will find that money – the money needed to improve payment for primary care – in the efficiencies we will create. In simple terms, we’ll cut out the waste in the system and reinvest part of the savings in the system.

Let’s pretend for a minute that we believe that we can come to consensus on how to find those savings. Let’s imagine that we live in a world where everyone with an interest in status-quo will give up the fight for the betterment of humanity. Let’s assume that we really can find the inefficiencies (probable), enforce policies that reduce those inefficiencies (less probable), and actually realize savings in the system by becoming more efficient (questionable at best). Now let’s imagine that next year, we are able to redirect a sum of money back into the system as a result of our success in controlling waste. What then? Does anyone believe that this year’s ceiling does NOT become next year’s floor?

Let’s play just one more “what if” game. What if the inefficiencies and waste in the system are so great that we will be able to ride the wave of savings for 5 or even 10 years in blissful ignorance of the coming judgment day when there are no more savings to leverage? Is it possible that the people making the decisions have actually seen a sponge and realize that regardless of how saturated it may be there is a point where you’ve wrung all the water out, and no matter how much you twist, it’s still a dry sponge? Is it cynical to think that we are allowing politicians to do what they always do…put off the truly difficult decisions, the ones that require true leadership and the risk that comes with it in favor of a fix that will last long enough that they can turf the problem off to those who follow?

Basing our ability to fund health reform on cost-savings alone will only put off the inevitable reality that we will someday face; that we cannot simply work the expense side of the healthcare ledger and expect that our methods will be sustainable. That means we either generate more revenue (can you say “taxes”), maybe not today, but certainly at some point in the future, or we restrict access and services. Neither of those choices are particularly palatable for most Americans, but they will be no more palatable 5 or 10 years from today. They will, however, be far more urgent.

This is just one man’s opinion. I’d love to hear yours.

Ray

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The Primary Care Revolution

It’s near. We deserve it. The only question that remains is if we’ll have the courage to do it, and the sense to do it right. Of course, I am talking about healtcare reform. I am frightened because we regularly compare our healthcare system to those in other countries…and cultures, and it seems to me that we forget how fiercely we value… and are influenced by…our own culture. While I understand the desire to avoid “recreating the wheel,” it occurs to me that the solution to the healthcare system in America will require old-fashioned American ingenuity, tempered by common-sense, informed by true creativity. The problem is that even as the theme in Washington is “Change we can believe in” I still see our Capitol in the terms that someone brighter than me once defined it: “64-square miles bounded on all sides by reality.” Perhaps more to the point, I see words like creativity, ingenuity, and especially common-sense as oxymorons when used in the same sentence as most politicians.

What I know is that Primary Care (and therefore Family Medicine) must be at the center of whatever solution is crafted, and I grow more confident in that happening every day. For more on why, see the article that ran earlier this week in the New York Times linked below. While I am not sure that the average primary care salary comes close in my part of the world, the point is well made and worthy of your read.

http://www.nytimes.com/2009/06/07/health/07health.html?_r=1

–Ray

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The Benchmark of a Civilized Society

“The benchmark of a civilized society is the quality of its justice.”
–Jack McCoy

Jack McCoy, for those who may not own a television, is the fictional District Attorney on the TV series Law and Order. Jack may be fictional, but his words are poignant, and while the quote above was not originally offered as an indictment of the way we deliver healthcare, it may well have been. I’d suggest that it is equally poignant to say that the benchmark of a civilized society is the quality of the healthcare provided to its citizens. Perhaps more to the point, the provision of quality healthcare, accessible to everyone, is the benchmark of a just society.

Recently, I received a discouraging email from a member Family Physician whose quality as a Family Doc may only be surpassed by his quality as a person. The note was discouraging not only for what he said, but for all of the implications that it held. This physician made a decision to practice in one of the lowest income, most underserved communities in our state. He has been a role model for younger physicians who want to make a difference. He’s been the access point to care for people who might not find that care without him. Last week, he closed his practice to new Medicaid patients. The economic condition of his practice also caused him to lay-off his Physician Assistant; he simply could no longer afford her. For a moment, as I read his email, I couldn’t help but think that if this Family Physician is no longer able to care for the community to which he is so clearly committed, then we may be beyond the point of no-return with regard to healthcare in this country. There was a time not so long ago when members called me lamenting the decision to hire a PA because they could not afford to hire another physician. Look how far we’ve come! Still, this situation highlights what I believe is the single most unspoken truth with regard to our healthcare “system.” The current financial model, which rewards procedures and proceduralists at the expense of wellness and those who would keep us well, will never provide us a path away from the fractured care that is not only bankrupting us, but is also leaving far too many without the care that a civilized society should – must – provide. Simply enough, even as healthcare reform is suddenly visible on the horizon, true change cannot – will not – ever occur until we, as a culture, begin to value primary care to a greater extent. Why don’t we? Some blame the big-bad insurance companies. There is probably truth to some of that. Others blame “Big Pharma,” and again, you’ll probably find some truth in those complaints. Some people argue that the only answer is a single-payer system (Medicare for All), while others fear that adding more government to any problem is simply a way to guarantee that we reach the lowest common denominator in the universe of possible solutions. I don’t know which of those answers is best, but I do believe that they are all ultimately red-herrings. I am also quite certain that the next few paragraphs will make some people uncomfortable, perhaps even angry. So be it.

We live in a society that values personal freedom above all else. We live in a time where too many people “learn” in sound-bites. We live in a culture where for far too many of us “specialized” is synonymous with “quality.” Yet in healthcare in the United States, study after study shows that we over-utilize services to exorbitant expense with little additional benefit to patients. Study after study shows that throughout the rest of the world, those societies who base their system on a strong primary care infrastructure get better results with lower costs. “We the People” get it. Lawmakers are starting to get it. The problem is that our system continues to focus the “reward” in the direction of fractured, costly care. Why? Because “We the People” can intuitively understand that we can no longer afford to spend disproportionate resources on the last six months of life with no benefit to the patient, as the Dartmouth Atlas of Healthcare has once again noted in its most recent release…until it is our loved one, or the thought of ourselves, at the end of life. “We the People” can quickly see the insanity of paying a Dermatologist three or even four times what a Family Physician or other primary care physician earns for providing the same care that a Family Physician can provide in many cases…until it’s our spouse with a suspicious mole and not the nameless, faceless “other guy.” Again, Why? Because we’ve heard the sound-bites that specialization is better and our personal freedoms demand that we are able to seek out any care at any cost regardless of data that would indicate that there is no difference in outcome. I’d suggest that any argument against that mindset, if not a losing argument, is certainly not an argument that can be won in anything close to the near term. Perhaps more importantly, even if we know the argument to be based in fact, attempting to change public beliefs fostered over decades and lifetimes keeps us from addressing the 600-pound elephant in the middle of the room, an “elephant” that may provide a more immediate result, if we have the courage to look at it.

Earlier, I noted that our system provides the bulk of the rewards to procedures and those who perform them. Until that reward system changes, I believe that we will never find our way out of the quagmire of healthcare financing in this country. It’s easy to say that we need to “value primary care,” but until we equate those words to the need to redistribute the payment provided to physicians they will remain just words. This is dangerous ground to be certain. Physicians have long been conditioned to maintain the “house” of medicine. It is certainly not popular for a physician to suggest that his or her colleague should make less. I suppose then, that it’s a good thing that I forgot to go to medical school because it is my opinion that a system that subjects primary care physicians, those who not only stand on the front-line of healthcare, but also those who coordinate an increasingly complex system for confused patients, to a condition and business model of practice that is not sustainable, while at the same time providing excessive wealth to proceduralists and other sub-specialists, is doomed to fail. Even if you take exception to that belief, I would challenge anyone to argue that there is a more obvious reason why it is so difficult to attract the best medical students to a primary care practice.

With all of that said, I am a realist. I am not suggesting that those physicians whose practice is based on procedures are not providing critical and necessary care. Nor have I lost sight of the fact that those physicians who bring highly specialized skills, acquired through long years of difficult training, deserve to be well compensated. Simply put, it would be unrealistic to suggest that the primary care physician and the neurosurgeon should be compensated at the same level. I am suggesting that the ratio of compensation needs to be brought to a more sustainable level if we truly want to rebuild our primary care infrastructure and provide the access that everyone deserves. We can continue to fight the common enemies. We can continue to advocate for a payment system that is not run by organizations whose primary motivation is their own wealth. However, while we fight those battles, we might want to consider that another solution may be as simple as bringing physician compensation into a more justifiable ratio.

The benchmark of a civilized society is the quality of its justice, and its healthcare.

That’s my opinion.  I’d welcome yours.

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