Thanks to everyone for your interest and involvement in the primary care issue. All the best to you all. John Geyman

Yes, Wendell. That is our challenge and task ahead. We have succeeded with big movements in our past, such as womens’ suffrage and civil rights, so we can do this too!

I hope so, but it really is a large part of the 99 percent that are hurting in our present health care system. It takes more than $19,000 for a family of four to pay for insurance and health care; that out of a median family income of $50,000 is more than a hardship, and many are increasingly delaying or foregoing care.

Yes, though I’m shamed to admit it, I was a Republican until about 12 years ago, when I finally realized what that meant, just a slow learner!

Yes, the training of more nurse practitioners and physician assistants are part of rebuilding primary care, with emphasis on team practice. But presently a majority of graduates of those programs go into specialty practice, where they find higher compensation. So both of those groups have much the same problem as physicians in opting for primary care.

ACOs will most likely make even more money for those in charge, whether expanded hospital systems or consolidated insurers with groups of physicians. There will be many opportunities to chase the dollar by cutting costs, limiting choice and services, and gaming the new system; some will be able to keep some of the “savings” that they make.ACO’s will try to avoid the sickest patients and game risk adjustment and quality measures, and our methods of measuring risks and quality are not up the task of preventing these games.

Yes, both are good books, and more preventive care is not necessarily better.It can, of course, be very important, but it can lead to more testing and increased costs if tests are false-positive. And testing can be overdone when it doesn’t have supporting clinical evidence (e.g. PSAs over age 75, or a great example, full-body CT scans on a fishing trip for a problem in asymptomatic people.

Yes, all big problems,and aren’t we tired of being so “exceptional” compared to other advanced countries—such an ill-informed and arrogant view.

Yes, that’s another part of the whole matter of increasing health care costs in a market-based system. As I’m going into this subject in my market book, one strategy supported by vested interests is to medicalize more of health care, including redefining the range of normal; statins and cholesterol level a good example, the lower threshold of “normal” greatly expanded statin markets.

Yes, the insurance industry becomes even more of a barrier to health care reform as a result of the PPACA. Insurers are getting even more powerful through mergers,consolidation and diversification. They are going head to head with hospitals in organizing networks of physicians, and will become more involved in the actual delivery of care, including more market clout to negotiate prices in their own interest.

Yes, this is what we are doing.

Yes, an approach to training more primary care physicians is in the book, including changing how physicians are paid, how medical education is financed, setting a specialist-generalist goal (such as 50:5)), redesigning primary care with greater emphasis on team training, and establishing primary care departments in medical schools. All with a greater investment in primary care and revision of present reimbursement systems.

Yes, I can! If in doubt, just follow the money.

I wish we could clone 100,000 of your grandfather! Yes, student debt is a big problem these days: medical school graduates average more than $125,000 in debt from many schools; we need more government assist with loan repayment, especially for those graduates headed for primary care. And the malpractice insurance costs could likewise be helped—that’s a complicated area,and its costs of total health care spending is actually exaggerated: it’s no more than about 3 percent of health care costs.

That’s the $64 question! We need a movement across the country. Perhaps the movement for national health insurance can become part of the 99 percent movement as it sorts out in coming months and years. Michael Moore offered a ten-point agenda several days ago, which I think is great; national health insurance is #7 on that proposal. My Hijacked book has more detail on that question.

Yes, the public sector is greatly underfunded, and our safety net falls apart more every year. Now only 42 percent of the 350-plus acute care visits in the country are to personal physicians; 29 percent are to ERs and 20 percent are to specialists. Access to real primary care is becoming the exception, and ER docs are having more and more difficulty in arranging ongoing care for their patients. We have enough money in the overall system, we just need to reorganize the system, get health care more on a service ethic and re-allocate where the money goes. A big political challenge!

Yes, they have overwhelmingly migrated to the non-primary care specialties. We have less than 30 percent of our physician workforce in the three primary care specialties of family medicine, general internal medicine and general pediatrics, many are nearing retirement age, and they are not being replaced.Moreover, many physicians are now in part-time practice.

No, Wendell. There wasn’t a lot to do with primary care in the 20 pound, 2000-plus page bill. Some provisions that fall way short of the needs, however, include more funding for the National Health Service Corps and community health centers, as well as a 10 percent bonus for primary care physicians (for just two years!).

Yes, all true. One more new twist is the feeding frenzy we are seeing among hospitals, insurers and physician group practices in preparation for the accountable care organizations (ACOs) called for in last year’s health care “reform” bill. As one example, reported today in a St. Louis paper: a 3 minute visit to dermatologist for a wart cost the patient $538, including a facility fee at the dermatologist’s office: sign of things to come!

Thanks a lot!