Health Care Policy and The Student Doctor: Gary LeRoy, MD

An SDN interview with family medicine leader, Gary LeRoy, MD.

SDN: Gary, your resume is pretty awesome. You currently hold the position of Medical Director of the East Dayton Health Center, a community health center with federally qualified health center status; and you are simultaneously Associate Dean for Student Affairs and Admissions at Wright State University’s Boonshoft School of Medicine in Dayton, Ohio.
Yours is a unique position, with major responsibilities in a community health center serving the disadvantaged, and as the dean of students for a medical school, which will include lots of students from more privileged backgrounds. 
From the perspective of these two different worlds, what do you see as the major healthcare issues that medical students should be considering?

GL: Sometimes students look at the world from the perspective that they are familiar with and grew up in; and get some degree of culture shock when they come across patients who do not think like they think nor share their world-view. Most students do not know what it is like to live in poverty and see health care as a luxury of life instead of a commodity that is always available to their household.
I see three issues of major importance – all inter-related. The first is that we are approaching a majority of persons in this country that simply cannot afford health care – at least with its current cost structure. Second, the aging of the population will place far more demands on the healthcare system than anyone seems to planning for. Third, we as a society are under-investing in primary and preventive care. A lot of people believe that the answer is political – simply elect the right people to run the government, have them mandate universal insurance coverage for everybody and the problem will go away. I think that is an illusion.

SDN: How so? Why wouldn’t universal health coverage work?

GL: It might work with fundamental system reform, and some of the proponents of universal health coverage include the idea of a single payer system of a kind that might wipe out whole industries. I personally don’t think our political structure will produce THAT type of change. But I do think some kinds of changes will come, and perhaps quite rapidly.
Even if you give people full access to care with our current system, it has be appropriate access. It is inappropriate for emergency rooms to be dealing with most primary care problems, and it would inappropriate access to care for a person with a stomach ache to show up at the office of a gastroenterologist as the first point of contact. What we have to address as a nation is a bottom up approach where primary care is the anchor of a health care system dedicated to providing quality health care for all.

SDN: What kind of changes do you foresee, and what should medical students be thinking about?

GL: I think there are parts of the health care cost structure one can think of as a bubble. We have the example of what happened to the technology sector at the beginning of this decade. Students were in computer sciences curricula dreaming of their high incomes. A lot of computer science graduates ended up bitterly disappointed. This isn’t to say there is not a lot of money in technology, but those who made it often had to work much harder than they thought they would, and some found the high salaries were not the cinch they thought they would be.
Students have to aware that modern medicine is constantly changed by innovations in technology, pharmaceuticals, and evidence-based changes in standards of care. Students could choose a specialty that is technologically lucrative and relevant at this time, but changes in community standards of care may limit the numbers of subspecialists needed in that field.

SDN: You advise medical students. How do you suggest that they prepare for the kind of systemic change that you see?

GL: First, to be very suspicious of the idea that you make specialty choices on the basis of perceived income or “lifestyle” of the specialty. Of course, if a specialty attracts you because you really like doing what that specialty does, you should pursue it. But, if you are thinking that this is a good specialty for you, because you will have a high income for a 40 hour work week or less, and can pay off your student loans rapidly, you could find out this is as much a bubble as the dot.com industry experienced (and more recently mortgage banking and investment banking) and that neither that super-high income nor the easy lifestyle will materialize for you.
If medical students know that a specialty gets high remuneration for not that much work, everyone else knows it too, and that can be perilous when everyone in a society is trying to figure out how to rein in health care costs.

SDN: But aren’t physician salaries determined by the marketplace?

GL: Not the kind of marketplace you learned about in economic classes. Our system is neither a planned system, nor a market-based system. Basically, it is a group of arbitrary pronouncements that prices will be set a particular level, and more often than not it is simply a group of physicians that has recommended what those price levels should be to some government entity that can agree with them, or do something else entirely.
If your income is based to a large extent on an arbitrary policy that can be changed more or less at will, I think that should give you pause. Probably, the most important health care financing agency is Medicare. When it sets a pricing policy, the rest of the system follows, often very rapidly. As an example, when it developed “diagnostic related groups” in the 1980s, it completely changed the ways that hospitals were reimbursed, and created great pain for many institutions.

SDN: Do you think Medicare might impact the incomes of sub-specialists?

GL: All projections of Medicare is that there is not enough money in the future to handle the aging of the population without significant change in the budget, either through increased revenues, decreased benefits or decreased costs in the current system. I don’t see much change in the benefit structure, nor a vast increase in revenues. These changes would require a consensus in our national politics. I do see Medicare changing rules of how it reimburses physicians and hospitals, and I would not be surprised to see a Congressional mandate that it do so. It will have to find a lot of cuts to keep the budgets reasonably balanced. The low-hanging fruit of those could well be those physician services where medical students see high incomes for comparatively little work.
The deepest cuts are very unlikely to occur with the primary care specialties, in part because that’s not where the money is, and because Medicare and other health agencies are understanding that the primary care infrastructure needs attention and infusion of more resources. The major studies of the cost-effectiveness of health care expenditures, all tend to highlight the value of preventive services, early treatment of acute illness, and comprehensive and continuous approaches to chronic disease. All of that is the arena of primary care.

SDN: What do you advise medical students to do?

GL: One of the lessons of economics is that if there is manifest need, and previous underinvestment in resources, that could very well be an area in which to expect rising incomes and other positive changes. I think there are several things that favor choices in the primary care specialties right now – especially family medicine, but also general pediatrics and general internal medicine as well.

SDN: The primary care specialties in the United States have had lower remuneration that such specialties as, say, radiology, orthopedics, anesthesiology, dermatology and surgery. Why should your student advisees consider primary care?

GL: If you think in terms of lifetime instead of annual earnings, even in our current system primary care does better than when you compare the average annual remuneration of physicians in established practices by specialty.
Remember, you still can become board-certified in family medicine after three years of residency, and can negotiate a pretty decent beginning income in a group practice. General internists and pediatricians also can be in established practices while their sub-specialty colleagues that entered residency at the same time still have years of residency ahead of them. Opportunities exist for primary care physicians throughout the nation, some enhancing the income with loan repayment.
What is more, some of the specialties that you might have several extra years to be able to enter, may turn out to be vulnerable to revenue decreases through technological innovations (since pharmaceutical and medical equipment manufacturers are always seeking to develop products that change the way care is provided), changes in reimbursement policies of such third payers as governments and insurance companies, or simply because too many of a given specialist are being produced not to affect the marketplace for that kind of a physician..

SDN: But isn’t the knowledge base required for primary care pretty bewildering, if someone wants to do it well?

GL: Primary care is intellectually challenging, but that is why it always has attracted a portion of the brightest medical students. I find family medicine very rewarding, and always have. However, this is an especially wonderful time to choose primary care, because the technology of being a primary care physician is advancing along with the rest of medicine. The electronic medical record permits the effective incorporation of chronic disease management and quality assurance guidelines into primary care practice. Practices are being transformed in other ways, to enhance the relationship between physician and the persons for whom he or she cares.
In quite a few medical schools and teaching hospitals, the faculties seem to believe the world revolves around the practices of the referral specialists. But that simply is not how the world works. Primary care practices tend to be one of the most important businesses in any neighborhood. When you are in medical school or in residency at an academic medical center, there may be little understanding of how much respect you have as one of your community’s local primary care physicians and how professionally satisfying are the long term relationships you develop with your patients. When you leave the teaching hospital and academic medical center, you find that in most communities there is a great respect and comfortable working relationship between the community’s primary care physicians and the subspecialty colleagues to whom they refer and with whom they collaborate.
For several years, a majority of medical students have chosen to enter the referral specialties. As a result, if you are a medical student with good clinical skills, you may find that some of the most prestigious of the primary care residency programs may be willing to interview you.

SDN: What is it like to be a family physician in an Internet age?

GL: Well, it’s fun. It helps in relating to people. Of course, some of my patients are not as Internet-savvy as others and some just want me to do something to make them feel better. Other patients have self-analyzed their symptoms, surfed the Internet, and come to me as their coordinator of care with pages of information.
There is a consensus emerging that people need a “medical home”. In my view, the primary care physician’s office has been the gold standard for the medical home in every part of the world., and the past 40 years we have seen an extraordinary enrichment of the primary care infrastructure, principles and practices in this country. I see these primary care improvements as becoming increasingly valued over the next few years.
Many of the primary care practices are already set up to use Internet extensively, including asymmetrical communications such as e-mail, and even are set up for patients scheduling their appointments by computer. This can help keep patients out of emergency rooms, when they should not be there, which is good for the whole society. For Internet-savvy patients collaborating with a primary care physician, it can help in the patient receiving comprehensive and continuous health care.

SDN: Is the Internet not a mixed blessing?

GL: The downside I see is one that is analogous to pharmaceutical advertising on TV.

SDN: How so?

GL: Most patients who need any kind of physician intervention have conditions that are appropriately managed at the primary care levels, and, except in a true emergency situation, those that need sub-specialty consultation or treatment are best identified by a primary care specialist. Television (and Internet) advertising helps promote the idea of the general public working directly with referral specialists. There is a current advertisement that suggests that you “consult your rheumatologist”. In fact, if the referral specialists had to handle any significant part of the primary care workload, it would erode their effectiveness as referral specialists. It is in the referral specialists’ interest also to promote the re-invigoration of the primary care system.
In fact, almost everyone, whether they are rich or poor, working class, professional or retired, should have a personal physician to help them navigate the health care system and to provide them or assist them in getting whatever services they need to meet their health care needs. It is very heartening for me to be the personal physician for whole families, as well as individuals. It is a great career choice in medicine, and one that will be ever more relevant, regardless of what changes occur in medicine.