May 5, 2022Liked by Merrill Goozner


I can always count on you to cut to the core issue. America’s compensation imbalance between primary care physicians and specialists has been a concern of mine for what seems like forever. As one who played a minor role in bringing DRGs to New Jersey in the late ‘70s, I had high hopes that Dr. William Hsaio’s Resource Based Relative Value Scale – incorporated into Medicare Part B in 1989 - would do for physician practice what DRGs had done for hospital care. Boy, was I wrong!

DRGs had an immediate and lasting impact on hospital care. By paying on a per-case basis, hospitals now had to find ways to deliver care in a more cost-effective manner. Although we were accused of forcing hospitals to discharge patients “quicker and sicker,” the opposite proved true.

Here’s just one example. In the mid-80s, I was working with one of the RWJBarnabas Health flagship hospitals (Hint: It’s been Leapfrog “A” since those ratings began). One of the DRGs we tackled was hip replacement, with an average LOS of 18.5 days. In 1994, my then 53-year-old wife had a right hip replacement with a four-day LOS. Last month, my now 81-year-old wife had that implant replaced successfully. Surgery began at 3:00 pm Monday afternoon. She was discharged to home at noon on Wednesday.

It’s disturbing that the same folks who rail against “socialized medicine” use their guilds to preserve the specialist/primary care income gap. The oft-maligned National Health Service does it better: a patient can’t see a “consultant” without a referral from a PCP. We love watching “Doc Martin!”


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The focus on fees and reimbursement is the distortion of medicine brought when financial capital descended upon health care and transformed it into the neoliberal enterprise of the Medical Services Industrial Complex. From care to reimbursable services. The AMA, dominated by specialty interests, made the deal with the devil and facilitated the regulatory capture of CMS and set out on an aggressive monopolistic campaign which set the framework for a new industry with no effective regulation. The current system is working perfectly as designed. It cannot be reformed incrementally, only dismantled and reconstructed from the ground up based on the heath needs of the population, not the greed of a parasitic industry. Ric Winstead, MD Family Medicine, Retired.

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