Let me offer the following propositions as postulates. They are unprovable but self-evident.

1. Primary care (including family medicine, internal medicine and pediatrics, and the nurses, nurse practitioners and physician assistants we supervise) is the force that holds health care together worldwide.¹ Try to imagine the most tolerant of your specialist colleagues dealing with the worried well, the demanding executives and the crying babies you manage daily. You can't. They are absolutely dependent on us. In contrast, we can always find a specialist.

2. The supply of primary care physicians is dwindling because of purely economic factors. If you are temperamentally suited and well trained, the long-term relationships of primary care can be professionally and emotionally satisfying. But the reimbursement differential with the specialties is so large that fewer medical students are signing up for primary care,² and we can't blame them.

3. The economic differentials are established and maintained by the congressionally mandated Centers for Medicare & Medicaid Services, which established the Resource-Based Relative Value Scale, which is updated by the AMA's Relative Value Scale Update Committee (RUC), which essentially sets Medicare's relative value units, which determines payment rates. The RUC has always been dominated by procedural specialists, and there is no change in sight. Many private insurers have adopted the path of least resistance and base their fee schedules on the work of this self-serving committee.

4. Primary care will slowly strangle under the present paradigm – no matter how effectively we reinvent ourselves – because the RUC is not interested in, much less impressed by, our reinvention.

So what are we to do?

If these four postulates are correct, we'd better spend some time thinking outside the box. Here's a start:

Scroll back to August of 1996. Bill Clinton was our president, elected on the promise (among others) to rein in “fraud and abuse” in health care. By that he meant Medicare, of course, because that was the area of health care on which he could bring the big guns of politically appointed federal prosecutors to bear.

We now think of the Health Insurance Portability and Accountability Act as a privacy statute. But in 1996, HIPAA (then known popularly as Kennedy-Kassebaum) was notable for its sharp teeth. For the first time, a physician could be prosecuted criminally for fraud. That meant jail, not refunds.

Some time in 1997 I saw a Medicare patient complaining of chest pain. I administered a treadmill in the office and found ST depressions characteristic of ischemia. She was referred to a cardiologist, who found significant stenosis on catheterization. He in turn referred her to a cardiothoracic surgeon, who performed a successful bypass.

A couple of months later I got a letter from Medicare asserting that my treadmill was unnecessary. I appealed, sending as evidence the reports of my consultants. My appeal was denied, and I refunded the money to Medicare. It was cheaper than hiring a lawyer.

Then I became acquainted with the felony provisions of Kennedy-Kassebaum. They were crystal clear, though buried in 150,000 pages of Medicare regulations. Had my patient suffered injury during my “unnecessary” treadmill, I could have lost my license and gone to jail.

Not long after, federal agents swept into the office of a family physician down the road, confiscating all of her office records. Although she was found innocent of wrongdoing, I imagine she had some difficulty getting her reputation back.

That was enough for me. I resigned from Medicare – and therefore Medicaid and CHAMPUS (now TRICARE). It was a package deal.

The authors of HIPAA thought the threat of losing the ability to participate in federal programs was a terrifying prospect for physicians. And, in fact, it is for some physicians – specialists.

It took me awhile to get the picture. The feds thought they had me over a barrel. In exchange for a reimbursement level that barely covered my overhead, given the complexity of problems with aging patients, they retained the privilege of tossing me in the clink if I screwed up. What a deal!

I hated to part company with my older patients, many of whom were friends. About a quarter continued to see me, paying cash for their office visits under the private contract provisions of HIPAA. (Their labs, X-rays, procedures, consultations and hospitalizations were still eligible for Medicare reimbursement.) I also decided to provide charity care for a few who really needed it. As for the others – well, I found out how much they valued a “medical home.” My services would have cost them fifty or a hundred bucks a year over what they would have paid under Medicare, but they moved on.

So I lost some patients who didn't think my work was worth much, and my bottom line took an immediate jump to the north thanks to less red tape and more room in my schedule for patients with better-paying plans.

It certainly makes you wonder: What would happen if primary care resigned from Medicare?