As part of a new series, Mission Loc@l will take advantage of the intelligence in the neighborhood.

Dr. Thomas Bodenheimer, currently an adjunct professor of Family and Community Medicine at the University of California, San Francisco and co-director of UCSF’s Center for Primary Care, is a general internist who received his medical degree at Harvard and completed his residency at UCSF.

Dr. Thomas Bodenheimer (Sara Syer)

He spent 32 years in primary care practice in San Francisco’s Mission District — 10 years in community health centers and 22 years in private practice in the Mission District. If you would like to read Dr.  Bodenheimer’s most recent piece in the New England Journal of Medicine on the crisis in primary health care, it is here.

Mission Loc@l was tempted to abbreviate Dr. Bodenheimer to Dr. Tom and was sure his patients must have done the same, but he explained that his largely Latino patients refused to give in to such informality. “I couldn’t convince them to call me Dr. Tom or just Tom,” he says.

ML: You’ve written extensively about the crisis in primary care physicians with the widening gap in income disparity that discourages medical students from going into primary care. How does this relate to a neighborhood like the Mission District?

Dr. Bodenheimer: “Only 7 percent of students graduating from U.S. medical schools choose primary care careers. That means we will have a growing shortage of doctors who can be your regular physician or family doctor. In the Mission District, the community clinics, for example Mission Neighborhood Health Center, Castro Mission Health Center, Family Health Center at San Francisco General, and the St. Luke’s Neighborhood Clinic, do not have enough primary care doctors to care for all the patients who need primary care. The same is true for private doctor offices at St. Luke’s Hospital, Los Portales or other places in the Mission District. That means that it will be hard to find a personal physician and it will be hard to get an appointment if you already have a personal physician.

ML: Do you see anything encouraging in the reform legislation that will address the issue of the crisis in primary care?

Dr. Bodenheimer: “Most people in Congress are now aware that there is a crisis in primary care. President Obama has stated that there is a serious shortage of primary care doctors. There is a lot of talk about trying to fix the problem by paying primary care doctors more, by forgiving medical school loans to medical students who go into primary care in underserved areas, and by helping primary care practices to function in a more patient-friendly way. Like all of health care reform, we have no idea what will happen in the next few months. Our group at the Department of Family and Community Medicine at San Francisco General Hospital has done a lot of education of people in Congress and we hope that will pay off with some good legislation.”

ML: This week there has been some indication that the public option may not make it into a final bill. We’re trying to explain to our readers why this may or may not be important.

Dr. Bodenheimer: “As we all know, insurance company premiums (the amount of money that we or our employers pay for health insurance) have been rising at a very rapid rate, making it impossible for many of us and our employers to afford health insurance. At the same time, insurance companies are making large profits. A public insurance company could keep down the cost of health insurance because it does not need to make profits or to satisfy stockholders the way the private insurance companies do. So, with more affordable health insurance, the public option would put a lot of pressure on private companies to keep their costs down in order to keep their customers.”

ML: The two elements of health policy reform that Congress agreed on by the end of the summer were:

1. Reforming insurance underwriting so that insurance companies cannot exclude clients based on previous conditions, and 2. Providing some subsidy so that people can afford insurance.”

Why is a public option necessary if insurance is available to all?

Dr. Bodenheimer: “There will not be enough money to provide adequate subsidies to people or employers who need or want to buy health insurance because the insurance premiums are so high and rising fast. The public option has the potential to reduce the cost of a health insurance plan, and to reduce the growth rate of health insurance premiums. Without the public option, insurance premiums will be so high that people won’t be able to afford health insurance with the inadequate subsidies that are likely to be offered by the government.”

ML: Does having a public option change the outlook for attracting primary care physicians?

Dr. Bodenheimer: “The public option will not have any effect on the crisis in primary care unless the public option insurer breaks with Medicare and private insurers and reduces the overpayments to many specialists and uses those savings to pay more to primary care practices.”

ML: What would you recommend supporters of health care reform do to participate in the debate?

Dr. Bodenheimer: “For people in San Francisco, the most important thing to do is to pressure Sen. Dianne Feinstein to support the public option and to support high levels of government subsidies for low-income people to obtain health insurance. Sen. Feinstein is very wishy-washy and cannot be counted on to support President Obama’s health care policies. It is especially important for senior citizens to support Obama, because seniors are the most skeptical about Obama’s health care proposals; they worry that the Medicare program will reduce its benefits, which is not true.

Dr. Bodenheimer is also co-author of Improving Primary Care: Strategies and Tools for a Better Practice, and the health policy textbook Understanding Health Policy (fifth edition). He has contributed numerous health policy articles to The New England Journal of Medicine, JAMA and Annals of Internal Medicine. A list of his articles and publications can be found here.

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I’ve been a Mission resident since 1998 and a professor emeritus at Berkeley’s J-school since 2019 when I retired. I got my start in newspapers at the Albuquerque Tribune in the city where I was born and raised. Like many local news outlets, The Tribune no longer exists. I left daily newspapers after working at The New York Times for the business, foreign and city desks. Lucky for all of us, it is still there.

As an old friend once pointed out, local has long been in my bones. My Master’s Project at Columbia, later published in New York Magazine, was on New York City’s experiment in community boards.

Right now I'm trying to figure out how you make that long-held interest in local news sustainable. The answer continues to elude me.

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  1. You’ve identified why primary care doctors are being paid a pittance, but your solution is the same mistake taken into a different direction.

    Specialists are overpaid by a system that had no real market based input to determine the correct price for a service. Insurance companies and the government “set” rates. How did those rates get to what they are? If the free market was allowed to function, prices for all goods and services would be determined by the laws of supply and demand, not a bunch of bureaucrats in some office.

    Your mistake is to keep looking to the insurance industry and government – a third party payer – to do what the free market can only do. You are asking them to pay you more and someone else less. How much more and how much less?

    The solution is to scrap insurance. Put the doctor and patient back together to arrive at a fair price for services rendered. This is the wrong place to explain why only eliminating insurance will fix health care costs, but it is the only solution that will work.

    Just think how many people in the insurance industry get their pay checks as part of the overall cost of “health care” and it should be obvious that these people have absolutely nothing to do in providing health care, but everything to do with driving up its cost.

    Please look at this situation logically and you can only conclude that insurance is the problem and not the solution.

  2. Thanks to Dr. Bodenheimer for a clear and concise review of the situation with respect to health care reform. Would that our policymakers, politicians and msm reporters could be half as clear (but then they wouldn’t be on insurance company payrolls).

    And with all due respect Bill, I think it is the idea of making health care services another commodity to be bought and sold got us into this mess in the first place.

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