01/03/2012 07:06 EST | Updated 02/28/2012 05:12 EST

Why You Can't Get in to See Your Family Doctor


My family doctor, Dr. Kramer, emigrated to the U.S. from Canada years ago. He has just installed an Electronic Medical Record (EMR) and qualified easily for meaningful use stimulus funds because he takes Medicaid patients. To qualify for meaningful use -- which means using the technology in ways that can be measured significantly in quality and in quantity -- under Medicaid, all you have to do is order the EMR; it doesn't even have to be up and running.

Medicare is more rigid; outcomes must be reported. To report on outcomes, Dr. Kramer had to buy another module of the EMR, probably because the EMR he bought was developed before the meaningful use standard or the stimulus money. In his opinion, it will be difficult to report significant outcomes for Medicare and Medicaid patients, because they often don't stay in his practice long enough. They move, they change insurance, they drop off Medicaid into the ranks of the uninsured.

People in the U.S. no longer stay with a medical practice long enough for longitudinal study -- which is why all our EMRs have to talk to each other and we have to track patients as they move from provider to provider.

As part of a wide-ranging discussion on the state of health care in America, Dr. Kramer told me a little about his experience and that of his family in Canada. He says America does not look at Canadian health care from the right perspective. We think it's great that Canadians have universal health care, but we don't understand what that means.

When he practiced in Montreal, and today, primary care docs were capped at a certain number of billable dollars and patients a month. After he hit the cap, which he did very early in every month, he was only paid 25 per cent of what he billed. His colleagues would limit the number of patients they saw a day to about 20, so they hit the cap at the end of the month.

Dr. Kramer liked to see 30-40 patients a day, so he would hit the cap way before the end of the month, and he wanted to continue to see patients because he enjoyed them. But he finally figured out that it cost him 35 per cent of what he billed to run his practice, so it didn't pay for him to see more patients. He left Canada.

In Canada, the untold story is that although they are insured, 300,000 people are without a primary care doctor, because no matter how many doctors there are, it won't be enough if they have to limit the number of appointments they can grant a month. He told me that's why people in Canada, including his own mother, have to wait two months for an appointment with a family doctor unless it's a real emergency.

I knew that was true of specialists, but I had never heard it about primary care scarcity before. Canadians also pay out of pocket for things like camp physicals; there's a chart of services and costs on the wall of the doctor's office that tells patients what the government doesn't pay for, and what the cost to them will be.

Dr. Kramer loves America because in his own practice he can now happily afford to see 30-40 patients a day. And unlike many family doctors, he continues to see Medicaid patients, even though they pay less, because they are interesting cases. That energizes him; he has problems he can solve.

But he watches the younger docs go on salary and limit themselves to 20 patients a day at places like the Mayo Clinic, and it worries him for the future of American health care. Dr. Kramer admits that it's a great improvement in the physician's quality of life, but he predicts a huge upcoming shortage of doctors as American docs go on a system more similar to that of Canada, and begin limiting the number of patients they see daily because they are no longer incentivized to see more.