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Join us for an insightful conversation with emergency physician Drew Remignanti as we explore the complexities of transitioning to Medicare for all. We’ll discuss the potential benefits, pitfalls, and misconceptions surrounding the concept, the importance of primary care physician leadership, and the impact on patient care and cost management.
Drew Remignanti is an emergency physician.
He discusses the KevinMD article, “Medicare for all could work if doctors lead the way.”
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Transcript
Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today, we welcome back Drew Remignanti. He’s an emergency physician. Today’s KevinMD article is titled “Medicare for All Could Work if Doctors Lead the Way.” Drew, welcome back to the show.
Drew Remignanti: Thanks a lot for having me, Kevin. I appreciate it.
Kevin Pho: So let’s jump straight into this most recent article about Medicare for All. Before going into it, just tell us what led you to write it in the first place.
Drew Remignanti: Well, my reflex feeling about Medicare being run by the federal government was one of unease because I don’t really trust them to do it right. You know, CMS—the Centers for Medicare and Medicaid Services—typically, when they do something that affects physicians, they reduce the amount of money they want to give to physicians. This year, I think they’re planning another 2.9 percent decrease in physician pay, which I think is the fifth year in a row they’ve done that. They’ve decided that the way to solve our health care problem is to pay physicians less. So, I started off with a reflex skepticism about Medicare for All as a concept.
Then I read this book by the health care journalist Ken Terry, who goes into a fairly extensive explanation of how it could work. The immediate appeal to me was that he proposed doing it over a 10-year period rather than an overnight fiat. I think as patients, you know, we like the idea—it’s appealing. Gee, if I can get the government to pay for all my health care, then I don’t need to worry, which is true. You won’t have any financial worries. But I don’t think it’s even the right way to start. I think we need to figure out how to do things better between patients and physicians.
Kevin Pho: So tell us the proposal that you have, inspired by reading that book. What would you like to see?
Drew Remignanti: Well, as Mr. Terry recommends, I think we should put physicians in charge of making any transition in terms of how we pay for health care. In the book that I wrote, I promote a patient-physician partnership. We’ve developed a passive role as patients, and the system has sort of encouraged that passive role. I think patients need to become much more active participants in their health care, and I think they need to have a stronger relationship with their primary care physician. I think that’s the key place to start, and we can do that regardless of who’s paying for it. We could start that part right now.
There are plenty of studies that I quote in my book in which patients who have the kind of trusting relationship with their primary care doctor can discuss their concerns and hear what the doctor has to say that might be helpful—not necessarily agreeing with their concerns—and together formulate a diagnostic and treatment plan. Those patients who become better informed, more involved in planning their treatment, are subsequently more adherent to those treatment plans. And here’s an amazing finding in my research: they then have half the mortality rate of people who are less knowledgeable, less engaged, less informed, and less adherent.
That’s a pretty big payoff. You know, if it was a 10 or 15 percent reduction in mortality, you’d say, “Well, that’s interesting.” But a full half? And there’s study after study showing that same reduction in mortality.
Kevin Pho: You talk about strengthening the primary care physician-patient bond. But how is that strengthened bond going to lead to an overhaul in our health care system? It sounds like we’ve been trying to strengthen that bond for decades now, and I talk a lot about this on my podcast about the deterioration of that primary care bond. Assuming we have it, how is that going to lead to complete reform of our health care system?
Drew Remignanti: I think patients need to do that first because they gain immediate benefit from it through the reduction in mortality risk. The system would gain from it ultimately because patients would be seeking out fewer unnecessary treatments. There would be cost reductions because you’d trust your physician who says, “No, you don’t need that particular test.”
I came across some interesting options. Apparently, without even a physician’s order, if you’re anxious enough about it, you can order a total body MRI scan. I think it’s a mere $1,500. And the businesspeople in health care want the physician out of the way so they can appeal to that insecurity and incomplete awareness on the part of patients and say, “Hey, this is a service you need.” There are other online lab services where you can order your own lab tests. But how are you going to know what to order if you don’t have a relationship with your primary care physician?
I think we need to incentivize primary care for both physicians and patients.
Kevin Pho: So how can we get to that point? Like you said, we don’t have that strong bond between patients and primary care physicians, and there’s a shortage of primary care physicians today. What do you propose in order to build up our primary care workforce?
Drew Remignanti: We need to incentivize primary care physicians by literally paying them more and giving them more time to spend with patients. The thing that strengthens the patient-physician relationship is when you don’t feel rushed, like your doctor is trying to get you in and out the door as quickly as possible. I had a friend say to me, “When I go to my doctor, he barely even sits down. He’s talking to me as he comes in the door, and he’s talking to me as he leaves the door.” But an actual face-to-face conversation where I can express my concerns and reservations? There’s no time for it.
I think we need to pay primary care physicians more so they can have a smaller patient panel and spend more time with patients. That’s something that would have to come from above. Insurers and hospital administrators need to take their focus off productivity—how many widgets you’re producing in an hour, how many patients you’re seeing in an hour. The idea that primary care doctors are given 15 or 20 minutes to interact with a patient, hear what they’re trying to say, and explain what they need to hear is totally unrealistic. Yet, it’s become an accepted part of modern health care.
Kevin Pho: How would you get more medical students to be interested in primary care? As you know, when the majority of them graduate, they tend to go into specialty care because of the disparity in pay. They also graduate with hundreds of thousands of dollars of medical school debt. How would you incentivize them to go into primary care?
Drew Remignanti: That has to come from the top down. CMS needs to recognize that the solution to our health care problems is not to pay physicians less—it’s to pay them more, specifically primary care physicians. This shouldn’t involve robbing Peter to pay Paul by taking from one group of physicians to pay another. But I really feel that primary care is probably the most important specialty right now if we’re trying to solve our health care mess.
You’re right—it’s a major hurdle. When I graduated medical school, I had $35,000 in debt, and I thought I was really way underwater. But now, the typical debt is a couple hundred thousand dollars. If you know your pay as a primary care doctor is going to be much smaller than that of a specialist, it’s a natural reaction to choose specialty care.
This has to be mandated from above. And as much as I’m leery and distrustful of the federal government, they’re the only institution in our country with the power to make these changes.
Kevin Pho: If you were in charge of Medicare in this new role, tell us the first things you would do to shift the health care system into your vision.
Drew Remignanti: I just read something today about the new incoming president proposing that the AMA—the American Medical Association—needs to be taken out of the process of determining what physicians get paid. The thing I like about Ken Terry’s book is that he says, no, physicians need to be the ones to lead this forward.
Specialists might balk a bit at the idea of paying primary care doctors so much more, but that’s step number one. I’d probably double their pay overnight. And I’d take away this whole idea of productivity being tied to pay. Health care should be humanized. We’re not talking about socialized medicine, but about individualized, humanized interactions. You can’t achieve that in 15 or 20 minutes, especially with a patient you’ve never met before.
This productivity-driven model—where time is money—is a business concept. But it doesn’t align with quality care. I’d put physicians back in charge of decision-making. It’s like if you’re sending a rocket to Mars—you don’t fire all the aerospace engineers. Yet, in health care, we’ve replaced experienced decision-makers with cost-saving substitutes.
I hate the term “provider.” As someone who has been a patient with a chronic autoimmune disease my entire life, I find it offensive. I’ve never thought of myself as a consumer of medical services. I’m a patient who needs medical services. Similarly, I’ve never considered physicians as providers. This term falsely equates non-physician providers with physicians, undermining the value of medical expertise. It’s a cost-saving effort by dollar-driven decision-makers.
Kevin Pho: How can physicians lead these changes? We’ve been talking about how these reforms need to happen at a grassroots level, but physicians often aren’t in leadership or influential positions. What can they do to position themselves better?
Drew Remignanti: I see this at two levels: societal and individual. Individually, physicians and patients can change their office interactions overnight. For example, as a physician, I could say, “In this office, I’m going to expect you, as my patient, to be knowledgeable about your health conditions. I’ll listen to all your concerns, and we’ll take the time we need to address them together.” On the other hand, patients need to come in with the mindset, “I’m an active participant in this process.”
Of course, this approach may ruffle some feathers. Your office might complain, “Kevin, you’re not seeing enough patients.” But the quality of the interaction matters more.
On a societal level, it has to come from the top. Decision-makers need to understand that non-physicians shouldn’t be practicing medicine and making health care decisions. We’ve let businesspeople take over health care to the point where they’re not even afraid to admit it. In one of my essays, I quote a health care administrator with 30 years of experience who said in a health care business journal, “Patients need primary care, but not necessarily a physician relationship.” She was comfortable putting that in print under her name.
That mindset needs to be reversed. The federal government is probably the only body with the authority to impose those kinds of rules. It’s wishful thinking on my part, but I don’t see any other way to address it.
On the positive side, patients and physicians can change their interactions immediately. A more trusting partnership doesn’t require policy changes. While it’s not an equal partnership, it’s complementary—patients bring their lived experience and symptoms, and physicians bring their expertise and solutions. Together, they can create a meaningful health care journey.
Kevin Pho: We’re talking to Drew Remignanti, an emergency physician. Today’s KevinMD article is titled “Medicare for All Could Work if Doctors Lead the Way.” Drew, let’s end with some take-home messages you want to leave with the KevinMD audience.
Drew Remignanti: As I mentioned earlier, any patient listening should stun their doctor by saying at their next appointment, “I listened to this conversation between Kevin and Drew, and I’m convinced I need to play a more active role in my health care. I’m committed to being more knowledgeable and engaged.” Then, you might need to help your doctor off the floor after they’ve fainted from surprise.
Many of us as physicians are ready to hear that. Of course, some might resist and say, “That’s not your role.” But for the most part, we’re eager for more agile, engaged, and educated patients. You don’t need anyone’s permission to take that step. You can start tomorrow by deciding to be more informed and involved in your health care journey.
Kevin Pho: Drew, thank you so much for sharing your perspective and insight. Thanks again for coming back on the show.
Drew Remignanti: Hey, Kevin, thanks so much for having me.
