Move over, Ozzie and Harriett.

In the heat of battle over health care, Marcus Welby, M.D., has replaced the Nelsons as the TV character most frequently invoked to conjure up a kinder, gentler time.

Richard Hannon, a senior vice president at Blue Cross Blue Shield of Arizona, uses the TV doc in a piece on the demise of the kind of family doctor Welby defined in the 1970s. It started with something that looked quite promising at the time:

In the mid-’60s, I remember my father-in-law, a real-life Dr. Welby, telling me the exciting news that the federal government was going to start paying him to see seniors-patients who before he had seen for the proverbial chicken (or nothing at all). That fabulous deal was Medicare.  

Medicare introduced a whole new dynamic in the delivery of health care. Gone were the days when physicians were paid based on the value of their services. With payment coming directly from Medicare and the federal government, patients who used to pay the bill themselves no longer cared about the cost of services.

Medicare costs skyrocketed, and to meet the crisis Medicare in 1992 began using a new formula to determine physician pay. It was the “resource based relative value system” (RBRVS), which rated doctors based on such factors as education, effort and specialized training.  Outcome, severity of the condition, or demand weren’t considered. This is the system used today, and it benefits specialists but isn’t so good for family physicians.

The primary care doctor has had to rely on patient volume, and with this enjoyed less satisfaction and income. In an era when government is moving more and more into medical decisions, it may be good to reflect on what happened to the family doctor:

So who really killed primary care? The idea that a centrally planned system with the right formulas and lots of data could replace the art of practicing medicine; that the human dynamics of market demand and the patient-physician relationship could be ignored. Politicians and mathematicians in ivory towers have placed primary care last in line for respect, resources and prestige-and we all paid an enormous price.

We are headed for even more centralization.