toon840For those who watch professional football, there is nothing worse than seeing your team’s quarterback blindsided. A quarterback, for those who do not watch football, is the guy who takes the ball from the center and either hands it off to someone else, runs it himself, or passes it to a person down the field. He does this with about 1500 pounds of collective humanity chasing him. Quarterbacks tend to be runty by comparison (Johnny “Mr Football” Manziel, it turns out, is under 6 feet tall and weighs 207 in gym shorts) and when turned to their dominant side cannot see people coming from their other (blind) side. If two 300-pounders meet at the quarterback they can turn a hundred million dollar investment into just another confused short person, especially if the quarterback isn’t expecting it.

Football teams learned that having a good quarterback was good, and good protection was better. Left tackles, the 300-pound dudes who keep the other guys’ 300 pound dudes off the quarterback, have quietly become among the highest paid ball players in the NFL, second only to the quarterbacks. Part of the reason is that the number of 300-pound men who can run fast, have tremendous peripheral vision, are smart enough to understand an NFL playbook,  and can fight off other 300-pound men are few . The other part of the reason is that without one of those dudes, you are paying a confused short person a lot of money to run for his life in front of a lot of empty seats. It wasn’t until players renegotiated the collective bargaining contract and lineman were able to become free agents that the true value of a great left tackle (for a right handed quarterback) was realized.

As Uwe Rheinhart discussed several years back, we have yet to learn the value of left tackles in American medicine. Every medical student wants to be the star who gets to brag about the robotic surgery success in the doctor’s locker room after the game and collect the star’s paycheck (an consequence of our current payment system). Fewer want to be the primary care doctor, who facilitates collaboration, engages in  probing conversations with patients, and takes the myriad of small steps that avoid medical errors. The primary care doctors, the left tackles of medicine, were left behind by the payment structure.

What free agency did for fast, smart, 300-pound guys, health reform might do for primary care. By paying less for bad care (readmissions, excess test utilization) and more for good care (satisfied patients, meeting benchmarks for chronic illness care) Medicare might add value to the primary care visit. While primary care docs will likely never generate over $200 an hour in a fee-for-service world like our surgical and radiologist colleagues do, in the future we will add value to their care by reducing bad care and improving care within the system. By holding the system accountable, everyone working as a team will allow effective care delivery to happen. For some now, for others of us in the near future, more money will flow into systems that deliver better care.

Of course, as a healthcare left tackle, this may just be my fantasy. Some think that left tackles are over-rated. Perhaps we can have the line count 1001, 1002, 1003, 1004, 1005 before they run in. Then everyone could be a quarterback.

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