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ALEX CHADWICK, host:

This is Day to Day with a story of our times that's one part handsome one part ugly. I'm Alex Chadwick.

ALEX COHEN, host:

I'm Alex Cohen. OK. Here's the part that looks pretty, sort of, cosmetic medicine is becoming much more widely available. Now you can get it in lots of ordinary doctors' offices.

CHADWICK: Here's the ugly part. General practitioners are now practicing Botox techniques because it's getting so much harder for them to make a living the old fashioned way. Rachel Gotbaum reports.

(Soundbite of music)

Ms. SHERYL HINDSMAN: This is the 10-64 NDAG laser. It is used for skin resurfacing. It helps with fine lines and wrinkles, horse eyes.

RACHEL GOTBAUM: Sheryl Hindsman (ph) is demonstrating how to use this laser machine to remove wrinkles and skin blemishes. These beauty services are not being offered in a skin care salon. Hindsman is a nurse at Cape Cod Internal Medicine Associates, a primary care private practice.

Ms. HINDSMAN: Acne scaring.

Unidentified Man: Does it hurt?

Ms. HINDSMAN: It feels like a little pin prick.

GOTBAUM: According to the American Association of Family Physicians more primary care doctors are offering cosmetic services to boost their incomes. While Medicare payments to all doctors have remained stagnant over the years, the cost to run a primary care practice has increased by 20 percent.

Ms. MARY ANN FANNY (Office Manager, Cape Code Internal Medicine Associates): The overhead has just skyrocketed.

GOTBAUM: Mary Ann Fanny (ph) is the Office Manager at the Cape Code Internal Medicine Associates. She attributes much of the increase in costs to the massive amounts of paper work.

Ms. FANNY: We're reimbursed at the lowest rate, yet we are the quote unquote "gatekeepers" which means we have to get prior approval for every x-ray, catscan, MRI, now mammograms are being added in. So all of this falls on the primary care person.

GOTBAUM: The percentage of overhead head expenses for primary care doctors is higher than almost every other medical specialty. Fanny says to make up for the financial shortfalls, these doctors have to see as many patients are possible.

Ms. FANNY: We try real hard in here to give the patients the time that they need. But it does mean that you have to cram more patients in during the day. You have to work longer hours just to keep your head above water.

GOTBAUM: Fanny's husband, Dr. William Fanny has been practicing on Cape Cod for 25 years. He says he's become disillusioned with his profession.

Dr. WILLIAM FANNY (Cape Cod Internal Medicine Associaties): I would not go into primary care if I had it to do again.

GOTBAUM: Why?

Dr. FANNY: Because of my long hours. Because of the poor reimbursement. Because of the loss of satisfaction of patient care.

GOTBAUM: Fanny won't say how much he earns. But primary care doctors make on average about 145 to 185, 000 dollars a year. And most say they have to work a lot harder to maintain that income.

Dr. THOMAS BODENHIEMER (Family Medicine, University of California): We've become a hamster on a hamster wheel.

GOTBAUM: That's Doctor Thomas Bodenhiemer, a professor of family medicine at the University of California at San Francisco. He says primary care doctors are paid to diagnose and treat patients and earn about 60 dollars for a basic office visit. Whereas a specialist who does a colonoscopy makes about 200 dollars for a procedure that takes approximately the same amount of time.

Dr. BODENHIEMER: We've been hamsterized. Seeing patients as fast as possible because we're really reimbursed for quantity not for quality.

GOTBAUM: A primary care doctor who offers Botox treatments can make 600 dollars in one 15 minute sitting.

Dr. JIM COX CHATMAN (Chief Medical Officer, Pro Health Physicians): We're going to have a lot of very good looking people who are very unhealthy.

GOTBAUM: Dr. Jim Cox Chatman is Chief Medical Officer of Pro Health Physicians, the largest primary care private practice in Connecticut.

Dr. CHATMAN: I think that's a distress signal for primary care because these are people who entered into practice with the intention of providing long term care for their patients, and they found that the system rewards procedures more than caring.

GOTBAUM: Each year, Congress must grapple with whether to cut payments to doctors in order to control Medicare costs. Though some doctors have few Medicare patients, the rate set by the federal health insurance plan are adopted by most private insurance plans as well.

Ms. GALE VALENSKY (Former Head of Medicare): Right now the way we pay physicians is the most broken part of the Medicare system.

GOTBAUM: Gale Valensky is former head of Medicare under the first President Bush.

Ms. VALENSKY: To just say, well pay this one group more money, misses the crisis we are heading into. We need to fundamentally change how we reward physicians and reward those physicians who do a good quality job, have good clinical outcomes, and get away from this notion of paying each and every service. We've got to get that better in balance.

GOTBAUM: Instead of cutting Medicare payments this year, Congress gave all doctors a small increase. But Valensky and others say until there is a major overhaul of how doctors are paid in this country, more physicians of all kinds will spend time attending to their patients beauty needs rather than to their health. For NPR News I'm Rachel Gotbaum.

COHEN: Ah, there's nothing like head banging a bit to the Kennedy's Show. Our colleague Madeleine Brand would appreciate this. She is a huge D.K. Fan, but you know what, Madeleine's on vacation. I'm here. So you're stuck with my musical choices. Let's listen to a little Rufus Wainwright.

(Soundbite of song "California")

Mr. RUFUS WAINWRIGHT: (Singing) California. California. It's such a wonder that I think I'll stay.

CHADWICK: You kids, you just don't understand real music and the beauty of a great beach boys harmony.

(Soundbite of song "BeachBoys")

BEACH BOYS: (Singing) I wish they all could be California girls.

COHEN: Speaking of youngens' let's give a little shout out to our California Dreamin' producer Sharen Maragy (ph). She's a little bit of a Tupac fan.

(Soundbite of song "California Knows How to Party")

TUPAC: (Singing) California love.

CHADWICK: There are so many songs about California. We'd like to hear your favorite. Please go to our blog right now. Tell us your favorite California song.

COHEN: And if you're a musician, you can send us your California tribute. We'll air the best songs when our California Dreaming series concludes on Labor Day.

CHADWICK: Get the details at npr.org/daydreaming.

COHEN: That's npr.org/daydreaming.

(Soundbite of song "California Dreamin")

MAMAS AND THE PAPAS: (Singing) California dreaming on such a winter's day. All the leaves are brown. And the sky is grey.

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