President Obama has made an astonishing discovery: We’re not producing enough primary care doctors, he recently told Congress. Although this may be news to the president’s minions, physician groups, legislators, insurers, and patients are all well aware of the dearth of generalists. Just ask anyone whose GP has retired how long it takes to find a willing and skilled replacement.
With as much opposition to increasing the pool of primary care physicians as there is to motherhood and apple pie, the devil is in the monetary details of how to incentivize all varieties of doctors to stay in the game. On the heels of President Obama’s $787 billion stimulus bill and a federal budget-busting $1.75 trillion deficit, significant financial incentives to lure medical students into generalist careers, and higher reimbursement to keep generalists in practice, are hard for Congress to justify. Nevertheless, Senate Finance Committee Chairman Max Baucus (D-MT) said that because Medicare payments were skewed against primary care doctors, he will push for an immediate 5% increase in Medicare reimbursement for office visits and other primary care services, without saying exactly where the money’s going to come from.
Joseph Stubbs, MD, an internist and 2009-2010 president of the American College of Physicians (ACP), argued that the compensation gap between primary care doctors and specialists is significant and that, by the end of five years, generalists should be paid 80 to 85 percent of what specialists earn. He said, Something’s got to be done, because we face an imminent critical shortage of PCPs [primary care physicians], but we don’t want to take anything away from specialists. That’s the tricky part. Can anyone figure out how to pay generalists more without paying specialists less? Budget neutrality is the issue here. In essence, budget neutrality robs Peter (the specialists) to pay Paul (the PCPs). The Medicare Payment Advisory Commission has recommended budget neutrality with an increase of up to 10% for PCP services, suggesting that Congress pay for it by reducing payments to specialists.
-Joseph Stubbs, MD
Dr. Stubbs pointed out that the alternative to chopping specialists’ pay may lie in practicing more efficient and effective medicine. The ACP strongly backs the Patient-Centered Medical Home (PCMH) model, currently being tested in national pilot projects, in which primary care practices are reimbursed for care coordination and referrals to specialists, and have strong incentives to implement electronic health records. The desired outcome is medicine’s holy grail-better outcomes and lower costs. Although the PCMH pilots just rolled out this year, Dr. Stubbs admitted that Centers for Medicare and Medicaid Services funding of more than 100 other demonstration projects with similar goals in the past few years has not uncovered many models (Geisinger Health System excepted) that both improve care and reduce costs. Yet he is hopeful that the PCMH model will do both.
Although a boost to Medicare rates would help ease the pain, there are other factors thinning the PCP ranks. Massachusetts, with its mandated health insurance coverage, is losing PCPs at a rapid clip just as more people are getting insurance. In the Massachusetts Medical Society’s 2008 report on its physician workforce, there wasn’t much encouraging news. An aging physician workforce (one-third are over age 55), a 3.5% increase in practice costs and a 5.3% jump in malpractice insurance rates, 12 of 18 surveyed specialties in short supply (otolaryngology-head and neck surgery wasn’t one of them), and 52% of medical residents leaving the state after completing their training compound the problem. Former Society President Bruce Auerbach, MD, concluded, We need more medical student slots and medical residency slots. We need payment reform to do things to encourage people to go into the primary care field.
Beyond Simplistic Solutions
Otolargyngologists-head and neck surgeons are in the vanguard of physicians offering insights and solutions to the PCP shortage beyond the zero-sum game. David Nielsen, MD, CEO and Executive Vice President of the American Association of Otolaryngology-Head and Neck Surgery, recently represented the Council of Medical Specialty Societies at a meeting in Washington intended to build consensus among major stakeholders on how best to solve the PCP shortage. Everyone believes primary care is in crisis and increasing their payments needs to be done, he said. But there’s also a crisis in the shortage of general and specialist surgeons as well as surgical emergency room coverage, and a budget-neutral solution may not be wise.
According to Dr. Nielsen, the group took aim at current incentives to practice inefficiently, such as defensive medicine, including tests, imaging, and medications that aren’t expedient and don’t improve outcomes; and some patients who demand unnecessary tests or treatments, such as the mother who requests (an unnecessary) prescription for antibiotics for her child’s otitis media, operating under the treat me because I’m paying you mentality. With so much pressure to keep revenues up, doctors often don’t have enough time to discuss treatment options adequately, he said. Citing the example of women preferring repeat Caesarean sections for convenience rather than medical necessity, he added that some patients have made up their minds about treatment and it’s harder for doctors to challenge their demands and take time to explore all treatment options and evidence-based clinical recommendations with them.
Mark Richardson, MD, Chairman of the Department of Otolaryngology-Head and Neck Surgery and Dean of Oregon Health and Science University School of Medicine, said that Congress will have to find cost savings in the health care system, but doing it at the expense of specialists will not succeed. The idea of budget neutrality has inflamed the specialty societies, he said. He pointed out that one solution to augmenting the PCP ranks is taking place by increasing the number of osteopathic physicians. Dr. Richardson suggests that DOs represent a substantial pool of primary care doctors, and that their training may make them more amenable than graduates of allopathic medical schools to careers in primary care.
-Mark Richardson, MD
A 2007-2008 survey of graduating seniors by the American Association of Colleges of Osteopathic Medicine bears him out. The percentage of 2000-2001 through 2007-2008 osteopathic graduates planning to specialize in general internal medicine, family practice, and general pediatrics increased by 2.7% among 2000-2001 graduates and 7.2% for the most recent graduating class. Osteopathic school graduates are more likely than allopathic graduates to embrace a career in primary care; one-third do so, versus one-fifth of their allopathic medical school peers. In the 2007-2008 survey, when asked what factors most influenced their choice of specialty, osteopathic school graduates who chose primary care cited liking to deal with people, whereas those opting out of primary care were statistically more likely to cite these factors for their career choices: intellectual content of the specialty, prestige/income potential, emphasis on technical skills, and medical debt level.
Dr. Richardson said that even an important incremental change such as an influx of osteopaths into primary care won’t fix the problem. There need to be sweeping changes in training, practice, organization, and incentivizing primary care doctors and even some specialists. Go to a city of 80,000 people, and its hospitals desperately need specialists, particularly surgeons. Communities must support their doctors because, nationally, they are competing for both primary care and specialists, he concluded.
A Slippery Slope?
Muddying the waters is the growing number and influence of nonphysicians with doctoral degrees, whose legitimate use of the Doctor title might lead patients to make incorrect assumptions about their levels of training and scope of practice. Advanced practice nurses, nurse practitioners, and physicians’ assistants all now have curricula leading to the doctorate, and it may not be too far in the future when practitioners without the doctorate are grandfathered into licensing. Another serious blow to physicians’ positions may be granting nonphysician practitioners, such as audiologists, direct access to patients rather than via physician referrals. This is a work in progress, and whether there will be state versus federal regulation about access to patients remains to be seen, said Dr. Nielsen. We support a collaborative team approach to sharing care of our patients.
No matter what paths the current administration explores to get more physicians to choose and remain in primary care, there is keen interest in what America’s physicians have to say about the matter. Dr. Nielsen watched Congressional staffers scurrying in and out of his meeting and taking copious notes on what the doctors and other stakeholders had to say. They implied that Congress will have a vote on some sort of health care reform within 60 days. It’s not ‘ready, aim, fire’ but just ‘fire.’ My sense is that they know what they do may not be the physician’s first choice, but they’re telling us we shouldn’t worry because whatever is wrong, they’ll fix it as we move forward. This is not very reassuring to physicians, he concluded.
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