Tuesday, June 8, 2010

Answer to Question #5: How Can We Remedy the Imbalance of Too Many Sub-Specialists and Not Enough Primary Care Doctors?

According to David S. Goodman and Elliot S. Fisher (New England Journal of Medicine April 17, 2008):
“… between 1979 and 1999, the physician supply per capita grew by 45% in primary care, 118% among medical specialists, and 21% among surgical specialties, yet four of every five new physicians settled in regions where the supply was already high”.

Additionally, the authors suggest that an unrestricted expansion of the physician supply would add to our fragmented specialist driven health care system because of the reimbursement systems underpayment for primary care. In Massachusetts since 1976 the physician-to-population ratio has doubled, now having the highest ratio including primary care in any state in the union, yet the medical society repeatedly makes claims of a physician shortage and patients report an ever increasing shortage of primary care.

These authors hypothesize that besides a skewed physician distribution the reasons for this disparity is the inadequate payment for primary care services forcing physicians to spend less time with each patient, referring more cases to specialists and having hospitalists care for their hospitalized patients and restricting their practices to patients they already know. This is because new patients take much more time during their initial visit.

Demonstrating that this problem is not a shortage of physician numbers, in the same issue of the Journal John K. Iglehart documented that in the U.S. there was an increase ratio of active physicians per 100,000 populations from 144.7 in 1960, to 278.5 in 2000 and expected to be 294.2 in 2020. As stated by Drs. Goodman & Fisher, the key for improvement is, “…..improve care coordination and chronic disease management; and accelerate efforts to reform payment systems so that they foster integration, coordination, and efficient care”. I propose a payment system designed to adequately reimburse primary care physicians based on being able to spend 1hr. for each new patient and 1/2hour for each return patient and some time to follow their patients in the hospital.

Concerned about the primary care workforce Dr. John D. Goodson recently wrote (Annals Internal Medicine June1, 2010), about various aspects of the Patient Protection and Affordable Care Act (PPACA). With thirty-two million Americans newly insured, our specialty oriented physician workforce (70% specialists) will be poorly suited to provide adequate primary care services, health maintenance and coordinating care of those with chronic diseases.

The bill reauthorizes funding to expand primary care by providing financial assistance to programs and individuals for five years. The law establishes a National Health Care Workforce Commission to recommend actions by Congress to meet physician manpower needs. The problem is that in the past these programs have languished for lack of funds. With Medicare funding being curtailed to help fund this new law and expanding federal deficits, I doubt that these recommendations will reach reality.

The bill states that the Secretary of Health And Human Services should adjust the Resource Based Relative Value Scale (RBRVS) to enhance payment for primary care. The law provides for a 10% increase of present day payments to primary care physicians for five years and increases Medicaid payment to Medicare levels for 2 years. The problem is that the RBRVS is deeply flawed, grossly underpaying for evaluation and management. Congress since 1991 has been unable to fix it and it should be scraped. Medicare payments, although higher than Medicaid are still inadequate to cover costs. Because of the long training period for physicians, by the time these increases could affect decisions, they will have expired, keeping in mind that it will take decades to increase the ratio of primary care to physician specialists.

A new Center for Medicare and Medicaid Innovation to help create new payment and service models was created. These new models would include expanded bundling, a single doctor payment for a disease event and follow-up, capitated payment that would cover hospital and doctor fees for an illness and a managed care type plan that would accrue monies to the providers for care costing less than expected. Other ideas to be tested are: a patient centered medical home (which in my opinion is what primary care physicians should be doing all the time) and Accountable Care Organizations that will contract with the Center of Medicare and Medicaid Services for complete medical care for a group of patients retaining any profit. The problems are as I see them is that physicians have not been trained to avoid excessive testing and rely on clinical judgment, the public has unrealistic expectations of medical care along with demands for non beneficial care, and the mistrust of managed care type models have not been addressed.

The reasons that many young doctors wish further specialty training are not limited to economics. In this age of molecular biology and advanced patho-physiology young doctors want to learn more, This makes them better doctors, not only in their area of specialization, but better doctors in general. Their skill set does not have to become narrower with appropriate further training. There are no active mechanisms in this law to change the physician and patient culture that pervades our system - too many tests, too much non-beneficial care, excessive demand for drugs and devices. The way to meet the need for greater primary care capability within a reasonable time frame is to have medicine and pediatric sub-specialists provide primary care for their patients who do not have ready access to a primary care physician.

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