When I think about the state of primary care today, I am reminded of this quote from Woody Allen: “More than any other time in history, mankind is at a crossroads. One path leads to despair and utter hopelessness, the other total extinction. Let's pray we have the wisdom to choose correctly.”
These aren't the only choices for primary care, but Woody's observation will resonate with many primary care internists who are profoundly pessimistic about their futures.
Most will tell you that there is nothing wrong with primary care internal medicine itself, that is, the importance of patients having an ongoing relationship with a well-trained internist who accepts responsibility for their whole person. They can point to studies showing that such a relationship results in better outcomes and lower costs.
Instead, primary care physicians are dissatisfied because they feel underpaid, overworked, underappreciated and overhassled. And their concerns are confirmed by independent studies:
Primary care physicians earn much less than subspecialists. One study found that a primary care physician earns $3 million less over a career than a cardiologist. The federal government's Council on Graduate Medical Education reports that primary care physicians' incomes would have to be increased to 70% of the median incomes of all other physicians to attract enough candidates to meet the needs of the general population. Right now, their incomes are about 40%.
A study of a five-physician general internal medicine practice in Philadelphia found that each physician responded to telephone calls or laboratory results an average of 43.2 times a day, and reviewed 13.9 consultation reports and 11.1 imaging reports each day. Not included in the analysis were some “high volume categories of documents” like the documentation required by summer camps. Because these activities fall outside the face-to-face office visit, insurers won't pay for them.
Another study found that primary care physicians spend 3.5 hours weekly on health plan interactions, compared to 2.6 hours for other medical specialists and 2.1 hours for surgeons. This amounts to $64,859 annually per primary care physician, nearly one-third of an average primary care physician's income plus benefits.
Health care reform provides expanded scholarships and loan forgiveness to medical students who go into primary care.
Beginning in January 2011, Medicare will pay 10% more for designated visits by primary care physicians. Starting in 2013 and continuing through 2014, Medicaid will pay no less than Medicare for office and hospital visits and immunizations by primary care physicians. These changes alone will increase federal payments to primary care by almost $12 billion. Also next year, primary care physicians will be paid for providing an annual Medicare preventive exam. They no longer will have to collect copayments or deductibles for covered preventive services.
Health care reform also requires that health insurers reduce the number and complexity of paper and electronic forms and data entry required by patients, physicians and other providers. Health plans that do not comply will be subject to fines. Large insurers will be required to show that administrative expenses are no more than 85% of the premium dollar collected. For small insurers, it is 80%.
But the biggest change may be the law's emphasis on patient-centered medical homes (PCMHs). Medicare will test new models of paying primary care, including medical homes, and states will be allowed to offer a new Medicaid medical home option. Grants will be made available for community programs to help primary care practices qualify. These federal efforts will dovetail with existing PCMH pilots by state governments, businesses, insurers and physicians.
PCMHs improve the traditional foundation of the caring relationship in office-based primary care practices by:
- Paying physicians for work outside of office visits. Qualified practices will receive a monthly, risk-adjusted care coordination fee for each patient to cover phone calls, consultations, and review of reports that are not now reimbursed;
- Allowing primary care physicians to share in the savings if they can prevent avoidable hospital admissions or unnecessary tests;
- Providing access to non-physician support teams to handle tasks that don't require a physician; and
- Paying in part for achieving good outcomes instead of billing more services. Since studies show that primary care already is associated with better outcomes and lower cost, it stands to reason that primary care will benefit if insurers pay for value, not just volume.
Many fear that PCMHs will end up meaning even more administrative work, with little or no increase in pay. Advocates still have to show that the model can live up to the hype.
Government and private payers could increase primary care payments and reduce red tape. But such incremental changes have been tried before (remember the resource-based relative value scale?) and they haven't been enough to restore the value and prestige of primary care.
A better alternative is to set our sights on a better way of financing and delivering patient-centered primary care, and to do the hard work of forging a path to take us there.