Thursday, November 13, 2008

Senator Baucus' Answer to Who Should Pay for Primary Care?

Yesterday, Senator Max Baucus, chair of the Senate Finance Committee, released his plan for reforming U.S. health care. The plan offers a road map for expanding health insurance coverage and improving health care delivery--with a strong emphasis on primary care, which he calls the "keystone of a high performing health care system."

He offers several specific ideas to strengthen primary care:

* A process would be created to reduce payments for services found to be overvalued under the Medicare physician fee schedule and redistribute them to increase payments for undervalued primary care services. The paper implies that this review would take place outside the usual RVS Update Committee (RUC) process.
* Medicare payments for evaluation and management services furnished by primary care practitioners would be increased. Congress would mandate a process for identifying which specific services would qualify for the increase and criteria for determining if a practitioner is truly focused on primary care.
* Medicare's testing of the Patient-Centered Medical Home would be expanded to include more practices that are able to demonstrate that "patients truly receive the primary care and care management services that the medical home is designed to deliver."
* The Medicare sustainable growth rate (SGR) formula might be replaced with multiple expenditure targets based on sub-sets of services. The paper suggests that separate targets have the advantage of "reallocating resources from high-growth, potentially overpaid aspects of health care to underutilized, potentially more valuable services such as primary care and prevention."

The changes in physician payment will be budget neutral, meaning "that any increase to primary care providers requires a corresponding cut to specialist services." The paper acknowledges that such redistribution "has the potential to create significant controversy among physicians."

No kidding. Every effort over the past twenty years to increase payments for primary care has created enormous controversy within medicine.

Senator Baucus' paper is a powerful statement that primary care has arrived as a top concern of policymakers. But the question of "who will pay for primary care?" remains a central challenge.

Today's questions: Do you agree with Senator Baucus that primary care is the "keystone" of a high performing health care system and needs to be supported with higher fees, even if that means taking money from other specialists, including some internists? If you don't believe specialists' fees should be cut, then how would you recommend Senator Baucus and his colleagues pay for higher primary care payments--if at all?


Jay Larson MD said...

Of course primary care is the "Keystone of a high performing health care system". Every country and community with a strong primary care workforce has been shown to have lower medical costs and better health outcomes.

An increase of just one primary care physician per 10,000 persons is associated with 1.44 fewer deaths. (Source: “Income inequality, primary care, and health indicators”. Shi L, Starfield B, Kennedy B, Kawachi I. J Fam Pract. 1999 Apr;48(4):275-84)

With each 1% increase in proportion of primary care physicians is an associated decreased yearly utilization for an average-sized metropolitan statistical area of 503 hospital admissions, 2968 emergency department visits, and 512 surgeries. (Source: Health Care Utilization and the Proportion of Primary Care Physicians. Steven J. Kravet, MD, MBA,a Andrew D. Shore, PhD,b Redonda Miller, MD, MBA,a Gary B. Green, MD, MPH, MBA,c Ken Kolodner, ScD,a Scott M. Wright, MD, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Md; Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md; and Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Md.)

An increase of one primary care physician per 10,000 persons in a state was associated with a rise in that state’s quality rank and a reduction in overall spending by $684 per Medicare beneficiary. By comparison, an increase of one specialist per 10,000 people was estimated to result in a drop in overall quality rank of nearly nine places and increase overall spending by $526 per Medicare beneficiary. (Source: “Medicare spending, the physician workforce, and beneficiaries' quality of care.” Baicker K, Chandra A. Health Aff (Millwood). 2004 Jan-Jun;Suppl Web Exclusives:W4-184-97.)

As far as where the money should come from, just look at how lop-sided the current system is set up. The “value” of a comprehensive medical assessment of a patient with multiple health problems is the same as applying a leg cast, destroying a ½” skin cancer, or suturing a simple 1” laceration.

If reimbursement continues to support speciality and procedural care then the U.S. will be full of specialists and no primary care doctors. How much would that system cost? 4 trillion? 8 Trillion? How far down would the quality of care go? To the bottom?

As far as another source of increased primary care funding... that would be the Medicare Advantage plans profiting from Medicare A and B and sucking money away from physicians.

DrJHO7 said...

MCR pays the same fee to a general internist for a 99214 level service as it does to a cardiologist in the same locale. To increase the payment to the generalist, and reduce the payment to the specialist for that level of service simply on the basis of specialty would be a huge slap in the face to specialist colleagues who provide excellent care to their patients. This is not the way to go. (I am a GIM).
I believe that some medical procedures are over-reimbursed, especially MRI, sleep labs, nuclear medicine procedures, hence their proliferation in our communities, and it is obvious that profit-based incentives exist that lead to overutilization of some of these procedures by some physicians. Level of payment for these services should be reevaluated and reduced to decrease the incentive for profit.
I can't understand why an anesthesiologist should make 3 times what a general internist makes for their 70 hour work week.
The procedures they perform are probably over-reimbursed.
Students and residents say that the primary care specialties are unattractive based on the relatively low income potential in the face of their high debt (often >200,000), burdensome hassle factors they hear about from these docs (unreimbursed paperwork, and being "dumped on"), and the restrictions on lifestyle that may come with 24/7 accountability to patients.
Making primary care specialties more attractive to med students and residents will require a mutlifaceted overhaul approach:
Yes, primary docs should receive prospective payment for care management activities that improve the quality of care they provide in addition to fee for service reimbursement for the E&M services they provide, through a PCMH model.
Yes, medical students will need structured loan forgiveness programs that incentivise them to choose primary medicine careers if they are so-inclined.
Yes, overvalued medical procedures should be reevaluated with regard to their reimbursement levels to reduce the incentive for overutilization with no added value to patient care.

Roy M. Poses MD said...

Whatever is done should be done outside the RBRVS Update Committee (RUC).

The AMA has made sure that the RUC membership includes a tiny minority of primary care/ generalist physicians, and a minority of "cognitive" physicians. By ensuring that they are grossly out-voted, the committee structure has ensured that primary care/ generalist fees are fixed to be low, while the amounts paid for procedures endlessly increase.

Furthermore, the AMA has apparently tried to keep the involvement of the RUC in determining RBRVS reimbursement rates as obscure as it can. Since I suspect until recently few generalists/ primary care physicians even knew what the RUC was and what it did, they had no opportunity to protest what was going on there.

Finally, the AMA has kept the names of RUC members and the proceedings of the RUC secret, so generalists/ primary care physicians who wanted a better argument to be made for them on that committee would not have known to whom they should talk about this.

The notion that the fees paid by a government agency, CMS, to all physicians are fixed by this inaccessible, obscure committee, run in secret, as the AMA's private "advocacy" group, without public input, is scandalous. It deserves federal investigation. And if Medicare is going to fix physicians' fees, the public deserves a transparent and accountable process for doing so.

See our posts on Health Care Renewal about the RUC, most recently here:
with links backwards.

David Catron said...

If you don't believe specialists' fees should be cut, then how would you recommend Senator Baucus and his colleagues pay for higher primary care payments.

Robbing Peter (the specialist) to pay Paul (the PCP), will only shift the physician shortage caused by these government price controls (which is what we're dealing with here) to the specialties that get cut.

The problem here is government price controls. So, the answer to your question about how Baucus should address this is to lift the price controls and allow all physicians to charge what the market will bear.

David Catron said...

If you don't believe specialists' fees should be cut, then how would you recommend Senator Baucus and his colleagues pay for higher primary care payments.

Robbing the specialists to pay the PCPs will only move the physician shortage to the specialties that receive the cuts.

The answer is to remove the price controls (the real disease here) and allow physicians to charge what the market will bear.

Jim Webster MD, MACP said...

The Baucus plan is a good start, but "we" need to be much more creative. Yes, medical homes should be the future salvation of primary care and should be well funded. Where will the money come from? Multispecialty groups should be the standard with closed end budgeting so "we" as physicians can decide what's truly important. Let's face the realities that:1) If Wall Street doesn't do in the economy, health will at 2 1/4 trillion/year; 2) Relman is right, 1/3 of what we do is of no value in terms of outcomes and the Wennberg date is right on; 3) it is not written that MD's should retire super rich llike CEO's.
What we need is a real revolution in how care is organized and reimbursed (get rid of fee for service)led by ACP and get back to our roots when medicine was a calling and thus restore our social contract with society.

Arvind said...

Agree with David. Disconnect ambulatory visits from ICD codes. Let each patient have a contract with every physician, and decide for him/herself which type of services they value more. If working with a specialist results in more patient empowerment and better outcomes, and specialists are available as better problem-solvers than PCPs, why should regulators or organisations like the ACP limit their choices? If patients surmise that their healthcare dollars are better spent on primary care, they can decide that. This is the only way out of this quandary. Eventually, only those practices that provide compassionate, comprehensive care with appropriate compensation will survive. Let's get rid of this price-fixed top-down system which has no value for the physician-patient relationship.