Monday, November 10, 2008

Who will pay for primary care?

Jeff Goldsmith, writing for the Health Affairs blog, proposes three health care reform scenarios that the Obama administration could pursue. One of his scenarios is to start out by laying the groundwork for improving health care delivery and putting off more controversial and costly coverage decisions to a later day:

"Obama could move aggressively and quickly to expand primary care physician payment under Medicare (through a version of the Medical Home idea), double federal funding for community health centers, and create a medical student loan forgiveness program for students entering geriatrics and primary care specialties ..."

I share Mr. Goldsmith's view that policies to rebuild the physician primary care workforce must be part of health care reform. As the Commonwealth of Massachusetts has found, giving people health coverage does not ensure access to care if there aren't enough primary care doctors around to take care of them. I am uncomfortable, though, with Mr. Goldsmith's suggestion that health coverage might be put off to another day, since primary care and health coverage are two sides of the same access coin.

Expanding and improving primary care physician payment will itself be controversial. I am writing this blog from the American Medical Association's House of Delegates meeting, where primary care and medical homes are both major topics being discussed. Many of the physicians lining up at the microphones have expressed support for primary care - as long as it doesn't involve redistribution of dollars among physicians.

It is not a good sign that some physician specialty societies already are drawing such lines in the sand.

From a political (and maybe a policy) standpoint, it would be less controversial if an Obama administration found a way to improve payments for primary care physicians without taking money from other doctors. The administration could find that there is sufficient data to conclude that higher payments for primary care and the medical home will pay for itself by reducing preventable hospital admissions paid under Medicare Part A. A portion of such Part A anticipated savings could then be used to raise primary care payments.

But what if the Congressional Budget Office isn't persuaded that primary care will pay for itself through savings in Medicare Part A? Where then will the money for primary care come from? Or what if President Obama and Congress decide that higher paid specialties should as a matter of policy and fairness give up something to raise payments for primary care?

The choice could come down to doing nothing to help primary care, or paying for primary care at least in part by redistributing dollars from higher paid specialists.

I would like to hear the views of Internal Medicine generalists and IM subpsecialists (and even from surgeons who might read this blog) on the following:

Should higher paid physician specialties be asked to give up something to increase payments for primary care? If not, then where should the money come from? Should ACP support reforms to improve payments for primary care - even if this will result in reduced payments to some IM subspecialists?


Glit said...

Of course the additional money for primary care has to come from specialists, hospitals, procedures and imaging. We successfully did that during the era of capitation, ca. 1998. Kaiser does it now. Any truly accountable health care system will be globally budgeted and will provide an adequate primary care system.

HealthyRookie said...

There is no question that increasing the level of primary care provided will decrease health care spending, but we can't use that money to invest now because that savings won't be realized for many years. If our federal budget were balanced, than I think Obama could justify deficit spending for a program that would eventually pay for itself. The way it is, I don't think he has that flexibility. The biggest question is "how to get there from here?" and to me, it seems like specialists may have to brunt the blow.

Expanding primary care at the expense of specialist care may be hard for some to stomach, but will ultimately be successful in improving the conditions for patients, doctors and the health care budget. If the increase in primary care is effective, then we should eventually see a decrease in specialty compensation anyways, as procedures for preventable disease are avoided.

Roy M. Poses MD said...

One question is the extent to which the specialty societies are influenced by their funding from pharmaceutical, biotechnology, and device companies, and the financial ties many of their leaders have to such companies.

Such funding and relationships are not often fully disclosed. But we do know about the financial relationships among one sub-specialty society and its leaders and device manufacturers.

For example, see this post on Health Care Renewal about AAOS funding from device makers:
Also, see this post on the relationships among AAOS leaders and device makers:

We know of these financial relationships only because of settlements of federal lawsuits against the device makers. It is likely, however, that other specialty societies have similar undisclosed relationships.

It is obviously in the interest of device makers that orthopedic surgeons get inflated pay for doing procedures involving their devices, since these payments provide financial incentives to do more procedures. It is likely that it is in the interest of other health care corporations to support inflated pay to other kinds of sub-specialists to do procedures that use specific devices, or who are likely to use particular drugs.

Such influences are not the only reason that sub-specialists may want to cling to their exaggerated compensation. But they may distort the discussion, and at least ought to be fully disclosed and acknowledged.

Jay Larson MD said...
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Jay Larson MD said...

As a general internist, I appreciate the assistance of specialists with medical management of patients, however, the reimbursement system is weighted too heavily on procedures. Primary care physicians are the only type of physicians that have been proven to lower healthcare costs and improve outcomes. The healthcare pie is 2.3 Trillion annually. If all factions (specialists, hospitals, pharmaceutical companies, and insurance companies) gave a small amount of their share to help primary care, there would be no hardships. Solely relying on specialists shifting income to primary care would only further fracture medical professionalism.

Jay Larson MD said...

The current healthcare reimbursement system is heavily weighted towards procedures and not toward cognitive skill, which significantly benefits many specialists. The CPT code book of procedures has 35 pages of E&M (evaluation and management) codes but 400 pages of procedure codes. This imbalance will need to be corrected or else general medicine will go extinct.

Since specialty physicians are consuming more healthcare dollars than primary care, primary care is collapsing. Specialists should review the following principles of medical ethics:

The AMA principles of medical ethics states that “The Medical profession has long subscribed to a body of ethical statements developed primarily for the benefit of the patient. As a member of this profession, a physician must recognize responsibility to patients first and foremost, as well as to society, to other health professionals, and to self”. “A physician shall support access to medical care for all people.”