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?