Tuesday, January 27, 2009

Where is the AMA on primary care?

Yesterday, I blogged about the controversy over where to find the money needed to increase payment to primary care physicians. The American Medical Association (AMA) addresses this question in a commentary by AMA Board chairman Joseph M. Heyman, MD. He says,

"This issue [increasing the number of primary care doctors], on which we all agree, threatens to break professional unity, cause rancor, divide us and result in everybody - including our patients - losing. We all want to do something to improve the state of primary care. So we need to be certain we are all on the same page when it comes to investing in primary care in this country. We must present a unified front." He then makes three points:

"The American Medical Association absolutely supports this important investment in primary care. Payments to primary care physicians must increase.

The American Medical Association absolutely opposes applying budget-neutrality rules that confine offsets to the physician payment pool. Congress should not rob Dr. Peter, the surgeon, to pay Dr. Paul, the primary care physician.

The American Medical Association absolutely is committed to working with Congress and the administration to find alternate pathways to offset the required increases in primary care payments."

ACP has urged Congress to consider ways to fund primary care outside of the usual budget neutrality physician payment rules. We have argued that primary care pays for itself by reducing preventive hospital admissions, duplicate testing, and so forth. We hope that argument is being accepted by policymakers. And to be frank, ACP will have its own membership issues if increased payment for general internists comes at the expense of reducing payment to IM subspecialists.

It should be acknowledged, though, that budget neutrality adjustments are made every year in Medicare payments to doctors, whenever new procedure codes and relative values are added to the fee schedule. Those adjustments benefit one group of physicians - the ones who do the procedures - at the expense of other physicians who do not. For the most part, primary care physicians are not the ones who benefit (except every five years or so when changes in the relative values for visit codes are put on the table).

Rather than drawing lines against any particular funding option, the conversation needs to shift to how primary care will be funded, recognizing that someone (maybe even some doctors) will have to give up something if primary care is to survive.

Today's question: What do you think of Dr. Heyman's commentary?


Jay Larson MD said...

Extraordinary times require extraordinary measures. The U.S. is in a major recession and does not have the resources to continue to dump 2.3 trillion per year into health care. Patients have limited access to primary care physicians, which continues to worsen as most medical students are pursuing procedure based specialty care. The status quo will have to be changed.

AMA Board chairman Joseph M. Heyman, MD seems to support the status quo. Unity? Where was the unity from the AMA when the RUC added more and more costly procedures at much higher RVU’s than using the brain and spending time with patients? Where was the unity when the primary care system started to collapse years ago? Perhaps the AMA should have had more foresight when upgrading the RVU system.

“But the money can not come from other physicians who, like primary care physicians, have been subject to Medicare payments that for the last seven years have failed to reflect increases in medical practice costs.” Really. It really does not matter if medical practice costs increase if there are more and more lucrative procedures to make up the difference. The bottom line is what the physician takes home at the end of the day and that has not changed much for the primary care physician who is running as fast as they can to keep up with expenses.

If there is to be “unity” amongst physicians, there has to be a paradigm shift. Patients come first!!! Time to get physicians out of the value game and let society figure out what is truly important in health care.

PCP said...

I can only support Dr Heyman's comments if and when the AMA supports a reconstitution of the RUC system such that Primary care has a representation there commensurate with the proportion of its residency positions to the total residency positions and when they endorse a reassessment of the changes in RVUs attached to cognitive services vis a vie procedures and imaging services over the last decade.
Asking primary care to hope for the best from our legislators when we stand united in this time of financial crisis is basically asking them to just sit tight.
This inordinate income and prestige disparity between specialty medicine and primary care medicine was created in large part by the AMAs own inability to reccommend the appropriate changes in the RBRVU system over time, and now that the crisis has it in primary care and is reaching the legislators, the sermon of unity is heard. We all want unity, but we also want equity in representation.
Even within the ACP, we have such a massive income and prestige disparity with certain specialties like Cardiology having taken pole position. We ought to all agree that Primary care must be better funded by whatever means.
If we can do it by going after other cost savings in Hospital care, Drug costs, Medicare Advantage, Home health care, Medical Devices and equipment etc. fine. If not, then some redistribution is needed. The only way primary care physicians can be assured of that goodwill, is through a reconstitution of the RUC to better represent them.

Steve Lucas said...

Along with Jay and PCP's comments I think it is important to look at the polished, politically correct, lobbyist nature of the comments. Speak with one voice, the AMA's voice, but the AMA represents a small minority of doctors. The AMA also has various financial relationships with other groups in the medical community.

This is not a rallying cry to support primary care, but a call to allow the AMA to expand its lobbying efforts on behalf of doctors in an effort to gain further financial control of the medical decision making process.

I wonder how many politicians would be happy learning of the AMA's control of medical matters in their district with no public oversight? Would that congressman be happy learning that the local hospital has closed because the AMA has set reimbursement so low that it can no longer stay open, or the constant shortage of doctors is due to decisions made by an AMA committee?

Steve Lucas

Toni Brayer, MD said...

The RUC, dominated by procedure specialists, will never allow primary care to flourish. The specialists use all of the same RBRVS codes for office visits (with the majority of those visits as a consult code or a comprehensive code) as well as using the procedure codes, which pay so much higher for time involved. As Bob Doherty said, the playing field is ridiculously unbalanced.

We do not need any more White Papers. The value equation from primary care has been proven. The exodus from primary care has been proven. We are already 8 years behind and this crisis could use a bailout as much as the 3 car makers.

Every time I see a patient in my office, I save someone (government?, insurance company?, consumer?) a boatload of money. I don't do unnecessary, duplicative tests and I solve most problems simply and safely without running up expense.

Dr. Larson is correct. Lets put the patient first. When the system collapses because of our outrageous costs and waste, the patients lose.

If the RUC is not reconstituted immediately, Comprehensive IM and Family Medicine should be pulled out and new systems of payments designed to account for the 40% time spent on patients but not face-to-face, and the value to the health of America via primary care.

Unknown said...

Where is the AMA on primary care? The AMA is, has been, and always will be a surgical tool. - Leslie Rose III, MD

Richard Neill said...

I couldn't agree with Dr. Brayer more. Primary care costs less and improves population health. Specialty care costs more and lowers quality of care. Payment adjustment is long overdue; budget neutral or not.

Among the many, many studies that support the facts as stated:
Franks & Fiscella, J Fam Pract 1998; 47:105-9
Macinko et al, mss 2005
Gulliford, J Public Health Med 2002; 24:252-4
Shi et al, J Fam Pract 1999; 48:275-84
Shi & Starfield, Int J Health Serv 2000; 30:541-55
Shi et al, Soc Sci Med 2005; 61(1):65-75
Ferrante et al, J Am Board Fam Pract 2000; 13:408-14
Campbell et al, Fam Med 2003; 35:60-4
Roetzheim et al, J Am Acad Dermatol 2000; 43:211-8
Fisher et al, Ann Intern Med 2003; Part 1: 138:273-87; Part 2: 138:288-98.
Baicker & Chandra, Health Aff 2004; W4:184-97.
Wennberg et al, Health Aff 2005; W5:526-43