Monday, January 26, 2009

Where, oh where, will we find $ for primary care?

As I've reported in several blog postings, it seems like everyone agrees, or at least they say they agree, that the U.S. needs more primary care physicians.

But when it comes to figuring out where the money for primary care should come from, well, the consensus just isn't there.

Dr. Benjamin Brewer, a primary care doctor, suggests in his Wall Street Journal column that the government could fund primary care by taking money from Medicare Advantage plans, cutting payments to hospitals for "high margin" surgeries and radiology services, revoking tax exemptions for hospitals that don't fulfill a mission of community service, or lowering Medicare pay for specialty care and procedures.

Noting Dr. Brewer's ideas, Jacob Goldstein asked readers of his Wall Street Journal blog what they thought of five different options for reducing spending to free up money for primary care.

These are the results from the 500+ plus respondents:

21%: cut Medicare Advantage.
20%: cut hospital pay for high margin services
26%: cut pat to specialists
11%: money shouldn't come out of existing health care spending
22%: primary care doesn't need more money

Granted, this was not a scientific poll. And Goldstein left out options that could have more support, such as prospectively applying some of the anticipated savings from reductions in preventable hospital admissions associated with primary care and using them to boost primary care fees.

Still, the fact that none of the options received more than one out of four votes (except for cutting specialists - barely - and one can imagine how that will play out in the political world) suggests trouble. And with 22% saying "primary care doesn't need the money," the consensus for primary care may be weaker than it appears.

The Wall Street Journal polls support two basic truths in politics. It easy to get people to agree to spend more money, but it is a heckuva lot harder to get agreement on where to cut. And those who have an interest in protecting themselves from cuts always start out with a political advantage over those seeking money at their expense.

Today's questions: Do you agree that the only way to fund primary is to take money from someone else in health care?


Unknown said...


Let's convince policy makers that primary care growth saves dollars and get's better outcomes.

Consider this study by Kravet, S et al: Health Care Utilization and the Proportion of Primary Care Physicians. Amer J of Medicine, 2008; 121:142-148

For population of 775,000, an increase from 35% to 40% primary care physicians could:
Reduce inpatient admissions by ~2500/year
At approximately $9000/admission = $23M
Reduce ED utilization by 15,000 visits/year
Reduce surgery by about 2500 cases/year

An investment in primary care growth could pay for itself--and then some.

Jay Larson MD said...

Increasing the $2.3 trillion annual health care spending to increase pay for primary care should not have to happen. There are many areas in health care including insurance companies, hospitals, and proceduralists that could reduce their revenues slightly to shift to primary care. Besides, as more primary care physicians leave practice, the less revenues that need to be shifted.

As one of the doctors on the blog wrote, many primary care physicians would use the extra income to pay for more ancillary services to unload some paper work burden. This would free up more time for patient care resulting in improved patient and physician satisfaction.

It will be interesting to see how this recession affects primary care physicians. With higher deductibles and the recession, many patients are choosing not to come in for follow appointments. This revenue drop for the small office PCP may be the lethal blow to their practice.

Brad F said...

Also, see this opinion piece in this weeks AMA news. With this kind of approach, reform and consensus, in this humble doc's perspective, is hopeless.

Give no quarter. Get more money. Subspecialists cede no turf. Good start.

proud grandpa said...

How to Fund Primary Care??
The obvious answer is to impose a logical, rational funding and dispersing strategy to our dysfunctional Health Care System. We need a system that spends our limited resources on the goods and services in the greatest need, not the most profitable.
We have had more than 30 years of ever more vigorous application of ‘Free Market Principles’ to our Health Care System’s organization and funding with ever more distortions that those principles create by promoting the profitable and discouraging the unprofitable. Our system now consists of a number of profit centers that do quite well and many more parts of our Health Care System that are not profitable or minimally profitable and are not doing well.
Until we restructure the incentives, we will continue to get greater disparity in our Health Care System. The unfortunate reality is that the most important parts of our Health Care System fall into the unprofitable or minimally profitable category.
Also if we do not act now to dampen down the profitability of the profit centers, health care inflation will continue to soar and the cost of future health care reform will cost tens, if not hundreds, of billions more.

William C. Seal, MD, FACP

Greg Hood said...

"the government could fund primary care by taking money from Medicare Advantage plans..."
" such as prospectively applying some of the anticipated savings from reductions in preventable hospital admissions associated with primary care and using them to boost primary care fees."

Our practice participates with a Medicare Advantage plan which does exactly as you propose. This physician originated and directed product is available in a number of markets, and is expanding each year. It is fulfilling the goals of Medicare Advantage as originally envisioned. To cut Medicare Advantage would hurt us as much or more than any stimulus I could imagine, and would also stamp out this glimmer of light which should be nutured and emulated. Certainly, the major insurers who have abused MA & skimmed profits should be held accountable, but there is a healthy baby in this bathwater...