Monday, January 12, 2009

Will primary care's "coalition of the willing" stay together?

Tom Daschle is the latest "mover and shaker" to climb on the primary care bandwagon. In an opening statement to a Senate Health, Education and Labor and Pensions Committee confirmation hearing on his nomination as HHS Secretary, Daschle had this to say:

"Even Americans who do have health insurance don't always get the care they need, especially high-value preventative care. In some cases, this is due to a shortage of providers - especially primary care providers in rural areas ... CMS must focus on prevention and primary care, steering its resources toward wellness rather than sickness."

Still, it will be a tough slog, as Donald Rumsfeld so famously said about the Iraq war, before we'll be able to say that primary care's poor fortunes have been reversed.

Right now, primary care enjoys the support of leading organizations representing physicians, consumers, employers, and nurses. Yet this coalition could weaken if the following occurs:

1. Primary care could split into an uncivil war between doctors and nurses. Workforce studies project that the demand for primary care is so great that the U.S. will need more doctors and nurses. Yet primary care physicians and nurses could end up battling each other for a share of the pie.

2. Opposition by specialists could cause division in organizations that represent generalists and subspecialists - including ACP. An email from a rheumatologist-member of ACP has this to say about ACP's advocacy for a 10% pay increase for primary care:

"I did not see any mention of Internal Medicine subspecialties in your letter. We probably reflect about one half of the 126,000 members that are claimed. However, it seems to me that you do not represent me (as well as the other sub specialists) any more."

It is not pre-ordained that these conflicts have to happen. If we put patients' needs first, internists (both generalists and subspecialists) and nurses should be able to come together and agree on the need for more primary care clinicians, doctors as well as nurses. But it will require constant care and attention to make sure that primary care's coalition of the willing does not fall apart because of divisions within its own ranks.

Today's question: Do you believe that internists, generalists and subspecialists alike, and nurses will be able to stay together on the need for more primary care clinicians?


Jay Larson MD said...

The patient care done by primary care physicians and nurses does not vanish if there are no primary care providers around. This work will fall onto the shoulders of subspecialists, ER physicians, and hospitalists. It is to the best interest of all parties (including patients) that primary care survives. The primary care crisis is on the Federal government radar and hopefully will be addressed despite push back by subspecialists. The primary care crisis is not a physician issue but a patient care and society issue. So long as the reform drive is towards “quality affordable health care” there will have to be a strong primary care force to achieve this goal.

I found the e-mail from the rheumatologist interesting. Two years ago you could have replaced “subspecialist” with “general internist” and have the same sentiment general internists have been dealing with for the past decade. Until recently, the ACP has only noted the primary care crisis and now they are stepping up to the plate for the general internist. This is appreciated by the “underdogs”.

DrJHO7 said...

Today's question: Do you believe that internists, generalists and subspecialists alike, and nurses will be able to stay together on the need for more primary care clinicians?

The pie of patients is and will be so big in most areas of the country for the forseeable future, that substantial competition between physicians and advance practice nurses simply won't be a major issue. Some degree of payment reform that is favorable toward primary care specialties will likely occur, and coincident with this, physicians and APN's will need to work together to improve our systems of care such that we can eventually demonstrate (through outcomes measurement) that the investment in the primary care sector made by the government, and perhaps by private payers, is justified by value added - as we suspect it will be.

Many medical specialists, be they internists, or otherwise, are somewhat dependent on the health of the primary care sector for referrals, and would prefer not to have to deal with the drudgery and hassles of primary care, so they should be generally in favor of policy changes that strengthen primary care, that is, unless such changes have a substantially negative impact on their income. If anybody thinks a 10% increase in pay is going to change the minds of debt-laden medical students, or cause sudden euphoria amongst primary physicians who feel they are lower than the lowest barnacle on the bottom of the hull of the Titanic in the medical hierarchy, they are not in touch with reality. Many med students are looking for careers that pay 2-3 fold what primary care does, with half the hassle, and twice the self esteem. This is reality.

The market will fix some of this imbalance over time (5-10 years?) and shift it back in the direction of primary care when there are too many physicians in specialties that "pay the better wage". They will compete for patients, volume will drop, as will pay, while business will be more robust in the primary care sector with a better supply of patients, and perhaps modest improvements in income for PCP's who are successful in innovating their practices to meet the needs of their patients, or as the PCMH takes off, with prospective payment for expanded services. Structured loan forgiveness programs may entice some students/residents to move back toward primary care if they have an inclination to do that kind of work to begin with.

PCP said...

I cannot and will not support any reform that puts Nurse Practitioners and other Mid levels on par with Primary Care Physicians. By all means we need more of all kinds of primary care clinicians. However please don't tell me that with all my education, training, skills, responsibility and everything else, My fee schedule will be exactly the same as that of a Nurse.
If that is the reform we must advocate to "stay united" then I am afraid that it is the sort of change that will never gain the acceptance of younger physicians. We are at such a low point now that a PCP receives a mere 20-30% more than a Nurse Practioner, and the after tax income gap may be even less. In real terms we may even be at parity pay since Doctors take more call, see more patients and sicker ones generally speaking, as well as work more hours. Some Mid-levels such as cRNAs and surgical PAs even out earn us by significant margins.
Who in their right mind can be expected to accept that as a fair solution. NPs have been/are/and will be about autonomy and pay parity without the same education/training and work. Just take a look at their website to see. How much longer are we as a profession willing to tolerate this nonsense. It is time we bring some closure to this ridiculous situation. I am all for more NPs and other mid-levels by all means, there is simply no other way given the primary care workforce predicament we are in, but this must be in collaborative arrangements with Docs. If I see Sicker patients, I want to be appreciated for this, If I work longer or take out of hours call likewise, Since I have undergone more rigorous training, I expect the reimbursement to show this up. Otherwise I say let them have it all, the sick and complex, the out of hours call, the litigation risk and the volume pressure. We Physicians will find other niches and when it all collapses as it invariably will, perhaps our value to the system will become more apparent.
We have been far too passive advocating for ourselves. We ether grow a spine this time or forget this altogether.