Wednesday, April 22, 2009

Democrats and Republicans don't seem to agree on much ... except primary care

Yesterday, the Senate Finance Committee convened a roundtable to get ideas on improving the health care delivery system. Senator Max Baucus (D-MT), restated his commitment to getting a bill through his committee by June to reform health care delivery and provide affordable coverage to all Americans. Senator Charles Grassley (R-IO), the committee's ranking minority member, expressed his commitment to working with Senator Baucus to achieve bipartisan health reforms.

The hope though that Republicans and Democrats will be able to agree on a bipartisan bill was called into question, when the committee took a break from the roundtable to vote on the nomination of Kathleen Sebelius as secretary of the Department of Health and Human Services. Every Democrat on the committee voted to recommend that the full Senate confirm Governor Sebelius, but all but two Republicans voted no. The only GOP "yes" votes were from Senator Pat Roberts, who supported his home state nominee, and Senator Olympia Snowe (R-ME). Senator minority whip Jon Kyle (R-Arizona) said he opposed Sebelius' nomination because she wouldn't commit to prohibiting the use of comparative effectiveness research in making Medicare coverage decisions.

Now, for the good news: Republicans and Democrats alike sang the praises of primary care and their shared commitment to federal policies to recognize and support the value of primary care. One way to tell what was on the Senators' minds is to go to the C-SPAN video library archive of yesterday's roundtable, click on "watch" and then the "search text" feature, insert primary care into the search window, and see how often it popped up in the Senators' remarks and the comments from the invited experts. You can use this feature to listen to, or read, the transcript of the roundtable and the specific discussion of primary care.

One of the invited experts was ACP's own Chief Executive Officer (CEO) and Executive Vice President. Dr. Tooker was the only representative of a physician membership organization invited to participate in the roundtable, an indication of the high regard that Senator Baucus and Senator Grassely have for Dr. Tooker and ACP.

Dr. Tooker was specifically asked to by Senators Snowe and Orrin Hatch (R-UT) to address the crisis in primary care and potential solutions. Click on this link to listen to or read the transcript of Dr. Tooker's response to Senator Snowe. Dr. Tooker made several key points on ACP's behalf, including the demonstrated value of primary care in improving outcomes and reducing costs and the need for comprehensive reforms - including a national workforce policy and reforms of physician payment systems - to increase the numbers of primary care physicians in the United States. (Click on this to read ACP's written statement for the record, the opening remarks of Senators Baucus and Grassley, and the testimony of the other invited witnesses.)

It is highly encouraging that national policymakers "get it" when it comes to the critical role of general internal medicine and other primary care physician specialties in creating a better performing health care system. Republicans and Democrats have deep disagreements on issues ranging from comparative effectiveness research to offering the public the choice of enrolling in a Medicare-like public plan, but not on the need to have more primary care physicians in their communities.

It is also encouraging to note the enormous credibility that ACP has earned by the quality of our policy analyses and recommendations. No other organization is in as good a place as ACP to influence the health reform to help ensure that it meets the needs of internists and their patients. I wonder though how much more effective we could be if every internist belonged to the ACP.

Today's questions: Do you think Congress will deliver on the bipartisan support for primary care? And how can ACP get the word out to ACP members and non-members alike on how well regarded and well-positioned the College is to influence health reform to create a better future for internists and their patients?


Jay Larson MD said...

I watched the entire round table discussion. The primary care crisis was mentioned several times by both Democrats and Republicans. Bipartisan support to help primary care will probably occur. The big question is how much primary care support. Is it too little, too late? MedPac recommended a 10% bonus to primary care physicians. Since reimbursement has remained flat for years despite rising office expenses, the 10% won't go very far. The paperwork burden was not addressed and this is choking primary care docs.

The ACP should put out a publication about its successes with health care reform. The other option would be a 30 minute infomercial.

Grrldoc said...

While I support my primary care colleagues, don't forget that there is also a looming general surgery shortage on the horizon. Despite technology, there is still nobody else who can take out a gallbladder, or help heal a polytrauma victim. But the road to becoming a surgeon is progressively more daunting: compounding interest from school loans over 5 years of residency, rising malpractice and declining re-imbursement. I support primary care, but not all of the specialties should be left by the wayside.

Steve Lucas said...

Credibility and prominence are two very different things. Some supposed medical groups have great prominence while representing a minority of doctors and receiving direct funding from pharma and other commercial enterprises. These groups measure their success by injecting themselves, with great fanfare, into the national debate.

The ACP has built it's reputation on fair even handed analysis. While not as splashy as other groups, over the long term, this will build the credibility needed to have a seat at the table. Various blogs point out daily the failings of the commercial aspects of the medical community. This work does not need to be duplicated.

The ACP needs to continue the focus on primary care of all types. This not only helps those front line doctors but also patients. There appears to have arisen the concept that patients and doctors are at odds when it comes to care. The reality is patient care and doctor's interest are tied and cannot be separated.

The ACP needs to take the long view and continue to press its message at the political level with facts and information. As a patient I can only hope the culture in Washington is changing as the financial realities of our economy shows the fallacy of some past reliance on certain groups.

Steve Lucas

Anonymous said...

I think it is already too late. No matter what they do, they are going to lose a number of physicians this year. The low reimbursement mentality for the last decade has put primary care physicians on a hamster wheel in order to keep their doors open.

With the economic problems the nation is facing, patients are putting off their chronic non-acute or low acuity visits.

The hamster wheel has now stopped. Primary care has no way to generate new revenue (since all the insurance carriers have contracted away their ability to raise fees or add fees) to pay expenses.

I have been witness to three practices closing down and reduction in staffing at many others. Once the staffing goes down to one or two staff members, the office is bound for closure.

The days of solo practitioners are numbered and group practices are under stress.

Anything the congress does to "help" will take their usual congressional time period of 6 months to forever to implement.
That will not be quick enough for many solo practioners.

PCP said...

One wonders, what the reform that the ACP is advocating will end up look like.
The emphasis appears to be on vague entities such as "primary care workforce" "Student Debt forgiveness". Coordinated care. Etc. Yet, Generalists already coordinate care, Debt forgiveness jobs abound, and Primary care is an ill defined term. Even so, the current dearth of those entering General IM is apparent.
If the ACPs view of Primary care IM is one of a CHC/FQHC doctor, then I am afraid that I can't support that. I've been there and done that.
The role of Mid-level providers in Primary care has never been adequately defined, in an employed setting it becomes even more vague, and this is one of the 800 pound gorillas in the room of a discussion about physician manpower in Primary care.
If the result of changes are for a shift in emphasis and resources from specialty care to Mid-level provided primary care, then I as a generalist don't see much benefit from it for me or my patients. If I must structure my practice to care for complex elderly patients, I must be adequately reimbursed to invest in the technology and staff to deliver that care.
Furthermore, a mere shift in resources from specialty doctors to mid-level driven care (such as at CHCs and FQHCs) may just lead to an equally demoralised specialty physician workforce, less willing to accept referrals, ER calls, consults, and out of hours call. Surely that will just put us generalists in a difficult spot. Again, I've seen this bad movie once previously working at a CHC with difficulties obtaining referrals etc.
I was very much taken aback by the ACPs position paper on NPs in primary care, which categorically stated that NP practices as Advanced medical homes should be one option. Far from it, IMHO, a NP should have to work in collaboration. Congress needs to understand that this along with the relatively minor CMS payment rate differentials between various types of primary care providers is behind the Physician desertion of General IM(arguably who see the sickest patients).
Underpinning all this mess of course is the RUC. The RUC must be reconstituted or broken up. It has been an abysmal failure for generalism and in the end since what is good for generalism is good for the profession(even if specialty medicine does not realise that today) then the RUC would have ended up sinking the ship.
Until we acknowledge the grossly unfair constitution method of the RUC and its role in causing this mess, I don't see much reason for hope. Internists will continue to gravitate to Specialty medicine and Hospitalist medicine, Administrative and Pharma jobs, and just about anything other that direct patient care.