Friday, April 24, 2009

Restoring R-E-S-P-E-C-T to primary care internal medicine

The American College of Physicians today released two major new policy papers proposing comprehensive solutions to the crisis in primary care. One paper recommends restructuring physician payment models used by Medicare and other payers to support the value of care provided by internists and other primary care physicians and to achieve overall better value for the health care system. This paper has two key components:

- Giving the federal government the authority to implement, evaluate and then rapidly expand new models of physician payment to align incentives with the value of care provided, not just the volume of service - including models that specifically support patient-centered primary care. ACP proposes specific criteria for identifying the models with the greatest potential to result in improved outcomes, which could then also be used to develop benchmarks for evaluating their impact on a pilot basis. Finally, the paper calls for a fast track way to expand the most effective models, with input from outside experts, so that they can be adopted more widely without getting bogged down in the usual, and painfully slow, Medicare demonstration project bureaucracy and rules.

- Concurrently improving payments for primary care under the prevailing fee-for-service system used by Medicare and other payers. ACP calls for providing annual bonus payments for primary care physicians beginning in 2010 until overall payments reach parity with other specialists; re-examining the processes Medicare uses to get expert input on the relative value units (RVUs) for physician services; creating a better way to identify potentially mis-valued services, which could then be redistributed back to primary care and other under-valued services; correcting distortions in the practice expense RVUs for advanced imaging; and providing separate payment for e-mail and phone consultations provided by primary care physicians and other specialists involved in care coordination.

The second paper released today calls for a creation of a new national workforce commission to recommend the appropriate numbers and mixes of physicians and other health professionals, including increasing the numbers and proportions of primary care physicians, and policies to achieve such goals. ACP proposes a comprehensive and coordinated strategy including payment reforms, as discussed more fully in the payment paper described above; emphasizing the value of primary care in medical schools and graduate medical education training programs; increasing the number of GME-funded primary care training positions; eliminating student debt for physicians who provide primary care in critical shortage areas; increasing funding for the National Health Services Corps and the Title VII primary care training program; reducing paperwork burdens on primary care physicians; and funding the patient-centered medical home and other models to provide primary care physician practices with financial and other resources needed to coordinate care effectively.

Combined, the two papers address the major causes of dissatisfaction so many general internists attending IM 2009 have expressed to me in conversations over the past few days: insultingly low and dysfunctional payment policies; enormous paperwork burdens; high levels of student debt; and a medical education system that contributes to the sense that the prestige lies in fields other than primary care. Underlying all of these concerns, though, is what I would describe as a profound sense that what they do is not valued or respected by society. Turning this around will require a coordinated national strategy that addresses every point of influence, from medical school through residency, of how their services are valued and reimbursed throughout their careers, for primary care internists to regain the respect they so rightly deserve, because of the importance of what they do for their patients.

Today's question: What do you think are the most important things that can be done to end the lack of respect for general internists and other primary care physicians?


Brad F said...

there is a lot of great stuff in these papers. however, too much to read and the executive summaries dont do them justice. In particular, payment methodology and PCMH czar all new slants.

Annals perhaps will publish concise summaries, or maybe a more casual distillation to come via ACP in the future?


Unknown said...

All that sounds great. The thing that bothers me is that the entire discussion lately seems to be over what sort of centralized planning we need. The fact is, for all the high-minded and (I think) genuine arguments for this or that model of reimbursement, even the best laid plans will be altered beyond recognition by the legislative process. Beyond that, the newly-created, or retooled, agencies that will oversee all of this will most certainly take on lives of their own (as agencies always do). In the end, I think it is a huge mistake for the medical community to place their very professional viability and ethical standards in the hands of politicians.

It seems to be taken for granted that it is the (very semi-) capitalistic side of the equation here in the US that is causing the problems. I would argue that it is the central planning side that is to blame. Why not get the government out of the healthcare business and let people make decisions with their own money? I know, the first response will be something having to do with ‘two-tiered’, ‘unfair’ or something along those lines. Let us not forget that those unfair conditions exist in countries with socialized medicine as well. Canada’s second tier is the US, the VA’s is community physicians, etc. (Not to mention that it is the existence of these second tiers that allow these otherwise closed systems to function at all.)

As an IM resident planning on a career in primary care, my first, second and third choice is to be left alone. I would much rather compete for patients’ dollars based on their individual (and well-informed) decisions, then continually beg a heartless, and most likely brainless, government agency for my living.

Just one guy’s opinion.

Robert J. Sobel, M.D. said...

What we need is coherence at the regulatory and FDA level, a playing field where new versus old agents and technologies do not have extreme price discrepancies. Our patients still want to respect us, but they can't understand why we have to fight to approve their new drug or change medications at the whim of a third party system (pharmacy-benefit efforts) that is both unethical and interfering with the practice of medicine.

When many of my complex, modern, patients, have clinically appropriate (in my professional opinion) regimens whose annual cost is well into five figures, it is clear that my prescription pad is driving everyone else's profit. The unregulated financing of drugs is a key problem that must be fixed if the primary care physician (whose job clearly involves being a steward of appropriate pharmaceutical management) is going to get any respect.

The Happy Hospitalist said...

How are you defining respect? Money?

Larry Wellikson said...

I was very happy being a traditional general internists for 20 years, but today we are in deparate times. I would hope we might consider having medical schools designate spots on admission for general medicine or peds or FP to fill the pipeline as we fix payment and respect issues. The current system of self selection at the end of medical school is not working to meet the eneds of an aging public

Jay Larson MD said...

Even though increased reimbursement would help, the greatest sign of respect would be not challenging an internist's medical decision. All too often prior authorization forms have to be filled out for patient care to proceed. Paperwork is killing off internists and the insurance companies have no hesitation to increase the paperwork burden.

DrJHO7 said...

I had always thought that respect is something that is earned. I sensed respect from all of the patients I saw in my office today. I sensed respect from all of the colleagues I interacted with at IM '09, last week. I sensed love and enthusiasm for our specialty, Internal Medicine, at that conference by its diverse group of attendees.
So what is not respected?
Answer: "primary care".
Primary Care is a label that some physicians were dubbed with in the late 80's, early 90's with the rise of managed care. It's a moniker that, like HIV to the mononuclear cell, like a worm virus to the code of a computer program, some physicians are inextricably and incurably infected with. When these physicians became "PCP's, with the second P standing for provider, we lost our identity as medical specialists, and we became something less than physicians, at times indistinguishable from other providers of medical care who are not physicians. The only way out of this is to throw off the yoke of "primary care" and become the physicians/medical specialists that we are, again. This will not be easy because "primary care" is now well known to the public, the legislators, the insurers, and various medical/surgical specialists, and like many infamous nick-names in the history of our culture, will not be easy to shed.
Significant payment reform is absolutely essential, and without it, we won't need to discuss "primary care" any more, because it will die.
Meanwhile, we can regain some of the respect we have lost by first being internists, pediatricians and family physicians, with emphasis on the word PHYSICIAN. "primary care" may be part of our job descriptions but it is not how we should be defined. As for internists, if we walk the walk and talk the talk of internal medicine, we will be known and respected for what we are, who we are, and how we do what we do, for patients.

rabornmd said...

As a third generation Florida medical physician, I am concerned about my sons attitude about the medical profession. I know a lot about helthcare in other societies. Most socialized medical systems require 1-2 years of social service before physicians can train for specialties. I believe that will be the case for the USA, perhaps even more time.