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?