Tuesday, June 30, 2009

Does President Obama have the right Rx for primary care?

Last week, President Obama made his most extensive comments yet on the crisis in primary care. In his responses to two questions - one from a nursing student and the other from a medical student - during a town hall meeting hosted by ABC News, Obama had this to say:

"Well, first of all, we need more people ... who are going to school and committed to the kind of primary care that's going to be critical to us bringing down costs and improving quality. We're not going to be able to do it overnight. Obviously training physicians, training nurse practitioners, that takes years of work. But what we can do immediately is start changing some of the incentives around what it takes to become a family physician.

Right now, if you want to go into medicine, it is much more lucrative for you to go into a specialty. Now, we want terrific specialists, and one of the great things about the American medical system is we have wonderful specialists and they do extraordinary work. But, increasingly, medical students are having to make decisions based on the fact that they're coming out with $200,000 worth of loans. And if they become a primary care physician, oftentimes they are going to make substantially less money, and it's going to be much harder for them to repay their loans.

... But what we're also going to have to do is start looking at Medicare reimbursements, Medicaid reimbursements, working with doctors, working with nurses, to figure out how can we incentivize quality of care, a team approach to care, that will help raise and elevate the profile of family care physicians and nurses as opposed to just the specialists who are typically going to make more money if they're getting paid fee-for-service.

... And one of the things that I'd like to explore -- and I've been working with the administration and with Congress -- are their loan forgiveness programs where people commit to a certain number of years of primary care. That reduces the costs for their medical education. That would make a significant difference.

If we provide the right incentives I think we're going to start seeing more young people say that going into medicine is a satisfying, fulfilling profession -- especially if we can eliminate some of the paperwork and bureaucracy that they have to deal with right now ...

But I also think that one of the big potential areas where we can make progress is ... how can we get nurses involved in more effective ways. If you look at what's happening in some states, like Massachusetts, where they tried to create a universal system -- and they haven't quite gotten there yet -- they have had a problem with an overload of patients.

... One of the areas where we can potentially see some saving is a lot of those patients are being seen in the emergency room anyway, and if we are increasing prevention, if we are increasing wellness programs, we're reducing the amount of emergency room care, then that frees up doctors and resources to provide the kind of primary care that will keep people healthier, but also allow them to see more patients and hopefully give more time to patients, as well."

It is good to hear the President describe primary care as "critical" to improving quality and bringing down costs. He also seems to have a good grasp of the reasons that young people aren't going into primary care, including high student debt, poor pay, and excessive paperwork.

Obama doesn't believe, though, that the answer is to just train more primary care physicians and pay them more. Instead, he wants reforms to "raise and elevate" the roles of both primary care physicians and advanced practice nurses under a "team approach" that "incentivizes" quality of care. And he wants to help reduce the debt of both doctors and nurses that go into primary care.

Today's question: Do you agree with Obama's prescription for the primary care workforce crisis and the roles of both physicians and nurses?


Jay Larson MD said...

The problem with the prescription is that it requires a "prior authorization". Considering the attitude of the medical system towards primary care, might as well prescribe a placebo.

How does one "incentivize" quality of care? Shouldn't have quality of care been the main goal of medical care anyway? How did the medical profession get so off track? Perhaps the RUC could answer that question.

The "team" approach is fine and dandy for efficiency; but isn't a hugh part of medical care is being a patient advocate? How can a doctor be a patient advocate if a surrogate meets with the patient.
Besides, nurse practitioners and physician assistants are going into specialty care just like the medical students.

Even with loan forgiveness and increased reimbursement (which will still be substandard to specialists) the grass will still be green on the other side of the fence of primary care.

PCP said...

Today I am more convinced than ever, that I want this crazy effort at health care reform to tank, so we can come back with a more sensible effort, basically "live to fight another day".
The notion that PCPs and APNs are equatable and interchangeable, and that we all get together on that basis is laughable.
This is not the prescription that will make Primary care attractive to young doctors. It is obvious that policy makers are totally missing the boat on this issue. Perhaps we have not been represented properly on this point for fear of a foodfight.
Loan forgiveness will help but not solve this matter either. We have to elevate Generalism back to what it was. The generalist must once again be the captain of the ship accountable to the patient and none else. The APNs must work in a team led by the generalist, and we alone must coordinate and hold accountable all specialty care services rendered. With that will come the influence within the health care system, with the hospital administrators, with the specialists and with nursing staff.
Failing this model, why would a medical student waste his/her time with primary care. Why would a patient see a primary care doctors role as any different to any labcoat in the room. Where would that longitudinal relationship be built form.
Mr Obama has zero grasp of this issue facing young doctors. He has listened to the vocal ANP lobby too much. The results of this reform are going to be terrible. Far from having a rejuvenated PCP workforce, we will end up with a angry, bitter, fed up and revolting specialty workforce, with manifestations such as disinclination to take call, cherry picking referrals, early retirements and other such actions that will make a PCPs life far more difficult. So far from helping us, we will end up stuck in tough situations.
If this reform is about helping APNs while hurting Specialists and being change neutral for generalists, that is a really raw deal for me. It sounds more and more like that now.
With regards to the Mass. Experiment, it is a grand failure for generalists, they have to work more, get less, have even less to distinguish them form NPs and pay has not really improved. Mr. Obama seems to feel if anything those changes have not gone far enough.
I have this sinking feeling right now.

Peter said...

A goal of reform should be to decrease the number of referrals to specialists and to have complex care managed by a primary care physician. Putting more burden on nurse practitioners who tend to refer patients more often to specialists will have the opposite desired cost effect.

Steve Lucas said...

From the other side of the desk, as a patient, I would most identify with Jay's comments. What we most see are nurse specialist. What we most lack is an advocate. What we all want is better system than we now have.

Steve Lucas

Leonidas300MD said...

Bob , with all due respect , you and ACP are insane . The proposed legislation will kill internists, elevate interlopers like PAs and NPs and doom private practice. I have quit my membership and will look to work with an organization which represents private medicine.