Tuesday, March 8, 2011

You say you want a revolution. . .

Dr. Bob Centor blogs that primary care physicians are staging a “quiet rebellion” by forming concierge practices and opting out of Medicare:

“The system has constrained primary care fees while systematically increasing overhead. The system has listened to well meaning researchers and -ologists to declare primary care physicians in need for quality improvement. The system has undervalued the value of a good primary care physician. The system has, without consciously meaning to, held primary care in contempt.

So what do primary care physicians do? They do what any sensible economic citizen would do, they alter the rules to their benefit.

So decreasing numbers of primary care physicians are taking Medicare or Medicaid. So primary care physicians are leaving their jobs to do hospital medicine. So many primary care physicians are leaving the CMS/insurance company grid and retreating to retainer practices or cash only practices.

The rebellion is a quiet one. No one has declared this rebellion. This rebellion has no Glenn Beck or Sarah Palin; no Abbie Hoffman or Che Guevera. This rebellion occurs one physician at a time, as that physician finds continuing their practice undesirable.”

I have the greatest respect and affection for Dr. Centor. He writes the always interesting (and entertaining!) DB's Medical Rants blog and has been a mentor to me on the fine art of blogging, As a member of the ACP Health and Public Policy Committee (which I help staff), Bob is unafraid to challenge conventional thinking, often expressing healthy skepticism about the latest policy fad of the day.

But now, I am the one who is skeptical. Bob’s premise that “decreasing numbers of primary care physicians are taking Medicare . . . “and that “so many primary care physicians . . . are retreating to retainer practices” just didn’t read true to me.

So I went looking for the evidence, and found that retainer [otherwise known as concierge] practices are growing—but they constitute a very, very small niche of perhaps several hundred physician practices, concentrated mostly on the East and West coasts. I also found, counter-intuitively, given the ongoing specter of Medicare payment cuts--that the percentage of general internal medicine physicians who participate in Medicare reached an all-time high in 2010.

• Six years ago, the GAO did a study that found that "Concierge care is practiced by a small number of physicians located mainly on the East and West Coasts. Nearly all of the 112 concierge physicians responding to GAO's survey reported practicing primary care.

• An updated 2010 report on retainer-based practices, conducted by the University of Chicago for the Medicare Payment Advisory Commission "found listings for 756 retainer-based physicians, which could be seen as a lower limit for the number of physicians practicing this model of care. This is an increase from the 146 retainer physicians identified by the U.S. Government Accountability Office (GAO) for a 2005 report...the vast majority of retainer physicians are primary care physicians. Of the 333 physicians for whom we were able to collect specialty information, more than three quarters were internists, and a fifth specialized in family medicine." The study also found that the presence and distribution of concierge practices is very uneven by geographic area, with most concierge practice being on the East and West coasts and many states have few if any retainer practices.

• According to official CMS data files, in 2010, over 97% of internal medicine physicians signed an agreement to participate in Medicare (and accept the Medicare rates), a record number, and the percentage of internists participating in Medicare has increased each and every year since 2000 (when it was a little over 90%).

• ACP’s 2009 membership survey found that that only 0.5% of respondents said that they would switch to concierge/boutique medicine when asked to describe their expected professional situation in the next one to three years.

I don’t question Bob’s overall hypothesis, which is that more and more primary care physicians are dissatisfied with current practice models and looking for alternatives. But at least so far, it doesn’t appear that internists are dropping out of Medicare, or that very large numbers see retainer practices as the solution.

I believe it will take a revolution in the way that primary care is educated, financed, organized, reimbursed, and delivered to elevate it to status and influence it should have in our health care system, and to make the beleaguered internist feel better about their futures. But when it comes to retainer practices being the solution, I have to answer like John Lennon did when he wrote the lyrics to the Beatle’s cynical “Revolution” in response to the revolutionary fervor of the 1960s:

“You say you got a real solution,
Well you know,
We’d all love to see the plan.”

Can retainer practices, which depend on primary care physicians seeing fewer patients and charging them out-of-pocket for improved access and time with the doctor, be the real solution to the crisis in primary care? Well, you know, I love to see the plan. Retainer practices may work for some physicians, and some patients, in some markets, but I don’t see the plan for them to be a real solution, and so far, it seems like most primary care physicians don’t either.

Today’s questions: What do you think of Dr. Centor’s premise that primary care physicians are staging a quiet rebellion manifested by more joining retainer practices or dropping Medicare? And do you see retainer practices as a real solution?


PCP said...

You bob on your perch in DC will not see the shift on the ground until very late in game.
The change is very slow and insidious. In your mind what is Hospital medicine? Hospitalists may "participate" in medicare but receive a healthy subsidy of over 100K a year on average, without which it is hard to imagine how the specialty could even exist.
There was a survey some time ago which showed that nearly 20% of General Internists were no longer in Medicne altogether. Some are moving into the management and business side of medicine, some are moving into other services like cosmetic medicine. Many more are trudging along, not because they are happy with the current situation, but because they feel trapped. Concierge medicine is but yet another manifestation of this escape. Some, esp. those over 60 who worked and saved in the pre-SGR era of medicine are calling it a day earlier than they perhaps otherwise would have.
There is no new General Internist under the age of 47 in our town.
That void is getting filled even if inadequately by a variety of providers, but it is not in a way that is beneficial to the patient as a whole. We are seeing more fragmented care, less well coordinated care, less quality OP care with more resulting admissions etc. A solution there is, but a very inadequate one and probably a more expensive one.
The sad part about all of this is that the public had no role in this destruction of OP General IM. This was inflicted on them by the RUC of the AMA. We have not been valued for what we contributed and having lost faith that things will change in the foreseeable future, are each making decisions in our own ways. Let the system go where it must, and its defenders in DC keep thinking there is no shift on the ground.

Steve Lucas said...

I only wish I could find a cash or retainer practice in my area, and I have looked. For over 20 years I have been bombarded by doctors who want to maximize my insurance.

As a business person I have cringed at some of the statements made by doctors. Good decent people all, but the nature of an insurance based practice turns them into something less than professional.

As a patient I would be disabled at best, or simply dead. The drug cocktails or surgeries, not recommended but demanded, leaves the whole profession at risk of being marginalized. One doctor wanted all of his patients to have a BMI of 20 or less and unlike other doctors, he was not afraid to up the dose of fen-phen. Another doctor also used the 20 BMI standard but preferred lipo, and my bad knees most certainly needed surgery to repair, even though previous specialist had stated this would be of no use.

The list goes on and on and delves into some very personal issues, but the rush of the insurance based practice does not allow the necessary time to deal with my personal situation.

My weightlifter body means I weigh more than others and my cardio responses are different, yet I have watched doctors disregard specialist reports in favor of what they know is best: Medicate me so as to maximize my insurance and their income.

This change can not happen fast enough for me. Bob has got this right, doctors don’t like the current form of practicing medicine, and patients who have a choice, will look to the cash or retainer physician for their medical needs. This is the future of private practice medicine.

Steve Lucas

Arvind said...

Unfortunately for the ACP, you Bob, will continue to believe what you have always believed. So trying to convince you is not my premise.

What I predict will happen in about 5-10 years is that there will be a two-tier system - one where patients will pay appropriately for the care and attention they feel they deserve (roughly 10%)and the rest will stand in lines to be seen by the next available PCP or more likely the next available PA/NP.

Even then you will be saying what you have just said, and you will not be incorrect. But PC IM will be nearly dead (long live the ACP).

Steve Lucas said...

Expanding on Arvind’s point, the coming market segmentation will produce some interesting dynamics. Those in a retainer practice will be not only the wealthy, but those who are able to combine this care model with a higher deductible insurance policy. Already some average people have found this to be cost effective.

The bulk of the population will continue with the insurance model now in place. They will feel their co-pays and monthly premiums equals’ quality medical care. The problem, from my perspective, is that with the growing corporate ownership of medical practices these people will be pushed into over use of our medical resources. There will be no cost savings.

These people will be pushed from test to test and medicated to the latest standards, all aided by a perversion of EMR’s, in an effort to maximize insurance revenue. Given the trend, this will translate into government spending.

Cash practices will not only attract the low income but also those who wish to opt out of the insurance merry go round and maintain a high deductible policy, or those with no real medical issues.

Next week my wife and return to Paris, a trip we have been making yearly for over two decades. Misconceptions abound on both sides of the Atlantic concerning medical care and payments. Many in Europe believe we have people wandering the street, thrown out of their homes due to medical bills. Those in America speak of our superior system.

My reality is that in Europe you are treated for the problem at hand. A doctor will ask if there are any other medical issues you wish to discuss, but treatment is confined to the issue presented. There is also only one price.

In America the drive is to feed the medical monster. Often presented medical issues are ignored in an effort to maximize income. Well sir this problem is minor, but we see you have put off some invasive test you insurance will pay for, we have an opening next week, does Wednesday or Thursday work best?

The retainer and cash practice returns doctors to practicing medicine, develops relationships, returns a patients voice to treatment decisions, and often can cost both the patient and system less while improving the doctor’s income and work/life dynamics.

What is there not to like?

Steve Lucas

Harrison said...

Do we really want to be in practices where patients pay extra for us to pamper them?
The patients who are ill and consequently less able to pay for extras will likely need us more, but we will be caught up with people who pay to talk endlessly about whether they really need annual carotid duplex scans because they occasionally feel dizzy.

I don't know.
I would choose hospitalist work over that.
It can be overwhelmingly busy, but it feels right to be taking care of people who need what I have to offer.

And I don't want to be a hospitalist.
I don't want our profession to become enmeshed in shift work mentality.


Jay Larson MD said...

I agree with Dr. Bob Centor that the "quiet rebellion" is the extinction of outpatient general medicine. Concierge practices and opting out of Medicare is not the main exodus. It is leaving practice all together, becoming a hospitalist, or going to the VA system. No matter what the path, the numbers of outpatient internists available to the general population is going the way of the dodo.

The best is yet to come. As Medicare starts to use sticks on the internists that are not using e prescribing, using EMR's, or reporting quality data, the pace will pick up. As Medicare requires a full blown progress note with certain data recorded to order a wheelchair or home health, the pace will pick up. As the RVU of office visits remain flat, the pace will pick up. As more and more non-reimbursed work falls onto the internist, because no one else is willing to do it, the pace will pick up.

Just like any natural disaster, only a few will know what devastation is on the way. The rest will be in shock after the storm has moved through.

dr_dredd said...

I disagree with Dr. Larson's comment about working for the VA system being the equivalent of an exodus from primary care. Right now I provide primary care for a panel of about 850 veterans of all ages and income levels. Visits for established patients are 30 minutes, and new patient visits are 60 minutes. Although there are plenty of bureaucratic hassles that I hate dealing with, it at least allows me to continue working in primary care. If I had to work in private practice or be a hospitalist, I'd switch careers.

Jay Larson MD said...

dr dredd,
I did not mean that internists going to the VA system is death to primary care. The VA system is much more primary care friendly than in the private sector. Since the VA system shifted to a primary care system, quality has gone up in the VA system. The point I was making is that when an internist goes to the VA, they are no longer available to community patients. Our community has lost several primary care physicians to our local VA system, and they are much happier for it.

Unknown said...

Now Hiring: Medicine's Martin Luther King

Enjoy year-round sunshine with a month paid vacation. Earn 300K plus production bonus. No state tax! No call! Daily I'm bombarded with glossy postcards promising the good life.

With so many options, why are physicians fleeing medicine? Some leave for teaching, waitressing, even homemaking. Others escape into administration, insurance or pharmaceutical positions. Many simply retire in despair.

Robert Centor MD writes about our quiet rebellion: "This rebellion has no Glenn Beck or Sarah Palin; no Abbie Hoffman or Che Guevera.  This rebellion occurs one physician at a time, as that physician finds continuing their practice undesirable."

And the truth behind the exodus?

There can never be year-round sunshine for physicians working in an unjust health-care system.
And $300,000 can never be enough to numb the pain of dedicating one's life to a profession that has lost it's soul. A month's vacation can only distract us from our suffering for about thirty days.

Now is not the time for doctors to give up call but to accept a call to action. Ours is a sacred obligation, a covenant with patients. America's greatest dreams can never be delivered by politician-saviors. We are the saviors we've been waiting for.

Years ago, I stopped pursuing the elusive production bonus; I stepped off the treadmill to follow my heart. And I discovered: To heal my patients, I had to first heal my profession. So I led town hall meetings inviting citizens to design their ideal clinic. Celebrated since 2005, our model has sparked a populist movement: Americans are creating ideal clinics and hospitals nationwide. One hospital CEO now affectionatley calls me "his MLK."

More than a quiet rebellion, we need a non-violent social revolution led by doctors. Medicine needs a Dr. Martin Luther King Jr. I think I'll apply for the job.

Pamela Wible MD