When I talk to internal medicine audiences around the country about the latest health policy flavor of the day - accountable care organizations (ACOs) - a typical reaction is skepticism trending toward cynicism. Many don’t quite get what ACOs are all about and certainly don’t want to be lectured about how they need to re-invent their practices. And they don’t buy the idea that ACOs will somehow save internal medicine primary care. The same can be said, perhaps to a lesser extent, about their reactions to PCMHs (Patient-Centered Medical Homes), P4P ( pay-for-performance), HIT (health information technology), MU (meaningful use), and the whole alphabet soup of other reforms being proposed to reform health care delivery and payment systems.
And who can blame them? Older internists have seen this all before, and the word has gone out from them to medical students and younger doctors not to trust policy prescriptions that promise to save primary care.
In the 1970s, doctors were told that HMOs would allow primary care internists to focus on wellness and prevention (that is why they were called “health maintenance organizations,” after all) and they would be paid appropriately for keeping their patients well. HMOs, of course, became managed care, which for most primary care doctors meant even more paperwork for even less money.
In the 1980s, they were told if they became gatekeepers, they would be back in charge of the system and be paid appropriately for it. A 2004 retrospective New York Times op-ed by Lisa Sanders, MD, titled “The Death of Primary Care” recounts the promise and perils of gatekeeping. She noted that in 1985, [the late] John Eisenberg, an internist and ACP fellow, wrote in the Annals of Internal Medicine that the gatekeeper concept ''sanctifies the internist's role as primary care physician and captain of the patient's ship.'' Maybe the idea could have worked if insurance companies didn’t turn it into a paper chase for authorization forms, but instead, as Dr. Sanders observed, “the gatekeeper kept people away from otherwise available specialists. It was a job despised by doctors and loathed by patients.”
In the early 1990s, the RBRVS was going to improve reimbursement for the “cognitive services” provided primary care physicians. It did some good for at least awhile, but the RBRVS begat the RUC, budget-neutrality conversion factor adjustments, behavioral offset assumptions, resource-based practice expenses, and its evil twin sister, the SGR – and a whole lot of other processes and policies. Now, some twenty years after the RBRVS first went into effect, payments to primary care doctors in the trenches have fallen even further behind other specialists. In the mid-1990s, it was capitation that was going to make things better, but capitation ended up being a transfer of insurance risk onto the back of the beleaguered primary care doctor, with the perverse effect that internists who took care of the most complex patients were paid the least!
Now it is P4P, PCMHs, HIT, MU, and ACOs that are supposed to save primary care, right? Given the history of other failed policy interventions, skepticism trending toward cynicism is a perfectly justifiable reaction from primary care internists.
The problem with cynicism, though, is that it can be an excuse from holding on to a status quo that itself is not sustainable. If every new idea is rejected because other ones didn’t work as expected, then primary care will remain stuck where it is right now—over-worked and under-valued.
The challenge, then, for those of us who believe that change is necessary and even inevitable, is to show that the PCMHs, ACOs, and other ideas for reforming payment and delivery systems can really work for the doctors in the trenches. Articles in prestigious journals, white papers from policy conferences, and well-meaning policy papers from organizations like ACP won’t hack it. We will instead need to demonstrate that the new models really, really, really can result in better payment, more time with patients, and fewer hassles for real doctors in real practices. We will have to fight to make sure that what seems like good ideas aren’t hijacked by insurance companies and other special interests into something entirely else, like we saw with gatekeepers and the resource-based relative value scale.
Like the legendary refrain from the legendary rock band, The Who, primary care doctors are screaming that they won’t be fooled again, and policy advocates would have to be deaf, dumb and blind not to hear them.
Today’s questions: What do you think the history of other failed policies tell us about the latest ideas for saving primary care?
P.S. I will be blogging from ACP’s annual scientific meeting in San Diego all week, and will be moderating several educational sessions on health care reform on Friday, April 8. Check the scientific program guide under the “Ethics and Health Policy” track for more details. Hope to see you there!