Strengthening Primary Care With A New Professional Congress

Strengthening Primary Care With A New Professional Congress

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Three months ago a post argued that America’s primary care associations, societies and membership groups have splintered into narrowly-focused specialties. Individually and together, they have proved unable to resist decades of assault on primary care by other health care interests. The article concluded that primary care needs a new, more inclusive organization focused on accumulating and leveraging the power required to influence policy in favor of primary care.

The intention was to strengthen rather than displace the 6 different societies – The American Academy of Family Physicians (AAFP), the American College of Physicians (ACP), the Society for General Internal Medicine (SGIM), the American Academy of Pediatrics (AAP), the American Osteopathic Association (AOA), the American Geriatrics Society (AGS) – that currently divide primary care’s physician membership and dilute its influence. Instead, a new organization would convene and galvanize primary care physicians in ways that enhance their power. It would also reach out and embrace other primary care groups – e.g., mid-level clinicians and primary care practice organizations – adding heft and resources, and reflecting the fact that primary care is increasingly a team-based endeavor.

We came to believe that a single organization would not be serviceable. Feedback on the article suggested that several entities were necessary to achieve a workable design.

So we propose here a new set of allied entities that, by convening clinical and non-clinical primary care stakeholders, will work to re-empower primary care’s role within the larger health care enterprise. In addition to aggregating and leveraging the strengths of existing primary care organizations, this new effort would collaborate with patients and health care purchasers to gather the influence required to effect positive change.

New Organizations

We envision four new organizations – an umbrella group and three professional entities – each independent and with its own governance structure. Membership in any organization would provide membership in the umbrella Congress. The names we have applied are suggestions only.

The Congress of Primary Care Professionals. This umbrella entity would bring all groups, including existing societies, together in a representative structure. The Congress would seek to galvanize and mobilize the power required to revitalize primary care, not only for primary care’s benefit but as a key remedy for America’s health care cost crisis. The effort must be about primary care, not a specific group within it.

The Section on Primary Care Physicians. Currently there is no physician organization that unites all primary care disciplines. Many physicians are adamant that they should have their own entity, and have expressed concern that physicians’ roles might be devalued inside a structure shared with mid-level practitioners.

The Section on Allied Primary Care Professionals. The accumulation of power requires inclusiveness. It makes sense to establish a separate section embracing nurse practitioners, registered nurses, respiratory therapists, radiation technologists, physical therapists and others participating in primary care.

The Section on Primary Care Organizations. A new society structure could mobilize influence by rolling up and leveraging the power of larger primary care practices. As one physician practice leader noted, “Market traction will come from organizations that facilitate more efficient and effective primary care.”

Where to Begin?

An undertaking like this begs several questions.

Will primary care physicians, other clinicians and organizations participate? We believe that primary care can be reinvigorated, but any campaign must first convince primary’s practitioners that a new effort is worthwhile.

Who can jumpstart this? Established primary care practices – particularly those that are sizable – have some resources and offer opportunities for collaboration and the development of a larger national campaign.

What’s in it for me? Why should I bother? Primary care practitioners have been diminished under old regimes that divide primary care by sub-specialty. Their other positive attributes notwithstanding, the standing societies have been unable to drive payment policy that meaningfully appreciates primary care’s measurable value. In turn, this failure has resulted in the diminishment of primary care’s current status and future prospects. A new effort would be dedicated to restoring an appreciation of primary care’s value in policy and the marketplace.

What will this Congress do (and not do)? We should emphasize that this effort does NOT aspire to assume most roles of existing societies (e.g., standards, continuing medical education). Instead, it will create structures that can more fully and fairly represent primary care’s interests. If the new primary care organizations focus on gathering strength that can create influence, then they must do several things.

– They must actively recruit members.

– They must develop approaches for easy, rapid communication with members (e.g., email bulletins, Webinars, semi-annual meetings). Taking advantage of more modern approaches like social media could streamline operations and costs as well as differentiate the new entity.

– They must analyze policy related to primary care.

– They must develop pragmatic alliances on policy advocacy with non-health care business.

– And they must drive advocacy that speaks for all primary care, and only for primary care.

Don’t existing primary care societies already do these things? Current primary care societies may respond that they already are engaged in these approaches. That said, despite their efforts, primary care as a whole is in desperate straits, and likely to remain so. Several societies maintain they can advocate for both primary care and sub-specialty interests. Comparatively low payment and stature has driven medical students away from this discipline. Most societies continue to participate in the AMA’s Relative Value Scale Update Committee (RUC), though its opaque and biased power structure has consistently undervalued primary care services. We believe a fresh approach is necessary.

Can primary care change health care? Not by itself. But primary care is the natural ally of health care purchasers, the one group with more size and influence than the rest of health care combined. Creating a unified primary care front is the first step in building an alliance that can reshape health care to be more reflective of broad primary care values and in the public interest.

Brian Klepper, PhD is an independent health care analyst and Chief Development Officer for WeCare TLC Onsite Clinics. His website, Replace the RUC, provides extensive background on the role that the AMA’s RVS Update Committee has had on America’s health care cost crisis.

This framework was developed with the participation and support of the following advisors:

William Bestermann, MD is an Internal Medicine Physician and Medical Director of Chronic Condition Management at the Holston Medical Group in Kingsport, TN.  Tom Emerick is a health care advisor to business, and the former VP of Global Benefits for Walmart.  Paul Fischer, MD is a Family Physician and Founder of the Center for Primary Care in Augusta, GA. He is the lead plaintiff in a lawsuit against HHS and CMS over their unaccountable relationship with the AMA’s RUC, in violation of the Federal Advisory Committee Act.  Tad Fisher is the former Executive Director of the Florida Academy of Family Physicians. He is now Executive Director of the Florida Physician Therapy Association.  Richard Glock, MD is a primary care internist and lead physician in the Internal Medical Group in Jacksonville, FL.  Paul Grundy, MD, MPH, FACOEM, FACPM is IBM’s Global Director of Healthcare Transformation and President of the Patient-Centered Primary Care Collaborative (PCPCC).  Jerry Miller, MD is a Family Physician and Founder of the Holston Medical Group in Kingsport, TN.  Patricia Salber MD, MBA is CEO of Health Tech Hatch. A former Internal Medicine physician at Kaiser Permanente, she later served as Medical Director for several large health plans.  Richard Young, MD is Associate Director of the Family Medicine Residency Program at John Peter Smith Health System. He has authored a book and blog, American Healthscare, and is in the initial class of CMS Innovation Advisors.

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48 Comments on "Strengthening Primary Care With A New Professional Congress"


Guest

I am really glad you wrote this piece, Brian. I am not sure I agree with the method suggested here, but unless primary care stands up to be counted now, right now, it will most likely become something no one wants to practice and will disappear of its own accord with huge consequences to most patients.

I am not certain that a blended entity is needed. I actually think that the current primary care societies should get together, just like they did in 2007 when they brought us the joint PCMH principles, which are changing the professional lives of their constituents (some supervision here is sorely needed), and pull their resources to truly represent primary care physicians.

My feeling is that such combined effort should target the people of this country to clarify the role of primary care and how it is being currently diminished and what this means to individual patients. It should not be a lobby for increasing payments or fighting specialists. It should be an advocacy for patient care, because primary care is the only specialty that aligns naturally with patients (not necessarily purchasers of health care). And unlike other purchasers, patients will support their doctors if they understand the stakes.

I appreciate your large tent approach, but I don’t believe this is how most physicians see their profession and, to my knowledge, most don’t believe that this is in the best interest of individual patients either. A professional association, or a consortium thereof, should represent its members, and we should step back, listen and accept the voice of the majority of physicians, even if it conflicts with current policy and other interests.

Right now, doctors in general, and primary care in particular, are being railroaded by powerful financial interests, and I somehow don’t see them supporting a new entity to more efficiently decompose their profession.

Guest
Oct 2, 2012

Margalit,

Why do you suggest that this would be about “more efficiently decompos[ing] their profession?”

For the past two decades reimbursement has been structured through the AMA’s RUC to dramatically favor specialists at the expense of primary care. In general, specialties are the gateways to revenues for the powerful financial interests you allude to. So long as primary care remains diffused and weak, it will die, and the real losers will be continue to be patients and purchasers.

Maybe I misunderstood your phrasing, but I so strongly disagree with your statement that I was shocked. You assert “a professional association should represent its members, and we should step back, listen and accept the voice of the majority of physicians, even if it conflicts with current policy and other interests.”

This is craziness. Health care has become about the interests of the industry over those of patients and purchasers. It must be the other way around, or we all ultimately lose. There is little evidence that what is good for the industry is by definition good for the rest of us.

A couple statistics. RAND calculated last year that, currently, $4 out of $5 in household income growth now is siphoned off by health care. Only $1 of growth is available for other needs, like education and infrastructure replenishment. At the same time, US firms competing in the global marketplace are at a 9+% disadvantage on health care costs, relative to competitors in other industrialized nations.

These figures are being driven by the regulatory capture of the specialties and other significant health care interests. Only an alliance of primary care and their most natural allies, non-health care business, can turn this around.

How do you see physicians in general, being railroaded by powerful financial interests? I’m certainly in the middle of the marketplace and I don’t see it. Give us some examples.

If you’ve got a better plan that I’ve presented to revitalize primary care, we’re all ears.

Guest
Pam
Oct 2, 2012

I know how to revitalize primary care—let the PA’s and NP’s do it. There solved.

Guest

Brian,
First my apologies if I wasn’t clear on my intent. I am not arguing that specialties have not contributed their fair share to the woes of primary care through undue influence on the RUC (I do, however, blame CMS for allowing this to happen). Either way, considering the economic situation of most people today, I don’t believe that leading the primary care charge with demands for more money is good political strategy for whoever ends up representing these physicians.

From what I see, there are concerted efforts from industry stakeholders to undermine the natural alignment between doctors and patients in general, and primary care in particular (i.e. railroading). This takes the form of continuously messaging the public on the “paternalistic” and materialistic conducts of doctors and the need to have them monitored and supervised by both consumers (not patients) and payers (public and private, including employers). It includes the revival of managed-care, where those managing the care are neither doctors, nor patients, the rise of technology algorithms (programmed by whom?), supposedly better suited than physicians to make decisions, and yes, the relentless advocacy to supplant primary care physicians with less expert resources, at least for the poorer folks. The 80-20 good enough rule may be OK for manufacturing, but I doubt it is ethically OK for medicine. To sum it all up, this is about reducing costs through redefinition of what quality of care means.
And I think that in this country, quality of care means that every American should have unfettered access to a personal physician. And the primary care associations thought the same way back in 2007. What happened in 5 short years to change that conviction?

This ties in nicely with my opinion that if we have to trust someone in health care, and we must, then my vote would be to trust physicians who have an ethical and moral obligation to do the right thing, and in particular, we should trust primary care doctors, who have practically no financial interest in all the things that make health care expensive, and the opposite may actually be true. This is why I suggested that we stand back and let the “members” of this fictitious organization lead the way. It’s their job to do so; it’s their professional responsibility which they accepted the day they chose to take that “old-fashioned” oath, and three quarters of them are telling us that what we are doing today (or proposing to do) is not likely conducive to better patient care (recent Medscape survey, amongst others). This should gives pause, if we cared for what we say we care.

My advice to primary care physician has always been to go to the public and enlighten people about the likely effects of taking away medical decision making from physicians and patients, and placing it in the hands of entities that either have shareholders to answer to, or are mired in a perpetual elections cycle. Primary care doctors were, and are, and should be, perceived as the natural advocates for individual patients. Not for purchasers. Not for job creators or financiers. Not for voters and elected officials. Just people, one at a time, as the Harvard maxim says. People need to understand that reformations and transformations aimed at neutering the patient’s one remaining powerful advocate, while providing lip service to “patient empowerment”, is not in their best interest (and it won’t cut costs either). Get this message out, and you will have 300 million people (99%) behind you.

Guest
Oct 2, 2012

This is a better explanation. Thanks.

That said, especially given the egregious record of self-interested health care waste, I believe we all need to be accountable, even doctors, and even primary care doctors. And the worry that self-interest is guiding everything becomes significantly less if the payment structure is care-neutral, rather than designed to promote more services that accrue to the financial benefit of the provider.

Guest
southern doc
Oct 2, 2012

“payment structure is care-neutral, rather than designed to promote more services that accrue to the financial benefit of the provider.”

What’s a care-neutral payment structure?

With a growing shortage of primary care doctors, shouldn’t we be encouraging them, financially and otherwise, to provide more services (E&M codes) rather than fewer? That’s a miniscule drop in the bucket of health care spending.

Guest
Oct 2, 2012

Southern Doc,

Sorry for using a shorthand term. A “care neutral” reimbursement methodology is one that doesn’t create a financial incentive to deliver unnecessary care or deny necessary care. In my onsite primary care clinics, we pass through the operational costs – the costs of the clinicians, drugs, labs, office supplies, utilities, insurance – with no markup, and then we charge a per patient (or per employee) management fee for managing the process.

I agree that we should be paying primary care physicians significantly more, so that the discipline becomes more attractive to students, and so that practices can invest in the tools/skills that will facilitate better identification and management of patients with risk.

In my clinics, physicians (or NPs) have patient loads of 1,600, which translates to 20 minute office visits. Compare this to most practices that are seeing 2,500-3,200 patients, with 7.5-12.0 minute visits. Those practices typically refer 25%-35% of their patients to specialists – double the rate of a decade ago – while we’re referring 12%-18%, and we can demonstrate that we get better outcomes. The difference is in the percent of traditional primary care patients that have been jettisoned into becoming specialty cases, often at 15x-20x the cost, because the specialists are financially incented to do diagnostics and procedures.

In other words, all reimbursement methodologies have tremendous impacts on care patterns. One that is neutral relative to the care provided is optimal

Primary care physicians should be paid based on their measurable value in the system, which if considered properly, is much greater than currently understood. The value they create by good management is easily offset by reduced costs downstream.

Hope this helps.

Guest
southern doc
Oct 2, 2012

Thanks for the reply. So are the docs in your clinics on straight salary, no productivity?

Guest
Ron Hammerle
Oct 2, 2012

The current system will change only if primary care professionals decide to quit mining the gold and getting left in the shaft. The referral-dependent Mayo brothers understood that a century ago.

Adding four new organizations to six existing ones won’t do it, but Brian knows that the current six pack can’t and won’t achieve the objective..

There are, however, lessons to be learned from the history of the AFL and CIO, stereotypes, professional egos and current market positions notwithstanding.

Recognizing this could happen in healthcare, hospitals and insurers are rapidly buying up primary care practices and retail-affiliated clinics far more rapidly than primary care can get organized. Like family farmers of old, rugged individualism has its limitations..

Ron Hammerle
Tampa, Florida

Guest
William Light M D
Oct 2, 2012

Primary care is already dead. The future willbe teams of NP and PA’s working with an MD team leader . Maybe 2 to 4 per MD . It will take a ratio that high to provide the number of patient visits needed.

Guest
Oct 2, 2012

Southern Doc:

Yes, our docs are on salary. There are incentives for hitting quality targets and also for seeing a targeted percentage of patients within available appointment slots. But there is no incentive to simply see more patients. We believe that is a counter-productive approach.

Guest
southern doc
Oct 3, 2012

Hmm, I wonder about that.

After four years of undergrad, four of med school, three of residency, is a salaried situation, with no chance of advancement, no possibility of ownership really going to attract the best and the brightest?

What’s going to motivate the docs to stay late and see those three extra patients instead of sending them to the ER, to come in on Sunday PM and see someone, to take two hours on the phone getting the pre-auth done?

Lawyers and accountants know that if they work harder they build their practices and get paid more. Do we really want to completely take away that from doctors?

Wouldn’t work for me.

Guest

Well, effectively, since they only carry about 2/3 of a typical patient load and have a 9 to 5 type of job, which from what I hear, people find attractive these days in medicine, Brian is paying docs almost double the per-visit market rates, assuming he is paying them a decent amount.

If we applied a similar pay rate across the board in primary care, I have a feeling that you would get the same results (i.e. longer visits), plus the commitment inherent in an independent business owner scenario, plus real continuity of care.
The “only” caveat would be that about 1/3 of people now having a doctor would find themselves doctorless. The solution may be to stop poaching internal medicine graduates for hospitalist jobs and have them go out and practice longitudinal care through the entire spectrum. Sort of like it used to be before some folks decided that breaking up continuity of care makes more money for hospitals.

Guest
Oct 3, 2012

Physicians and NPs like working for us, and we have no problem at all recruiting top notch clinicians. We pay at the 90th percentile. Clinicians use 21st century clinical decision support tools. No money changes hands in the clinics, so it changes the “tone” of the practice, something the clinicians find very attractive. They have no administrative responsibilities. Physicians aren’t rushed, and so they can spend time with their patients. It’s much more like the medicine they imagined they’d practice in med school.

That said, the purpose of my article wasn’t about describing how my clinics work, but to make the point that current primary care medical societies have squandered their ability to meaningfully influence policy in ways that benefit patients, purchasers and primary care physicians. A new Congress is necessary to unite and give more leverage to primary care.

That would be the first step in real health reform. The next is to galvanize non-health care business, primary care’s natural ally. Together, these groups could begin to rationalize health care and bring it back into homeostasis.

Guest
Oct 3, 2012

Very thoughtful and interesting. Over the years the sub-specialists used this strategy. They stayed separate but took control of the AMA and the RUC to advance their mutual interests.

I think it is important to have each type of primary care professional be supported by their respective professional organization. Family Physicians, pediatricians and general internists overlap in their philosophy of care and scope of practice. But their differences are also important and need to be sustained – which their specialty organizations can handle.

I think it is important to mention that the AOA is not a primary care organization but represents all Osteopathic specialties. Also the American Geriatric Society is composed almost, but not completely, of Family Physicians and Internists.

The issue of what is and what is not primary care is a tricky one. There are a small but growing number of clinical pharmacists who argue that they should be recognized as primary care professionals. Their schools of pharmacy are upgrading their curriculum to prepare their graduates to practice as independent primary care clinicians.

I applaud the idea of a common “political” front to represent primary care. At that same time I think there is need to clarify and respect the boundaries among the various professionals.

Guest
Oct 3, 2012

Dr. Bauer:

I believe the proposal presented here satisfies the criteria you lay out. As I describe above, existing primary care societies representing all disciplines would be preserved and convened through a larger house of delegates, which they would participate in but not control. This is important because, as you point out, several of the current societies – AAP and ACP, for example, represent both primary and specialty care physicians.

In a sensible world, the clinical pharmacists you mention would be welcomed as primary care professionals.

In other words, the Congress would unify and strengthen primary care as an overarching discipline, while maintaining the distinctive characteristics of each professional group within the House of Primary Care.