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Primary care crisis is HERE

I recently heard from a UCSF physician who was flabbergasted when he sought an
appointment in our general medicine practice and was told it was “closed.” Turns out we’re not alone: there are also no new PCP slots available at Mass General. The primary care crisis has truly arrived.

I’ve written about the roots of the problem previously, and won’t restate the sad tale of woe. But I hope you’ll take the time to listen to two very powerful NPR reports on the topic – the first, a WBUR special by healthcare journalist Rachel Gotbaum called “The Doctor Can’t See You Now,” is the best reporting on this looming disaster I’ve heard (here is the MP3 and the show’s website). The piece is long (50 minutes), so I’ll summarize a few of its moments that really hit home.

First, it is true – MGH is not accepting any new primary care patients. Like UCSF, therefore, getting “a regular doctor” at MGH now takes the combination of cajoling, pleading, and knowing somebody generally referred to as “working the system.” In other words, the process of finding a primary care doc is now like getting a great table in a trendy restaurant. Obviously, this is horrible for patients, but it is also no fun for doctors. For example, in the NPR special, MGH’s director of Emergency Medicine laments:

“If you really want to give me heartburn, you can say, excuse me but I know you work at Mass General and I would like a primary care physician please.”

As someone who gets requests like that about once a week, I can empathize. Of course, things are far worse for the patients. One woman described her efforts to find a primary care doc this way:

“Yeah, I asked people who had really good doctors that they would put a word in for me and it was almost like writing a personal ad: ‘Hi, interesting woman who’ll talk to you, gives good history…’  ‘Gives good history,’ that would be a really good thing to say!” [she laughs]

The report also makes clear that providing more “access” through expanded insurance coverage won’t do the trick. Massachusetts, you’ll recall, markedly expanded its coverage a couple of years ago (in legislation proposed by that ex-liberal, Mitt Romney). Scott Jasbon, a 47 year-old contractor/bartender, thought he was all set when he enrolled in one of Massachusetts’ subsidized health plans. He was wrong.

“I received a card with my doctor’s name on it and I was told that was my primary care physician. I called the office. They told me that they no longer took the insurance. So then I went through every list of doctors in Sandwich, in the book, called each doctor, and each doctor told me the new plan that I received, they, no one took the insurance… I knew that there was something wrong with me, and I was explaining to each doctor actually as I called them, ‘I’m having problems urinating.’ Hot flushes, I was hot all the time. I knew something was wrong, and I couldn’t get anybody to take care of me.”

Jaspon ended up in an ED, where he was diagnosed with diabetes and hypertension. The ED staff helpfully suggested that he should think about getting a PCP.

What’s happening is old news. The combination of 15 minute visits to see patients bearing both complex medical problems and 20 pages of internet printouts to discuss, the loneliness of a small group practitioner, the lack of prestige, the woefully low pay (the income of the average PCP is less than half of that of many specialties, including dermatology and radiology) in an era in which the average medical student finishes school more than $100,000 in debt, and the sensibilities of Generation Y trainees –- who now are looking for reasonable “lifestyles” and incomes without the need for martyrdom –- have combined to push all but the most unusual medical student and resident away from primary care careers. At Mass General, one out of the 50 graduating internal medicine residents last year was planning to become a PCP; at UCSF, our numbers are only slightly higher.

Some primary care educators used to say that the problem was that students didn’t have opportunities to see the real practice of primary care docs –- if they did, they’d recognize the subtle satisfactions and be more inclined to enter the field. But an upcoming paper by UCSF’s Karen Hauer and others demonstrates that such exposure actually discourages trainees from choosing primary care. Primary care docs are frustrated and demoralized, and most of them are honest enough to share their angst with their students. In other words, It’s The Practice, Stupid.

The dwindling number of PCPs who remain in practice are being far more discriminating about the patients –- and insurance payments –- they will accept. With Medicare reimbursement tightening (Congress just overrode the Prez’s veto of a proposed 10% Medicare pay cut, but you can bet that the proposal will be back again next year), Medicaid reimbursement near Starbucks barista levels, and states proudly providing subsidized insurance at Medicaid-like reimbursement rates, the result is primary care “access” that sounds good in a press conference but is not real.

You might ask, won’t the existing PCPs need to accept even these low insurance payments? After all, they need to see some patients to generate an income. Well, as it turns out, no.

The remaining PCPs are in such demand (not only because so few people are entering the field, but because so many are leaving it –- an ABIM study found that 10 years after initial board certification, approximately 21% of general internists were no longer in the practice of general medicine [vs. 5% of subspecialists leaving their field]) that they can afford to limit their practice to patients with better paying commercial insurance. A few, of course, are limiting their practices even further –- to well-heeled patients willing to provide an up-front stipend of several thousand.

And, for big academic practices like UCSF’s and MGH, opening up new primary care practices involves substantial subsidies, which most academic medical centers are increasingly unwilling to provide. The 1990s theory that you needed a big primary care base to feed your neurosurgery and liver transplant programs has not materialized. Many academic hospitals (including ours) are packed to the gills; with managed care de-fanged, most patients can get to us without necessarily receiving primary care in our system. The result: more “Closed To New Patients” signs.

Won’t the market and the political process work this problem out? Not so much. Even though everybody recognizes the crisis at hand, bumping Medicare’s primary care reimbursement presently involves changing the formula used to calculate reimbursements to all physicians. This is handled by a Secret Society known as the "RUC": the RBRVS Update Committee. In a 2007 JAMA article, Harvard’s John Goodson described the RUC’s membership:

“The RUC has 30 members (the chair only votes in case of a tie) with 23 of its members appointed by ‘national medical specialty societies.’ Meetings are closed to outside observation except by invitation of the chair. Only 3 of the seats rotate on a 2-year basis. Other members have no term limits. Seventeen of the permanent seats on the RUC are assigned to a variety of AMA-recognized specialty societies, including those that account for a very small portion of all professional Medicare billing, such as neurosurgery, plastic surgery, pathology, and otolaryngology.”

In other words, representation on the RUC is like the Senate rather than the House, and in this case, Montana isn’t very excited about turning its money over to California. And since the dollars available for physician payments are capped (at best), bumping primary care reimbursement significantly can only be accomplished if dollars are freed up through lower payments to radiologists, plastic surgeons, and other specialists (and guess who has the better lobbyists). (A percentage or two won’t help because the increases needed to change the dynamics are on the order of 20-40%.)

For more details on the RUC, check out Roy Poses’ blog, which has made a cause out of exposing the committee’s biases and secrecy, and Maggie Mahar’s terrific description of the RUC’s history and inner workings.

The state of primary care is not only sad, it is incredibly stupid. Mountains of research have demonstrated that primary care-based care is less expensive. Without access to primary care doctors, patients get their basic care in emergency rooms, or from subspecialists, or not at all. In any case, care is fragmented, technology over-intensive, and wickedly expensive.

The second NPR report I liked described primary care in the Netherlands, where the cost of health care is far less than that of the U.S… and the doctors make house calls! How do dey do dat? Easy. They’ve determined that providing superb access to primary care, even in patients’ homes, is not only humane and effective, but probably saves money by preventing unnecessary ED visits and hospitalizations. Just one more reminder of how dumb our present system is.

The forces of inertia getting in the way of solving the primary care crisis are so strong that only a very powerful implosion will create the political wherewithal to overcome them. Specialists don’t want to forgo income, medical students will continue to vote with their feet, existing primary care docs have resigned themselves to more of the same and are hunkering down for retirement, and many patients are perfectly happy bypassing primary care docs to get their care from hordes of subspecialists. The patients who take the biggest hit, of course, are poor and middle class folks with chronic diseases – even those with insurance, who can’t find a PCP and can’t afford a VIP doctor, and who therefore live in perpetual fear of the next crisis.

When insiders like medical school faculty members can’t find a regular doctor, though, you know that this dysfunctional and unsustainable situation is now coming to a head. Once gas prices and the mortgage meltdown begin receding from the headlines, expect that the primary care crisis will become a Page One issue.

It’s about time.

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mulberry outlet yorkDepartment of Family MedicineContrarianconnie sansMedical Schools Sacramento Recent comment authors
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mulberry outlet york
Guest

5:06 Nets center Andre Blatche hits a jumper to make the score 62 57, and Pacers announcer Chris Denari mentions that like in Boston, Kevin Garnett has to come out early in the first and third quarters. This reminded me of the Pacers pregame show I was listening too on 1070 The Fan when Austin Croshere mentioned that he doesn fully buy in to this Brooklyn squad to be a top seeded team. Basically Croshere believes that with the years of basketball mileage on their body, Garnett and Pierce could perhaps reach their full potential if they played once every… Read more »

Department of Family Medicine
Guest

Primary Health care centers of the National Guard Health Affairs have access to Family Medicine back up on the campus and in the Hospital. The Department is sharing a significant work load by classifying patients in routine management and specialty referrals. Pre-employment check up, and annual evidence based screening services are the key provisions., to learn more please enter her

Contrarian
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Contrarian

I suppose physicians are like the Obama administration in that they have difficulty in getting the general public to understand major underlying issues when it comes to healthcare. Let’s take the $70 per patient payment as just mentioned. The doctor works 7 hours and sees 10 patients. That becomes $700 a day or $100 per hour. Now let’s double the number of patients to 20. This now gives us a total of $1400 a day. That’s twice as much as some people think an over paid doctor should make. Wow $1400 a day or $336,000/year! Now let’s say the doctor… Read more »

connie sans
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connie sans

Hello, If Medicare pays a doctor 70.00 a visit for example. IF the doctor sees ten patients a day isn’t he making at least 700 dollars plus you know he’s making money more on other insurances. I am just wondering if doctors just want a bigger pay hike and how much of an issue is this really? I believe other issues exist. My doctors make over 100 a visit. Are their lifestyles just demanding more money or is this really an issue? Most doctors i see live very nicely. How are they affording that? Many are in 6 figures working… Read more »

Medical Schools Sacramento
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its really useful article thanks for sharing such a nice information..i want to share some useful information from Medical school Sacramento this blog about medical studies please check this out for your useful comments thanks
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FP
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FP

as a primary care physician, i’m grateful to read this article. many of us did not go into primary care for the money, needless to say, but we did because we love what primary care was about–knowing the whole patient, and caring for the whole patient. i feel this is taken for granted. i don’t think many specialists can appreciate how hard it is to manage seeing 20-30 patients a day who have 5-10 concerns, ranging from the mundane to life-threatening. it’s a challenge to be able to translate their problems into medical language–to make it fit in the framework… Read more »

anon
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anon

Who do you suppose CMS went to for advice on how to pay for a medical home? That’s right, the RUC, who came up with a ridiculous scheme that no one in their right mind would sign on to. Primary care is now the career of choice for the discerning student who, after residency, can set up a cash only practice in this wide open field, cherry pick patients and net 3x the average salary of an FP. After years of being undercompensated by third party payers through the auspices or the RUC, I became cash only and this year… Read more »

slippingsloth
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slippingsloth

I go to a state medical school(UCLA) and my student budget is $48k annually. Multiply by four and $125k is not the number you come up with. Its more like $200+ interest. Before getting accepted at UCLA, I was planning on going to USC whose current cost per student is in the $66k range. Realistically if you average out the public and private medical institutions my guess is $250k is a reasonable debt expectation at graduation. This debt continues through residency while you make $35k/yr. Honest question as a medical student though, is it that specialists make too much at… Read more »

tcoyote
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tcoyote

US med student debt is almost double the $125k in Canada.

Tom Lacroix
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Tom Lacroix

In Canada medical students pay approx $15,000 per year tuition. Average debt on exit is $ 125, 000 which is on par with the US. We are still able to get 40% of students to choose family medicine. My belief is that there is a better culture of valuing the primary care specialist. As an example 7 of the 17 medical schools in Canada have family physicians as Deans of Medicine! All schools have departments of family medicine (http://www.carms.ca/eng). There is also a national concerted effort to move more funding and residency positions into family medicine. While it is tempting… Read more »

bostondoc
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bostondoc

@DP: Harvard has no department of family medicine…this is about as close as it gets, I believe: a Tufts residency in a hospital that happens to also have a Harvard affiliation. http://www.tuftsfmr.org/curriculum/academic_affiliates.shtml But that isn’t to say Harvard trains no primary care physicians. Harvard-affiliated hospitals do train a small number of general internists and pediatricians (as well as a handful of med-peds docs). But Harvard still isn’t a significant source of primary care physicians. Very few of its students or even the residents of its primary care programs actually go into full-time primary care. Hospitalist practice, with higher salary for… Read more »

Manny Hernandez
Guest

This is an issue that is also extensive to areas such as endocrinology and diabetes treatment. In its most recent issue, the diaTribe newsletter touched on the numbers of medical students planning on pursuing endocrinology with an emphasis on diabetes as their area of focus and the results were pretty scary… decreasing numbers of specialists for one of the fastest growing chronic conditions there is in the US.

SReynolds A4H
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SReynolds A4H

The Future of Family Medicine (FFM) report documents the current crisis in the U.S. health care system and how family physicians are uniquely positioned to address it. One of the few bright spots to come out of the report is the TransforMED http://www.transformed.com/index.cfm initiative which is a 24 month National demonstration project to transform family practice in the US. The American Academy of Family Physicians (AAFP) took a leadership role in creating a new, not-for-profit initiative, TransforMED, to put the FFM recommendations into action. It includes projects at 14 medical schools to transform the content and structure of their residency… Read more »

DP
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DP

Does Harvard have a department of family medicine? If so, how large? If not, why not?

Peter
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Peter

jd, Does any other nation force as much debt on all college students? I’d be in favor using free schooling to create more primary care but it should come with some payback strings. I’d also use this carrot to attract students from low income and “rural” communities. No free ed for specialists though.