Can Health Plans Explain Why They Aren’t Re-Empowering Primary Care?


Sometimes a whisper is more powerful than a shout. Here’s a cartoon from Modern Medicine that shows a Medical Home counseling session between a primary care physician (PCP), a specialist and the health plan. The PCP looks forlorn, while the specialist and the insurer have their backs turned, fuming. It is perfectly true.

Along with changing the way we pay for all health care and creating far greater pricing and performance transparency, we need to turn around the primary care crisis if we hope to substantively improve quality and cost.

Over decades we allowed the combined actions of the AMA,
Medicare and the nation’s commercial health plans to marginalize
primary care
, so that now the typical cardiologist makes up to 4 times
more than a PCP, and only 7 percent of medical school graduates now
enter office-based primary care – not nearly enough to care for the aging boomer population that’s growing by leaps and bounds.

Worse, as the most recent Dartmouth Atlas report
made clear, the greatest concentration of "unwarranted variation" –
waste – is concentrated in the specialties and inpatient
arenas. This explosion in services and cost has largely resulted from tying the hands of America’s PCPs, preventing their involvement in downstream decision-making. Equally corrosive culprits have been a fee-for-service reimbursement system that financially incents specialists to conduct unnecessary procedures, and a lack of transparency that would allow us to more easily identify the excesses when they occur.

There’s hardly any question whether empowering primary care would dramatically improve the system. As Sepulveda, Bodenheimer and Grundy pointed out in a March Health Affairs article, literally dozens of studies show that more primary care in a community is associated with lower costs and better outcomes. More specialists lead to higher costs. In the US, the ratio of PCPs to specialists runs about 30/70, while in other developed countries its typically around 70/30. Their costs are generally about half ours and their outcomes better. Can anyone really argue with a straight face that empowering primary care is an iffy proposition, and that it demands more study before acting?

The entire premise of the Medical Home movement, seen most vividly through the efforts of the Patient Centered Primary Care Collaborative (PCPCC), is based, first, on empowering PCPs to do the things they were trained to do, and second, giving them the tools, programs and authority to optimize their roles. The PCPCC has been built around the power of Fortune firms and business health coalitions, each with considerable stroke, as well as several primary care associations. The health plans are at the table too, busily showing their support through pilot projects that test what happens when PCPs are paid a pittance more.

Even that is critically important, though, because the commercial health plans are the linchpins of change for this aspect of American health care. Unlike public health plans, who must adhere to policy that is dictated by the health care industry’s lobby, the commercials can respond to market forces. Health plans also are the only ones who can reach and transform the practices of the 250,000 or so community-based PCPs faltering under the lash of our current reimbursement paradigm. Their salvation is absolutely vital to re-establishing American health care’s stability and sustainability.

But so far as we’re aware, not one national health plan has yet decided to move beyond a pilot and unilaterally improve their medical management performance by paying PCPs significantly more. So far, there are no broad-based efforts to empower PCPs to have a say in what happens to their patients once they’re referred downstream to specialists. Nor are health plans systematically helping PCPs acquire the sophisticated patient management information technologies that can result in better outcomes at lower costs.

What are they waiting for? Why aren’t health plans making this obvious and straightforward adjustment to their medical management models? Skeptics might argue that, despite their protests that they’re in business to hold down costs, health plans make a percentage of total claims, so they certainly don’t want total claims to be less.

The plans might respond that they don’t want greater PCP involvement to antagonize the specialists, who they rely on. After all, its clear that, interference notwithstanding, collaborative decision making at the specialist level drives down specialty utilization and, with it, specialist incomes.

Or they might argue that they run enormous, complex operations, and big course changes are difficult and take time. Whatever.

Hence the inherent truth of the cartoon.

Still, there’s no question that we’re at a tipping point and that the time for action has come. Health plans have reported weaker enrollment figures, with reductions in the sales of even their much skinnier High Deductible Health Plans (HDHPs), as more employers and families are priced out of insurance. The coverage market is eroding as health costs continue to spiral upward, exacerbated by a credit crisis that is freezing liquidity. These economic trends are abetted, of course, by a primary care structure that is unable to exert control over the unbridled provision of specialty and inpatient services.

All this would be academic if there weren’t a very visible alternative model that performs MUCH more efficiently. Employers with strength and foresight are actively moving around the health plans by establishing worksite clinics, effectively staff model primary care practices that are fully realized medical homes. In general, these enterprises pay PCPs far better than they make in private practices, giving them access to excellent tools, and letting them loose to provide the care they know how is appropriate. The results are dramatic. Clinic companies routinely report significant savings, both on group health costs and occupational health and productivity costs, which are corroborated by their clients.

If the reports from the big benefits firms are right, more than half of all jumbo Fortune firms will have put up worksite clinics by 2010. Because these clinics are scalable, the trend is now catching like wildfire with large and even midsized (down to about 250 employees) firms as well. Several clinic firms are also working to bundle commercial insurance products with clinics in ways that allow smaller businesses and individuals to come together, collaboratively using the clinics to enhance access and drive down cost.

But the core problem remains. We won’t have real change in the delivery of care until the health plans either voluntarily change their relationship with primary care, or are forced to do so. As the cartoon  suggests, they’re not inclined.

So here’s a sincere request. If you’re a reader of this blog associated with the health plan sector, how about provide us with a lucid explanation of your hesitancy to change. What EXACTLY are you waiting for? Tell us.

If you’re a primary care physician and you agree with us on this, then please send this post to your regional health plans and pointedly ask why they’re dragging their feet. Pass this along to business leaders you know as well, and ask them to contact their health plans too.


Brian Klepper PhD is a healthcare market analyst. David C. Kibbe MD MBA is a Family Physician and Senior Advisor to the American Academy of Family Physicians who consults on healthcare professional and consumer technologies.

31 replies »

  1. It will no doubt include a reallocation of RVUs to primary care activities and away from some overused diagnostic testing procedures. Like MG mentioned, there are some powerful vested interests, but we’re past the point of allowing them to rule the day. Everyone is going to have to give a little. For instance, I think the technical component of ultrasound is overvalued and needs adjusted. I am shooting myself in the foot because my group gets a significant amount of revenue from ultrasound. However, it’s just something that must be done.

  2. Along with changing the way we pay for all health care and creating far greater pricing and performance transparency, we need to turn around the primary care crisis if we hope to substantively improve quality and cost.

  3. This is a great discussion. In particular the exchange between Deron S., Brad F., and MG regarding the RVU system is especially germaine. The RVU system, and particularly the RUC (AMA Relative Value Update Committee) is a root cause for the discrepancy between PCP and specialist pay. The RUC sets these values; CMS accepts almost all its recommendations. Of the 29 members of the RUC, only five currently represent primary care specialties. The vast majority of the representatives to the RUC are appointed by other surgical, procedural or subspecialties. As a result, the outcome of the RUC’s deliberations have usually been procedurally focused and oriented, to the detriment of the “cognitive” medical disciplines. How the members are chosen is up to the AMA and the specialty societies. The proceedings of the RUCare not public and are not available to the public. Thus, a private organization has tremendous influence over the public and private payment system with essentially no transparency or accountability. Reform of the RUC is a very good place to start, and one that could be changed fairly quickly, if only to open up the deliberations to public scrutiny.
    I am a physician in subspecialty surgery, but understand completely the need for many of the reforms cited in this tread, especially the PCP/subspecialty payment spread.

  4. Another great discussion.
    Responding to the comments about medical education: The Mayo Clinic Health Policy Center is hosting a Medical Education Reform Symposium in April 2009. The purpose it to identify, discussion and come up with actionable steps to reform medical education to support health care reform in terms of coordination of care and creating value. There will be sessions on the overlap of health care reform and medical education reform, realigning the health care training system (at all levels) for coordinated patient-centered care, designing what a medical education system should look like, life-long learning in the health professions, and financing medical education. The end result will be a set of steps (a roadmap of sorts) that need to be taken for change to occur.
    I encourage you to check it out on our Web site (http://www.mayoclinic.org/healthpolicycenter/2009-agenda.html). This is a critical discussion — not just for phsyicians, but for physician extenders, nurses, and allied health professionals. We must begin to train a work force that can collaborate in new ways and provide better outcomes more efficiently.

  5. Is it possible to encourage or mandate the ACCGME, ABMS, AMA to increase the # of pcp/specialty slots per year to say a 50/1 ratio. Perhaps a moratorium on specialty slots for 5 years. This could curb the supply and demand problem and eventually lead to greater pcp emphasis and filling the needed gaps across our communities. In support of specialists this would increase their net-value to the industry as they could control their pricing power by volume limitation. In support of medical schools and specialty training programs, the programs get reverse incented for limiting specialty slots. Use this extra funding to support ongoing specialty research.
    Healthcare is kind-of like the current auto industry, we all want to transition from foreign-oil to environmentally friendly hybrid/electric types; sort of analogous to primary preventive medicine. But the Big-3 like the current health system is so high on the hog (oil); analogous to turning our expensive specialists at the expense of pcps.

  6. I’ve seen “inept know-nothing” primary care docs, but I’ve also seen plenty of inept, narrow-focused “chance to slash is a chance for cash” specialists, too.
    I appreciate the help of a good cardiologist in a complex cardiac patient, but I don’t think a good cardiologist is 400% more valuable to the community than a good family doc or internist.

  7. Deron S – The brutal truth is that specialists in this country have to adjust to the reality that they are overpaid. Granted everyone always thinks they are unpaid and under appreciated to some degree but I have found having this conversation with specialists is particularly difficult even when grounded in facts (e.g., a number of specialties in this country are among the highest average annual salary per capita in the US, salary difference between specialists in the US vs. specialists in other countries is greater than the salary difference between PCPs in the US vs. specialists in other countries).
    There are two things I find most amusing though. One is that if specialists become defensive about their salary is that they inevitably bring up the compensation of health plan CEOs and large health care delivery systems. This happens in almost every conversation. When you try to point out that the average hospital CEO makes less than they do, they scoff and point to an individual exception who makes more than this amount.
    The most amusing point though is when a specialist talks about how they could have gone into other more lucrative fields like private equity. Maybe but the reality is that the true guts of any hedge fund are quant. geniuses. I have friend who does this and he is a math savant. While strong with numbers, I could never do what he does. Just don’t have the natural ability and I doubt my attempts at seeking education in this field would have succeeded either. I am willing to bet that most specialists wouldn’t be able to hack the quant. stuff either. Plus, there are a bunch of investment bankers and hedge funds who have going to have to look for other types of work right now. Specialists have life-long employment.

  8. I’m more optimistic than most. I think Congress will take notice if there is a more coordinated and comprehensive push for some of these changes. If the right people can get around a table and develop a proposal that shows exactly WHY we need to focus on rebuilding the primary care delivery system, and HOW to do it, Congress will listen.
    It will no doubt include a reallocation of RVUs to primary care activities and away from some overused diagnostic testing procedures. Like MG mentioned, there are some powerful vested interests, but we’re past the point of allowing them to rule the day. Everyone is going to have to give a little. For instance, I think the technical component of ultrasound is overvalued and needs adjusted. I am shooting myself in the foot because my group gets a significant amount of revenue from ultrasound. However, it’s just something that must be done.

  9. Really, really good comments. Yeah you can tweak how GME (graduate medical education) is funded and what residency programs receive or implement other solutions but when you get down to the heart of the matter, there are only two broad solutions to this problems:
    1. Ultimately tear up and replace the RBRVS with something entirely new in the next several years.
    2. Fundamentally change the process by which the RBRVS is set and calculated on an annual basis.
    Either one of these is going to require some type of serious action from Congress ultimately though and will all of the other issues that have to be deal with over the next 12-18 months, I just don’t see this being a high priority. Plus, you also have a number of powerful vested interests who do everything they can to largely keep the status quo. Maybe something changes in the next session of Congress but I wouldn’t be willing to bet on it.

  10. Why is the ability of a PCP to use their analytical and intuitive thinking to find the root cause of illness determined to be worth less in this health system? True diagnosis isn’t easy given all the contributing factors and that there is no two alike. I agree with docanon in his comparison of intellectual difficulty working OR and a surgeon doing his 500th stent placement and trying to justify reimbursement – although each has it’s degree of repetitive learning leading to routine. A surgeon looks like a savior because the process looks complicated (and it is) but the skills needed to be a good PCP can’t hold the same TV excitment because that process is in their brain. We should pay PCPs more not less if you look at their potential value on health. My dissatisfation with my PCP encounters has probably been due to the reimbursement system coupled with the PCPs own financial goals – not my health goals. They find out they only need basic training to make a living. But PCPs should not just be viewed (in the best system) as simply a gateway to specialists.

  11. Deron
    The CPT bump was mostly smoke in mirrors. Because changes have to be budget neutral, they upped the RVU’s but rejiggered the multiplier against which it is multiplied. While some codes when up, in the end the equation robbed peter to pay paul.
    I am too tired to offer commentary on payments to surgeons/subspecialists. I am biased, truth is somewhere in the middle obvioulsy, but payment system is based on outmoded, Eisehower/Kennedy era paradigms on technology, how physicians should be compensated for its application. I am not a PCP, but boy, after seeing them in the office after 25 patients and a long day. they deserve as much as anyone else.

  12. The RVU system was recently tweaked to add quite a bit more value to E&M codes. Why aren’t PCPs talking about that? I agree that there’s still room for more tweaking, but if I’m not mistaken, the bread and butter CPT code of 99213 was increased by more than 12%. That had to produce a nice bump in compensation, as long as PCPs negotiated a corresponding increase with the non-Medicare payers if their fee schedules weren’t already tied to Medicare.
    It would be easier to justify further primary care increases if PCPs can offload some of the more routine work to midlevels. Physicians tend to balk when I say that, but I’ve seen it work very well in our group. You have to match the work to the qualifications, otherwise there are wasted resources.

  13. “Guiding rational medical consumption…we’re 10% -30% lower cost, but can’t get paid more…a different physician-staffing mindset…defined population and meeting its needs…things don’t work if you do them for only a fraction of patients…first mover penalties…”
    These great comments convince me that we certainly know what the problem is, and we know the barriers that stand in the way of its solution. There are so many good and skilled people who want a PCP-based health care system to emerge in this country. How do we push it through? DCK

  14. docanon,
    I realize that – after not having been in an OR for 7 ys or so – I developed a romanticizing view of surgery, overestimating the average difficulty and stress involved. Some surgeries may be high stress and nerve wrecking, but most lap. choles and colonoscopies are quite comfortable routine. I still think that your suggestions of absolute pay equality are not realistic, but maybe I am too meek.
    That aside, the degree of difficulty, however, is a very rational way to estimate payment for a medical service (You seem to agree with that at least to some degree based on your very first paragraph):
    1) there is more training involved for invasive procedures, which is not or poorly paid
    2) there is more room for mistake (and thereby litigation) – you can reassess your office patient or change your mind about his management, but you cannot easily fix a surgical-technical error
    3) people try to avoid demanding work (unless there is an inherent attraction such as an intellectual challenge), so if you don’t pay anyone more for the hard stuff, it won’t get done. If you don’t pay an oncologist better than an FP working the same hours, you will have barely anyone going into oncology.
    Moreover, that’s the way other professions are paid – by degree of specialization and complexity. A subspecialty lawyer earns more than his general counterpart.
    Re. your paragraphs 2-4, you seem to make the same argument as Maggie Mahar about 2 weeks ago in this blog. I think it is unrealistic to pay based on outcome only – value of medical services is hard to define (QALY? Pt. rating?), and I do think that there are thankless tasks in medicine that need to be done anyway – e.g. take doctors taking care of ALS patients. They do not prolong life significantly, improve quality of life marginally, and the rather tedious diagnostic process only matters, in terms of outcome, if one catches the very rare misdiagnosed case of something treatable. I think it’s wrong to pay much more for a stunningly beneficial appendectomy as opposed to cancer surgery just because the cancer’s chances of cure may be fair to poor (I am not talking about futile surgery here).
    But worthless procedures/imaging? Of course we have to cut down on that. But except for clear cut cases (e.g. brain MRIs for typical episodic migraines), this does not appear to be an issue that can be easily regulated by reimbursement, but one that should be addressed during physician training, and backed up by tort reform.

  15. just a comment on reasonable PCP salaries.
    the overall yearly income may not need to change as much as everyone thinks. What needs to change is what it takes to make that number. Right now, many are burning out, running themselves ragged, working long hectic days, never feeling like they can give proper care, seeing too many patients daily. It’s the only way to maintain incomes. The result? Too many patients on their panel. Too much paperwork, too many phone calls, too much responsibility, etc. Overworked, underpaid, basically.
    Either pay more per visit (rvu changes) or pay a management fee per patient, or whatever else would work. Then PCPs can take the time to practice medicine the way they should, and the system, over time, should reap the benefits. And maybe some med students rotating through PCP practices will decide that looks like a good way to make a living.
    It doesn’t look that way now.

  16. rbar-
    Respectfully disagree on the fundamental payment idea here. But first, an aside: I’ve been in OR on long cases. The amount of intellectual fortitude required to withstand 9 hours of complex primary care patients–all while accurately identifying the truly sick ones–and doing the required documentation far exceeds a couple of surgeries by an experience surgeon. It’s not even close. As technical skills improve, the intellectual requirement goes down…it’s routine. This is especially true of some of the quasi-surgical procedures like screening colonoscopies.
    But regardless of the “degree of difficulty” of each service…this isn’t a rational way to pay for anything, medical or not. I don’t care how hard you whittled on that ugly sculpture. If it’s ugly, it’s worthless. I don’t care how many pints of perspiration you sacrificed over that hot stove. If the food tastes bad, it’s worthless.
    Same goes for procedures and imaging. If there’s no evidence behind it, I don’t care how hard it is to do said procedure or imaging. It’s worthless. And you shouldn’t be paid anything for it. Knee arthroscopy, anyone?
    Bill Hsaio, the economist who invented the Medical RBRVS, fully intended to pursue the value side of the payment equation but lost a political fight. He also didn’t have a chance to assign values to the practice expense component of the RVU…which is loophole through which specialists first undermined Medicare’s current Part B payment system.
    We have plenty of effectiveness and efficiency data, both aggregate system-level and individual procedure-level, that proves that we need to pay less for procedures and imaging and more for cognitive services. This includes higher relative pay for you (as a non-procedural specialist) as well as Joe the PCP. I say go hard, push the pedal until it’s politically impossible to go harder. Or until every state’s health care consumption patterns look like Minnesota or Utah.

  17. Our 50 provider primary care practice utilizes a robust emr with continually enhanced point of care decision support and quality improvement RNs resulting being recognized by payers as outstanding in quality. In addition we have payer data showing that we are 10% to 30% more cost effective than our peers. In spite of this & agressive negotiations we are paid less than our high cost lower quality hospital owned peers. We have the same question, why?

  18. docanon,
    I always looked at the reimbursement situation in the US (where I am currently working) with morbid fascination.
    I do think that adjusting the medicare fee schedule alone could cure many woes of the US healthcare mess. I think that your suggestions are too drastic.
    If you just take a doctor’s work hour, I do believe that someone doing surgery or an invasive procedure deserves more money than a physician taking an H+P – the proceduralist is doing a high stress job that requires additional training and expertise. You cannot do 9 hours of procedures/surgeries per day on a regular basis, while you could spend the same time in your clinic every day. I am not a surgeon (but a nonsurgical specialist), but I am perfectly fine with surgeons making something like double of what I make, for the same productive hours. Radiologists reading films are, in my opinion, somewhere in between – they do not do anything invasive, but they are responsible for every detail in the pics going over their desk, including appropriate notification of critical results.
    The question is whether reimbursement should be production based in a linear manner. An orthopedic surgeon doing excellent work certainly should be financially encouraged to use his skills most effectively and to operate a lot … on the other hand, one has to prevent that surgeons start operating on evrything that moves in a sloppy manner, so I think that reimbursement for elective surgery should have some ceiling, in that the 100th case in the month should be reimbursed less compared to the 5th.
    Analogous to the discussion what CEOs should be able to make in comparison to a factory worker, what is fair for docs, considering what they are getting right now? I would think that PCPs should be getting slightly (10-15%) more what they make now (they would be then getting anything from 160 to 230 K, I would imagine), and one could also consider helping these docs with loan repayment as a special incentive. Nonsurgical specialists have more training and could be a little above that, maybe up to 250 K. Diagnostic radiologists oncologists up to 300 K. Surgeons up to 400 K, maybe up to 500 K for some very productive and highly trained ones (e.g. Neurosurgeons, cardiothoracic surgeons trauma surgeons).
    These numbers are still high, but when talking about pay reductions, one has to consider what is politically feasible and that a physician shortage is looming. I would find it interesting to hear what other physicians would find fair in terms of compensation. I do think that physicians should be well compensated, but the physicians entrepreneur making 700 k by focussing on what pays best is part of the problem here. Physician entrepreneurs do exist in some other countries, but not as widespread as here in the US.

  19. I would like to reinforce jd’s observation as to the practicality of changing the PCP incentive model for what is usually a small subset of a community physician’s patient base.
    One of the many reasons that community network-model plans have never duplicated the success of the Kaiser plans is that they can’t realistically emulate the underlying staffing and management philosophy on a piecemeal basis. Permanente’s staffing approach is designed to meet the clinical needs of a defined population, using a defined clinical management philosophy that is truly primary care-driven.
    When you try to emulate that model for 10% of a PCP’s practice while the other 90% is dominated by typical FFS incentives, you are asking a physician to change their behavior for every tenth patient. Not surprisingly, it doesn’t happen. Maximizing the clinical and financial benefits of primary care requires a staffing model that allows the PCP to spend a lot more time with each patient than what one typically sees in a FFS setting, which in turn requires a very different physician-to-patient staffing mindset.
    What Kaiser and other group/staff models plans are accomplishing (and have been for decades) is virtually impossible to pull off in the FFS community in the absence of PCP-driven,global incentive models and the ability to direct critical mass patient volume. Perhaps that’s why we are seeing so much employer interest in worksite primary care centers; an employer has a much better chance of creating a defined population and designing a delivery system to meet its needs, just like Kaiser and, increasingly, the VA. Conventional health plans can’t do it and as has already been mentioned, market demand for gatekeeper plans is non-existent at this point.
    I ran health plans for 16 years, the first 11 of which were in group models. Stepping back into the FFS health plan world provided valuable perspective as to how nonsensical our “system” must look to Europeans who need medical care when they visit the States.

  20. As Charlie rightly points out, none of the private health plans–even the larger ones–control enough purchasing power to unilaterally change the PCP/specialist income incentive facing medical students. Nor do they have the market power needed to reduce the overproduction incentives of procedurists and imagers. Frankly, many patients make bad choices…not because they’re unintelligent, but because they don’t have medical training or experience. They think the latest scan is a great thing (even if it’s free of any proven benefit, a la coronary CT), and they gravitate to insurance products that allow unfettered access to all manner of medical shenanigans. So expanding plans that explicitly limit specialist and test access are out.
    As Brad points out, PCPs can only do so much in the current high-utilization (i.e. specialist-rich) environment…our ability to guide rational medical consumption is limited. The number of specialists needs to be reduced, and their incentives to overproduce need to be curtailed. Ask any health economist: specialists are very good at generating their own demand. Case in point, I can’t tell you how many times I’ve gotten a useless consult letter from a specialist “thanking me for my kind referral”…when I never referred the patient! I have to chide these patients later, explaining that yes, I can actually do cardiac risk stratification without the assistance of the cardiologist (who, incidentally, owns a stake in a coronary CT machine that he advertises).
    What we need is a dramatic change in the overall composition of the physician laborforce, and only CMS can pull this off. The specialist-PCP income gap needs to be reduced until we see a 50-50 split in the career choices of U.S. medical grads. I don’t care whether we do this by raising PCP incomes or reducing those of specialists who do procedures or imaging. If this election concludes in a real mandate for change, I’m hopeful that CMS will take a big step in this direction.
    I suggest the following:
    1. Separate SGRs for cognitive services and procedures/imaging. That way the specialists can drive up volume all they want without financial benefit.
    2. Immediate annual per-patient bonus to all physicians determined to provide primary care to Medicare beneficiaries. Only one PCP per beneficiary, please!
    3. Significant cuts to facility fees for radiology equipment. Keep cutting until the average take-home pay of the diagnostic radiologist is below $250K.
    4. End all Medicare Part B payment for injectable drugs. Injectables enter Part D, eliminating physicians’ ability to profit from marking up injectable drug prices.
    Then sit back for a few years and watch what med students do. Not enough change? Repeat 1-4 (plus reforms to other areas of clearly perverse incentives) with larger $$ amounts until we see what we like.

  21. since you mentioned the pay differential in cardiology, every article i have seen indicates that there is an impending shortage of cardiologists as well. certainly not as critical as in primary care, but if you think it was the money that sent people running from primary care, why do you think they didn’t go to cardiology?
    or another way to look at it, maybe we aren’t paying the cardiologists enough to attract them from the less critical specialties? or maybe money isn’t the answer to optimal staffing of medical specialties including primary care?

  22. This is one of the better discussions I’ve seen on THCB for two reasons: various stakeholders are represented and politics is left out of the discussion. Nearly everyone added an interesting angle. What this illustrates is the complexity of the current system and the problem we face. It won’t be solved simply by having health plans pay PCPs more money. A lot of other things need to happen, and preferably they need to happen either simultaneously or in the right order.
    – Better education for both physicians and patients
    – Reallocated RVU system to better distribute reimbursement between PCPs and specialists
    – A more robust and more easily accessible evidence-based care database
    – More standardized and widespread use of IT to enhance coordination efforts
    – Better use of midlevels to handle prevention and coordination efforts
    – Better communication in general among the various stakeholders
    I would love to see this discussion continue in some way because this is exactly what needs to happen. The real solutions will come from discussions like this.

  23. Of all the factors of why primary care has taken a back seat in the US health care system, health plans fall kind of far done down the list. At best a “secondary” cause. Guess I kind of miss the point of the article.

  24. Primary Health Care – Now More Than Ever
    World Health Organization
    October 14, 2008
    The World Health Report 2008 critically assesses the way that health care is organized, financed, and delivered in rich and poor countries around the world. The WHO report documents a number of failures and shortcomings that have left the health status of different populations, both within and between countries, dangerously out of balance.
    Inequities in access to care and in health outcomes are usually greatest in cases where health is treated as a commodity and care is driven by profitability. The results are predictable: unnecessary tests and procedures, more frequent and longer hospital stays, higher overall costs, and exclusion of people who cannot pay.
    To steer health systems towards better performance, the report calls for a return to primary health care (PHC), a holistic approach to health care formally launched 30 years ago. When countries at the same level of economic development are compared, those where health care is organized around the tenets of primary health care produce a higher level of heath for the same investment.
    This report structures the PHC reforms in four groups that reflect the convergence between the evidence on what is needed for an effective response to the health challenges of today’s world, the values of equity, solidarity and social justice that drive the PHC movement, and the growing expectations of the population in modernizing societies: reforms that ensure
    * that health systems contribute to health equity, social justice and the end of exclusion, primarily by moving towards universal access and social health protection — UNIVERSAL COVERAGE REFORMS;
    *reforms that reorganize health services as primary care, i.e. around people’s needs and expectations, so as to make them more socially relevant and more responsive to the changing world while producing better outcomes — SERVICE DELIVERY REFORMS;
    *reforms that secure healthier communities, by integrating public health actions with primary care and by pursuing healthy public policies across sectors — PUBLIC POLICY REFORMS;
    *reforms that replace disproportionate reliance on command and control on one hand, and laissez-faire disengagement of the state on the other, by the inclusive, participatory, negotiation-based leadership required by the complexity of contemporary health systems — LEADERSHIP REFORMS.
    In high-expenditure health economies, which is the case of most high-income countries, there is ample financial room to accelerate the shift from tertiary to primary care, create a healthier policy environment and complement a well-established universal coverage system with targeted measures to reduce exclusion.
    Even in the United States, its exceptionalism stems not from lower public expenditure… but from its singularly high additional private expenditure. The persistent under-performance of the United States health sector across domains of health outcomes, quality, access, efficiency and equity, explains opinion polls that show increasing consensus of the notion of government intervention to secure more equitable access to essential health care.
    Primary Health Care – Now More Than Ever (148 page PDF):

  25. David, I’m much farther down the totem pole than Charlie (and at a different health plan), but I’ve had some involvement in a medical home pilot and here are some issues not yet mentioned by you or Charlie:
    For a health plan acting independently to make a medical home payment system work, it has to have a lot of business with the physicians affected. No physician is going to want an entirely different payment system for 10% of his/her patients. Similarly, it makes sense for a physician who changes his/her practices to do so across the board, not just for a fraction of patients. But if the physician does improve care coordination across the board while only one plan is paying the higher fees, there is a first-mover penalty for that health plan.
    This creates a need for health plans to either (a) focus medical home-type payments on a small subset of providers who have see the highest percentage of health plan members to minimize first-mover penalty, or (b) collaborate with other health plans to create a more uniform system that all plans participate in. Right now the pilots you see are mostly using model (a), I think. Model (b) is hard to pull off for many reasons, most of them obvious.

  26. In regard to primary care and Dartmouth atlas, 2008 version did not draw conclustion you cite above. Primary care practices in high cost regions did NOT provide the expected efficiencies. Surprising but true, and primary care will probably succomb to local practice culture.
    In term of PCMH, i have been involved in many planning disucussions. As they say, there is politics, and then there is policy. it is so complicated to make this happen, that current lack of inertia has as much to do with problems with payers as it does with model itself. Small practices vs large, lack of IT, paying consultants and specialists from one bucket, bundled vs FFS+stipend payments, and cost of upgrading a practice (and what if it fails–who picks up sunk costs), etc., are all a black box. We need pilots badly and with proof of concept, the money might follow.

  27. eLisa, Charlie, rbar: Many thanks for your fine comments. We couldn’t ask for better, more thoughtful feedback. I want to address Charlie’s comments first, simply because this is a piece that targets the health plans, and he’s laid it out clear as day why most health plan have responded the way they have. Very honest excuses. However, I do think the conversation is changing, and we all will benefit from helping it to change. PCPCC wouldn’t be happening otherwise. Are some “buyers” so angry with the health plans that they’re simply no longer sending signals? If self-insured companies opt to do worksite clinics and/or direct contracting with PCP networks, they’re creating disruptively innovative solutions to the problem, and DIRECTLY working to make care more affordable. It seems to me that health plans don’t know how to make PCP practices and networks deliver care affordably, and have left this part of the market to others to solve, e.g. Wal-Mart and CVS Caremark. Isn’t it the case with all disruptive innovations that the upscale, high revenue product companies don’t “get it” that there is an underserved market? Kind regards, DCK

  28. rbar:
    I’m not convinced by your argument that patients do not respect and trust PCPs. Maybe I’m just lucky in my doctors, PCP and specialists.
    -If I have a neurological concern, I call my multiple sclerosis nurse who does a phone triage of sorts. She helps determine if I need to come in to the office to see the neurologist (or his assistant) for evaluation and acute treatment. Otherwise I stick to the follow-up appointment schedule.
    -With my rheumatologist, I stick to the follow-up appointment schedule. If I need something (like new prescriptions or bloodwork orders) in between visits, I call the office and will receive the new orders in the mail. My rheumatologist’s office is comprised of the doctor, the nurse, and the front desk. That’s it. And appointments are scheduled every 30 minutes, only two patients per hour rotation.
    -My PCP is great. Very knowledgeable and competent. If I have acute concerns, I call and am usually scheduled later that day or the following day. If I have nothing serious going on, I might go more than a year without needing to go into the office. Then I might get – “don’t be such a stranger next time” – when I realize too late that I needed to go in, get thyroid levels tested, so that I could get a new prescription for medication.
    The best part of my medical team is that they communicate with each other. Although separated by location and in independent practices, each doctor sends a report to the others after I’ve been in for a visit. They keep each other in the loop and watch my back in case there is something they see which could be better addressed by a different doctor.
    One thing which my PCPs have learned with me is that if I feel ill somehow, I really am.
    -Once I went in thinking I might have strep throat or the flu. Rapid strep test was negative, and although PCP doubted flu, she went ahead and took a nose swab to test. Test came back positive for Influenza A. I received much more sympathy when she returned to the exam room and a prescription for Tamiflu.
    -A different time I went in complaining of a virus which wasn’t going away and I felt heavy in the chest. Doctor said lungs were clear and to continue to rest. That was on a Friday morning by Sunday night I was in the ER and dx with pneumonia. Next time I thought my chest felt heavy with similar symptoms, I received medication to combat possible pneumonia and got much better quickly.
    -As with any relationship, patient and doctor need to discover how to communicate and respond to each other’s concerns. My doctors do not like to medicate if it’s not necessary and indicated. But we both have learned how my body responds to illness and how I listen to my body. That’s what we need more of in the health care field.

  29. Brian and Dave – as a health plan executive, I hesitate to get anywhere near this question. Answering it kind of falls into the “no good deed” category. But hey – it’s a good one, and it’s one worth asking. I’d offer up five reasons, in no particular order…
    1) Many of us tried to raise the pay and status of the primacy care provider (remember the original HMO movement?), but found that many employers, patients, physicians, moviemakers, journalists, legislators and others didn’t approve of the rules and limitations that came with the PCP-based HMO movement.
    2) Most of us choose to sell the products people want to buy – and the PPO product has been growing for the past ten years at the expense of the HMO. Many employers and many consumers want to go where they want to go, and don’t view having a PCP as an advantage.
    3) Everyone in the care delivery world translates what the plans pay them into Medicare equivalents. Everyone. If you choose to pay using different terms, criteria, etc., you are adding to the administrative complexity of health care. Medicare pays for technology, and not for time. Most private plans, for simplicity’s sake, follow suit. If the Medicare rules change, ours will change, too.
    4) Medical schools chase research funding. The vast majority of public and private research funding goes into specialty care. Medical schools – like other professional schools – understand the importance of research dollars, and factor this into the way they structure their organizations, build faculty, and support departments. Medical school students aren’t stupid. They see this too, and act accordingly.
    5) The case that good primary care is cheaper than specialty care hasn’t been made long or loud enough to penetrate the puchasing community. Not once, in ten years, has anyone on the “buy side” asked me what we’re doing about enhancing or improving primary care to improve quality or reduce costs. It’s simply not part of the conversation.
    I’ve written many posts of my own about this issue. It’s a major problem for the country. However, there doesn’t seem to be – at least not yet – an organized effort out there that I’ve found yet that’s willing to take it on.

  30. rbar, I agree and admit I hold most PCPs as “inept know-nothings”. This from experiences in Canada and the U.S. I can’t think of one diagnosis that a PCP I’ve used got right – except to prescribe necessary anti-biotics to get me through crisis. I had to dig deeper and analyse further, without specialists, to get to the root of my symptoms and arrive at a proper diagnosis and treatment – usually through alternate medicine. I’ve had a PCP say, “try these pills and if they work just buy a barrel full”. My mid twenties ashama was not helped at all by any PCP and I finally beat it with diet and exercise – diet being the bigger factor. My painful arch was just treated with a shot of steroid to the bone when I actually needed an arch support. And as I’ve recounted here before my recent digestive problem was diagnosed as, “too much stomach acid” when it was actually difficulty digesting wheat – not found or concidered by the PCP.
    I think PCPs are very poorly trained, too poorly paid and too money/volume motivated to take the necessary time to get to the root of sickness.

  31. Brian and David forgot to discuss a huge factor: patient preference. A lot (if not most) patients see the PCPs as inept know-nothings, and the healing begins with specialists and, even better, subspecialists.
    And isn’t this intuitive wisdom? And don’t I (as a nonsurgical specialist) see patients, almost on a daily basis, that I can treat better than the PCP?
    Yes on both counts. But one has to see all the other patients that did not need medical care (let alone specialty care), other than reassurance. One also has to consider the costs of all this specialty care. Since a specialist is basically not allowed to err or to watch and wait, he/she will throw all diagnostic means at the patient, and often even at the very first visit.
    Possible solutions:
    -strengthen primary care financially and educationally (see below)
    -have patients see the PCP first before there is a specialty referral (the PCPs, however, should be rather liberal with referrals so that patients don’t feel trapped)
    -all docs need to feel protected from litigation as long as they can document a reasonable level of consideration for the patient’s problem
    -educate PCPs better to make them (evidence based) experts on common conditions such as pneumonia, strains, headaches, sinusitis, preventive care etc. – a lot of them already are, but there is room for improvement for very many.