Physicians

The Primary Care Workforce: Help is on the Way

The best electronic health record on the planet isn’t going to help anybody unless a physician uses it. The HITECH incentive scheme should enhance the woefully poor EHR uptake rates among US providers, as should innovative vendor business models that remove cost-barriers which have prevented many from getting in the game.

But there’s an even more fundamental issue, which is a looming manpower shortage among the ranks of US primary care physicians, a topic we’ve covered numerous times, most recently here. There simply aren’t enough physicians to use those EHRs!

Communities across the nation have long suffered from a lack of PCPs. The problem is expected to worsen as baby boomers age and the number of medical students who enter primary care continues to drop. If nothing is done to change current trends, the Association of American Medical Colleges estimates our country will be short 21,000 and PCPs in 2015 and a whopping 47,000 in 2025.

Now, finally, something is being done. And while it may not be enough, it certainly points us in the right direction. More importantly, it sets a precedent for future interventions by the federal government.

This Wednesday, Department of Health and Human Services Secretary Kathleen Sebelius announced $250 million worth of new investments designed to support the training and development of more than 16,000 new primary care providers over the next five years. The investments were mandated by the Affordable Care Act, that controversial health care bill signed into law by President Obama in March.

“These new investments will strengthen our primary care workforce to ensure that more Americans can get the quality care they need to stay healthy,” Sebelius said in a press release. “Primary care providers are on the front line in helping Americans stay healthy by preventing disease, treating illness, and helping to manage chronic conditions. These investments build on the Administration’s strong commitment to training the primary care doctors and nurses of tomorrow and improving both health care quality and access for Americans throughout the country.”

According to HHS, the investments will be used as follows:

Creating additional primary care residency slots: $168 million to train 500 new primary care physicians by 2015;

Supporting physician assistant training in primary care: $32 million to train 600 new physician assistants, who practice medicine under the supervision of a physician, and can be trained more quickly than a physician;

Encouraging students to pursue full-time nursing careers: $30 million to encourage 600 nursing students to attend school full-time which will increase the likelihood they complete their education;

Establishing new nurse practitioner-led clinics: $15 million to cover operating expenses for 10 health clinics that help train nurse practitioners. The clinics will be located in medically underserved communities.

Encouraging states to plan for and address health professional workforce needs: $5 million to fund state programs designed to expand their primary care workforce by 10-25% over the next 10 years.

In addition, the Health Resources and Services Administration will direct some federal dollars towards repayment of the loans held by medical school graduates who choose to practice primary care in medically underserved communities. Grants will also be given to community colleges, Hispanic-serving institutions and historically black universities, which were recently ranked as the top producers of primary-care doctors. Students will be able to tap new financial aid, and health professionals working in underserved areas will get expanded tax benefits.

The AAMC’s Atul Grover said the feds’ plan was a laudable, if not altogether comprehensive effort to address the PCP manpower shortage.

“It’s just a small first step, but it’s a step in the right direction,” Grover told the Washington Post.

Glenn Laffel is a physician with a PhD in Health Policy from MIT and serves as Practice Fusion’s Senior VP, Clinical Affairs.  He is a frequent writer for EHR Bloggers, where this post first appeared.

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28 replies »

  1. If done at the hospital level it would be pretty easy. Use slim networks to make members identify with a specific system. If per member cost is lower then additional payment to the system would be made.
    Back in the HMO days withholds where common, providers would get say 85% of their payment then based on plan performance or some other criteria all or part of the additonal 15% could be earned.
    We could increase reimbursements to some new higher amount putting said increase aside. If they improve care and reduce cost or increase inefficency then they get the payment.
    i would want to vary incentives. Teaching hospital A that is already getting 30% higher reimburserment isn’t going to get the same opportunity for additional payment that smaller equally good hospital b gets.
    The cost to be in slim network A would also be higher then slim network B. If B improves, even with the incentive their cost would grow even more favorably compared to A and in theory draw even more business from A. Some hospitals are going to be left on their own to fund EMR, I don’t want to subsidize further failure.
    I don’t see this happening in the fully insured market. Government has bastardized the system to much in my opinion. If healthplan Good Guys does this and it works their loss ratio could fall below the legal limit and they would owe refunds to their members and the providers.
    The self funded market in defined markets would be a great place to test this

  2. Nate, I, too, believe free markets and competition are far more efficient regulators than government, and the engines for innovation. But I also believe government has an important role to play both economically, in guaranteeing a level playing field, and socially, in looking out for the needs of many of our people.
    But being a pragmatist, I focus on what is doable — and in my opinion the draconian changes to our health care system that you propose simply won’t happen.
    Thus, I go back to your earlier suggestion that payers might share with providers the cost savings resulting from provider adoption of EMR systems. If we can figure out how to accomplish this, I believe care providers will be far more likely to consider EMR systems. And if vendors — both new and old — will design EMR systems that meet the needs of care providers, I am certain they will embrace them.
    Given your knowledge of health insurance mechanics, can you design a way to identify savings and a mechanism for payers to share them with providers? For example, is there a way to relate over-all improvements in an insurer’s claims ratio to specific health plans and/or care providers who treat the insurer’s patients? If so, it might be possible to tie reimbursement rates to cost reductions — so docs and insurers each share in the savings.

  3. The fact that Sebelius’s response to the primary care crisis is so grossly inadequate makes this very bad news, not a cause for celebration in any way.

  4. This isn’t going to go over well here but I would say the free market……few minutes for everyone to get over groaning…..I don’t think we can count on government and I don’t know any other way to accomplish it that can’t be gamed.
    If we had started this 5 years ago I think the system could have afforded to start infreasing reimbursement immediatly while providers worked down waste. Now the financing side can’t afford to pay more while we see if it works.
    I think it is time for the system to undergo another metamorphisis. When Indemnity stopped working we didn’t try to fix it we replaced it with PPOs. When PPOs weren’t doing the job we moved to HMOs. This is where we made the mistake, nothing new really replaced HMOs, we sorta digressed back to PPOs eliminated the aspects of managed care we didn’t like and were surprised with the counter forces took over.
    Something new needs to replace the current large national carrier dominated model. Insurance should be forced to being just an after the fact reimbursement to smooth out cost. Individuals and businesses need to take responsibility for the small day to day stuff again. Average healthcare expenses should not be insured.
    Above that providers should be taking the risk and responsibility of delivering the right care, they are after all the care providers, why look to a third party for this direction. It has to be clear if you want the freedom to pratice as you see fit you also need to be accountable and liable for those decisions.
    This will allow providers to invest in their pratice and reap the rewards of efficency.
    At the top and rarely used would be insurance, for those rare and unforseen events.
    Finally government must be out of all healthcare, Medicare and Medicaid need shut down. Their ability to dictate reimbursement absent any relation to actual cost or need is what distorted the current system to where it is today.
    To balance budgets they cut reimbursements for needed care and fradulent care at the same time with no distinction, they promise trillions in benefits they can never deliver, the pass cost from different parties in unfair and inefficient manners.
    A completly private system while more volotile is underwritten annually, you can have issues but they are forced to be resolved annually. The entire system won’t collapse and bring the nation down with it. With Medicare and Medicaid they rack up trillions in debt, destroy the private system then blow up leaving who knows what.

  5. Nate, if I understand you correctly, you are suggesting that if physicians (through access to better information from EMRs) could reduce the cost of caring for a patient, insurers could afford to share the savings with the doc by increasing his/her reimbursement rates for the care actually delivered.
    This sounds like a great idea but would it work? How would you measure the savings so you’d know how much to pay the doc or hospital?

  6. Hopefully no carriers are reading this, want to know what my employers and myself would really like, For the hospitals and providers to step up and take the risk and get rid of or greatly reduce the role of the insurance companies all togehter. If XYZ hospital could eliminate 30% of their claims by implementing EMR they could offer rates that would blow away any other insurer in the market, with a slim network they would blow away any competing hospitals as well. It would seem any hospital CEO looking to make a killing would embrace EMR instead of running from it. Then again these are the same people who thought giving BUCA the best dicounts and screrwing everyone else was a good business decision as well….

  7. Merle I believe and see redundant or unnecessary tests do in fact cost billions. The estimate that 30% of care might be unnecessary might be high but I am sure it is up there. If we back away from the forest and look at…whats bigger then a foirest? Why are reimbursement rates what they are today? In some asinine display of antilogic it was detwermined that paying less for all test was the best way to control cost. I don’t know many people that think office visits, and a good portion of other reimbursements are over priced. Mose people will agree reimbursements should be higher.
    We can’t afford to pay more though for both good care and bad redudent care. If redudent test where eliminated then my plans could afford to pay more for the needed test. We could also afford to pay for better or more hands on care.
    While the savings won’t directly and immediatly return to the providers it will allow for their reimbursement to be increased.
    For example if you have a bad employee that isn’t very productive that ask you for a raise what are you going to tell them? If you have a highly efficent employee that delivers high value that ask for a raise aren’t you more likly to agree?
    Providers are asking for more money but delivering inefficient care, i.e. ordering redundent test. Fix that I’ll pay you more. If it cost providers 10 billion to implement EMRs which reduce claims 50 billion then providers can get a raise, premiums can remain flat so employers’ cost is controlled and insurers will make the same. people forget that insurers can’t increase profits that much without inviting competition. If carriers start making 10% profit margins other carriers will enter the market and groups will go self funded. Groups wont take the risk for 5% but if they could save 10-15% they will dump the carriers.
    We already pay 10-15% more in annual inflation, if wasted care isn’t eliminated how do we also increase per unit reimbursement? Claim cost are obviouslly increasing every year so providers are already making more in total reimbursement, it requires they do more work but that is chicken and eggs. I can’t pay more until you do less.
    If I give you a scouts honor of higher payments if you eliminate waste will you invest the money and get this moving?

  8. With all due respect to your comments, Nate, I believe you are looking at the trees and missing the forest.
    Studies done in the past three or four years by McKinsey, Rand and ThomsonReuters, establish that medical errors and redundant or unnecessary tests add several hundred billion dollars to the cost of healthcare in the US. I believe McKinsey in 2006 pegged such costs at $300 billion. Rand subsequently identified a similar amount. Then, in 2009, ThomsonReuters pegged it at $700 billion.
    The McKinsey and Rand studies established that one third of these costs, or about $100 billion, was due to the fact that physicians lacked the information they needed to properly treat their patients. The costs they identified included the costs of hospitalizing and treating patients who were made sick rather than cured because of the errors and the costs of unnecessary or redundant tests.
    Whether you want to accept the McKinsey/Rand range of $100 billion or apply their 1/3 ratio to ThomsonReuter’s more recent figure of $700 billion, is immaterial to me. It clearly is a huge target and well worth attacking in order to reduce the cost of care in the US.
    Since these excessive costs are attributable to the lack of information about the patient, it is reasonable and logical to assume that we will reduce these costs by equipping physicians with complete information about their patients. Ergo, the push to get docs to adopt EMR systems and to link all care providers in an electronic network so they can access their patient’s complete record anytime they treat the patient.
    This, then, is the “forest.” It has little or nothing to do with claims processing or other administrative concerns. I’m sure there are savings to be had from administrative improvements — by docs, hospitals and payers, but that’s not my focus. I believe our national goal and policy should be to cut medical errors and unnecessary tests.
    This is where the “disconnect” comes in. We are trying to force physicians and hospitals to invest in exorbitantly expensive EMRs to get these savings. But these types of savings don’t flow to the physicians or hospitals. They flow to payers and employers in the form of reduced claims — which is a key reason physicians and hospitals have refused over the years to adopt costly EMR systems.

  9. ” so let me say that what you have in your database, is information for your current customers, not prospective ones, unless you pay for it.”
    ? This would be illegal under HIPAA unless people signed a release to give it to me. How does EMR give me claims data on people that aren’t customers?
    “maybe you don’t need to know anything about folks that wish to buy insurance,”
    Under the new rules no one is going to need such data. Currently groups over 50 do disclosue forms they don’t collect individual health apps. Even if a small group is applying for coverage I don’t see how provider EMR is going to help me get the data to underwrite.
    “you have no information that is not claim related, such as medical history or family history.”
    This is by design, GINA makes it undesirable to even know this info let alone have it on file. Until GINA is repealled I don’t really want that info any where near me.
    “you were complaining in the past about docs sending you paper claims. Is that not a problem for you anymore?”
    It is what it is, would it be nice if all providers used standard forms, sure. Would it be nice if they would all bill the PPO and the PPO would remit to me for free, sure.
    “As to clearinhouses, if EMRs actually implement the required administrative simplifications, it is possible that they will be able to connect directly to payers. Even today, some already do.”
    There will always need to be a ubere clearing house or clearing houses. When members travel there are providers that will only ever bill a specific payor once. Someone needs to connect National Provider IDs and National Payor IDs. A knockoff of the Fed that also facilited payment back would be a nice improvement.
    ” I’m sure they’ll find some loophole to account for the extra money.”
    Not so sure DC seems pretty determined to limit those expemptions, if the gradfathered regulations are any sign it won’t be favorable. But this point is an opinion and yours is just as valid as mine.
    ” It is just simple math that if we pay less for care, then those who supply care will see reduced income.”
    In our Universe certain certainities have exceptions. One of those is any time politicians tell you something will save money it will some how cost more. It’s like gravity, it just is. Medicare has paid less for certain segments of care numerous times and I am not aware of a single case where it actually reduced expenditures. It might slow growth but I don’t believe it will reduce incomes. Some how providers always manage to maintain their incomes. managed care matters had some examples where reimbursements where cut in workers comp but cost still increased. Its been proven time and again reducing the unit reimbursement instead of targeting undeeded units never works. We need to pay more for legit care and nothing for bogus care, paying less for both doesn’t accomplish anything.
    For example many test ran now are unneeded, supposedly doctors who own labs run needless test, why would EMRs change that? Providers billing questionable care will continue to do so regardless what the EMR suggest.
    “Yours is the insurers’ truth,”
    You and ExhaustedQuack keep saying this even though it should be very clear I make my living taking business away from insurance companies. I have no love for them and would love to put a couple of them out of business. Just becuause I compete with them and would love to see them gone doesn’t mean I am going to make stuff up. There are plenty of legit complaints about insurance companies and the system, complaints that if addressed would actually improve things. The stuff you, Peter, Maggie and others make up is just that, made up. Besides trying to push an agenda and pass legislation wasting time on your made up problems won’t solve or improve anything. Fixing an imaginary problem has no real world benefits. Debating EMRs because only insurance companies benefit is just flawed and pointless.
    Break it down into different parts and address them and you will see where the real benefit lies.
    Take ePrescribing for example. Those that would gain are patients who would be served by a safer system with fewer errors. Pharmacies who wouldn’t have to try and read doctors writing, and doctors who would be liable for fewer mistakes. I was at Minute Clinic in CVS few weeks back and they electronically sent my Rx to Giant Eagle. I have seen the system work, it did great by me as Giant Eagle has free anti biotics. I can’t imagine how the investment in such software could be greater then the savings.
    That would be meaningful discussion to have, then on to other aspects of EMR, instead a few people wanted to take the opportunity to attack insurance companies when they have next to nothing to do with it. That doesn’t mean I am pro insurance company I’m just smart enough to see the problem and where the discussion should be.

  10. Nate, I wouldn’t want to keep you waiting, so let me say that what you have in your database, is information for your current customers, not prospective ones, unless you pay for it. Since you are not an insurer, maybe you don’t need to know anything about folks that wish to buy insurance, but insurers do.
    The current claim data is incomplete. You have nothing for things people pay cash with. You have nothing historical from previous payers, unless you pay for it, and most important, you have no information that is not claim related, such as medical history or family history. You may have tests and labs, but you have a minority of actual results.
    As far as doctors are concerned, you have no comprehensive picture regarding prescribing habits or any other practice habits. If you are an insurer, which you are not, this data is important for contracting decisions.
    If my memory is correct, you were complaining in the past about docs sending you paper claims. Is that not a problem for you anymore?
    As to clearinhouses, if EMRs actually implement the required administrative simplifications, it is possible that they will be able to connect directly to payers. Even today, some already do.
    While lounging in my cave, I noticed that MLR calculations do not include only direct payments to providers, but other expenditures which can be shown to be somehow related to patient care. I’m sure they’ll find some loophole to account for the extra money.
    I have no idea where you found anything in what I said regarding payment cuts. One of the advertised advantages of EHRs is that they will reduce redundancy in testing and improve care. These things ought to reduce the overall costs of care, otherwise why bother? It is just simple math that if we pay less for care, then those who supply care will see reduced income. I’m not sure what exactly your argument here is.
    As to the truth, it seems there’s no such thing as absolute truth. Yours is the insurers’ truth, and it seems to be the prevailing one in DC too, so enjoy while it lasts.

  11. Margalit once again you have no idea what you are saying. Are you and Maggie really the same person, she disappears and you pick right up with the crazy baseless comments.
    “When all data is electronic and computable, insurers can refine their “risk” calculations to improve their financial model”
    All data is already electronic and computable, I have every ICD9 CPT Rx etc in my database. What additional piece of data that I don’t already have in my database will EMRs add? While I wait for an answer to this I’ll move on as I don’t expect to get one.
    ” and deny even more claims.”
    Payors deny 3-7% of claims and that includes duplicates, policy termed, bundeling, etc, a fraction of a fraction of 1% of claims are denied for medical necessity. Your full of BS with this argument, it has no truth in private insurance. Medicare on the other hand denies around 2% of their claims for Medical Necessity.
    “Receiving all claims electronically will cut down on manual processing expenses.”
    You ignorantly assume paying a clearing house is cheaper then manual data entry or OCR, again helps to know what you are talking about before you run at the mouth.
    “Better data collection will also help insurers fight real fraud more efficiently, and also imaginary “fraud”.”
    What better data collection, so far it only exist in your head.
    “ePrescribing will provide PBMs and payers priceless data for assessing risk.”
    Once again you have no clue what your talking about, I already get 100% of all Rx data and get it free, ePrescribing will not directly benefit me outside not killing and maiming some of my clients.
    “If EHRs really succeed in making care more efficient, i.e. reducing redundant tests, keeping folks healthier, insurers will be the first to see a reduction in costs. Do you think they will pass it on to subscribers? I wouldn’t hold my breath on that one.”
    Sorry but it appears you just pulled your self out of a cave and are unaware healthcare reform passed, small federal law got a touch of press last few months, had a lil ole section about carriers spending 80 or 85% on claims, so actually yes I do believe they will pass it on, being federal law and all. Not ot mention you where apparetnly deprived of the internet on this cave as you don’t seem aware that carrier profit margins pretty much stay the same the past 20 or so years. Once again the educated non cave dwelling guess is it has been passed on.
    “Whoever they pay to, will of course see a drop in income.”
    Will they? of course? Medicare cut radiology few years back and providers made more money. Workers comp cut Rx reimbursement and spending went up. In fact I bet you can’t link to a single speciality that has had a decline in income despite countless cuts, and redirections of spending.
    My educated guess would be some people will see a stagnation in income but no one will see a cut.
    Why don’t we start by basing things on the truth and not some liberal pipe dream of propoganda?

  12. Nate, here is how insurers realize profits from EMRs.
    When all data is electronic and computable, insurers can refine their “risk” calculations to improve their financial model and deny even more claims.
    Receiving all claims electronically will cut down on manual processing expenses.
    Better data collection will also help insurers fight real fraud more efficiently, and also imaginary “fraud”.
    ePrescribing will provide PBMs and payers priceless data for assessing risk. And, BTW, there are no conclusive studies showing exactly how much time docs actually save by using ePrescribing, if any. In addition to that, ePrescribing is “gently” guiding physicians to prescribe only drugs that are on the preferred formulary, saving even more money to insurers.
    If EHRs really succeed in making care more efficient, i.e. reducing redundant tests, keeping folks healthier, insurers will be the first to see a reduction in costs. Do you think they will pass it on to subscribers? I wouldn’t hold my breath on that one.
    If EHRs live to their full advertised potential, patients will receive better care, or at least more convenient care and insurers (including Government) will see a drop in what they have to pay out. Whoever they pay to, will of course see a drop in income.
    For all this to happen, doctors have to buy and install EMRs, and above all use the software to collect all this data that everybody needs. The financial subsidies are not enough to offset the cost of ownership and the cost of data collection.
    However, we are telling docs that they should do this to improve patient care, since they have an ethical obligation to do so. At the same time, we are telling docs that we don’t trust their ethics to make the right decisions for their patients because they are financially conflicted.
    I suggest we make up our minds. Either we build a system based on physicians ethics, or based on MBA/CEO, or even Government, ethics. We can’t have it both ways.

  13. Certainly a step in the right direction, but 500 new PCPs (at $168 million) seems like a tiny dent in the 21,000 doctor shortfall, and an inefficient one at that.

  14. Merle has delusions: “so docs benefit from their investment in EMR systems, I strongly doubt they will change the way they keep patient charts.”
    There is little benefitof EMR as recently documented in England: They waste time, disrupt the flow of patient conversation, cause mistakes, do not improve outcomes,etc.
    The entire program of HITECH has been a boondoggle for the HIT vendors who faked out Congress with inflated and false claims about the devices they are selling. HHS=MMS.

  15. “You work for an industry that is exempt from federal antitrust laws,”
    Actually no I dont, I am subject to all the same anti trust laws you are.
    If you are referring to the misunderstood exemption insurance companies have, I don’t have an insurance license they are still not exempt from federal antitrust laws, you need only look at the federal involvement in mergers to see this urban myth is not true.
    “which set fees and contract terms on a “take it or leave it” basis,”
    You apparently never heard of Partners Health or any of the other hospitals that dictate prices. You don’t seem to understand how the real world works outside liberal propoganda land.
    “that rescinds coverage when members get sick”
    you mean coverage of people who lied to get coverage they weren’t entitled to or lied to get a lower price then they should have. As an honest premium payor I am damn glad and wish they would do it more. I pay my fair share so should everyone else.
    “In any other industry the firms that make an investment in economic producing services would be able to garner the savings which resulted, but not in health insurance. Who will benefit from the vast investment in health IT? The isurers who will see more efficient care. Will these insureres even think of ever sharing some of these savings with those who produced them?”
    By this statement I’ll assume you don’t actually run an office or have any idea how it is done. So by not paying postage and paper cost to bill doctors are actually saving insurance companies money? I wasn’t aware that I was paying for their paper and postage in the past.
    E prescribing which saves providers time and eliminates errors which prevents them and pharmacist from getting sued saves insurers money how?
    Electyronic health records which reduces transcrribing, storage, file access time, improves data flow saves insurance companies money how?
    Can you cite even one example of how insurance companies or health plans will save money?

  16. Nate, you are missing the point. To the extent an EMR system reduces the cost of care, the benefits — in the form of improved claims ratios — flow to the payers, not the docs. That’s where the real money is, not in claims processing. So it’s not surprising that physicians have refused to invest in EMR systems.
    This is the critical disconnect. Until it is resolved and the costs to purchase and install EMR systems are reduced, so docs benefit from their investment in EMR systems, I strongly doubt they will change the way they keep patient charts.
    Until we align the financial interests of doctors, patients and payers, I predict one unintended consequence of HITECH will be that in 2015, when Medicare reimbursement rates will be cut for docs who do not have EMR systems, the non-EMR-docs simply will refuse to treat Medicare patients. This will be a very unwelcome development because the number of Medicare patients is growing, and they will need care.

  17. You said: “The best electronic health record on the planet isn’t going to help anybody unless a physician uses it. The HITECH incentive scheme should enhance the woefully poor EHR uptake rates among US providers, as should innovative vendor business models that remove cost-barriers which have prevented many from getting in the game.”
    Interesting. The EHR impedes care, really. It kills patients according to Margalit’s blog post and comments. The billions spent on viral EHRs, as in the UK, enriches the vendors and detracts from the care of patients. Sebelius has her priorities a$$ backward because she is influenced by HIM$$ and $EE$HIT. Pathetic.Another Deepwater Horizon. She is running the MMS twin.

  18. Nate,
    You work for an industry that is exempt from federal antitrust laws, that has a few firms with a monopoly in almost every state, which set fees and contract terms on a “take it or leave it” basis, that works to disaggregate physicians who dare to try to push back against such conditions, that rescinds coverage when members get sick and who pays their CEOs obscene levels of compensation. In any other industry the firms that make an investment in economic producing services would be able to garner the savings which resulted, but not in health insurance. Who will benefit from the vast investment in health IT? The isurers who will see more efficient care. Will these insureres even think of ever sharing some of these savings with those who produced them? Not a chance.

  19. “requiring that they adopt expensive IT systems that benefit payers more than physicians.”
    How has EDI benefited me more then providers? I had to pay out of my own pocket to upgrade mysoftware, providers have been given billions to do it.
    There is a federal law saying any doctor that wants to send me an electronic claim I need to take it, no laws that require they send electronically or even use standard paper claim form, I still get custom hand written forms.
    It use to cost a doctor paper, postage, and time to mail every claim and cost me nothing to receive it. Now the doctor pays no paper and postage and it cost me $0.40 to $0.50 to receive it.
    Most doctors can send me unlimited claims, including claims that aren’t mine or duplicates at no additional cost, every thing they send cost me money.
    Where is all this benefit I am missing out on, I’ll trade places with the providers in a heart beat and get my share of the billions. The only thing I get from government is unfunded dictates.

  20. A fundamental flaw with the proposed reforms to healthcare IT is that they don’t solve the serious disconnect that Glenn and the commenters here have pointed out.
    Everyone insists upon cutting physician income while, at the same time, requiring that they adopt expensive IT systems that benefit payers more than physicians. That formula will surely bankrupt our physicians.
    Until we resolve this disconnect and develop systems that meet what docs want/need and actually help increase their income, more and more docs will drop out of Medicare, Medicaid and even the practice of medicine.
    Our MedKaz™ System is such a solution. By embracing it, a PCP can increase his or her annual income by $25 thousand to $50 thousand — all while helping to improve the quality and coordination of care, reducing care costs, and giving the patient control over his/her records.

  21. How do you spend $168 million to train 500 doctors? Where does the 336,000 per doctor go? In most industries underpaid interns lower cost not add to them. Are training slots just slush funds for hospitals to cover up other inefficiences?

  22. Thanks for a great post. It’s not an easy task to follow what has been happening with health care reform and your blog has helped me with this process. I think that this is certainly a step in the right direction. Luckily my family has a great primary care physician but I understand that they are very difficult to find in this day of “specialists”.

  23. I agree that this seems to fall short. I don’t understand, in particular, how some new residency slots would help – the number of med. students remains, and if FP is not attractive, the slots won’t be filled.
    The solution is quite simple: adjust the medicare fee schedule that doc’s pay depends only on: time for service, expertise for service (i.e. a service that requires special expertise – longer residency or fellowship will be paid higher), risk level of service (for instance, risky surgery better paid then a hospital non-ICU admission, and the latter better paid then outpatient care for nonthreatening complaint). All this adjustment within a certain window, so that the highest trained docs doing the most risky stuff make about double of the docs doing lowest risk/complexity stuff. By that, you eliminate all that nonsense with docs eager to do procedures/pictures (and the suffering of specialties with few or no procedures like e.g. PC, peds and neuroophtalmology), and PC will become attractive again because a lot of docs like to be a community physician following their patients/families longterm.

  24. This a load of BS. If the fee cut is not reversed my group will stop seeing Medicare patients. I will not work for free. Remember, we have to pay the overhead on 21% less. That 21% is me.

  25. This is a homeopathic response to a serious systemic problem which people in Washington have consistently underappreciated. We have a five figure problem.
    These are three figure solutions.

  26. “$168 million to train 500 new primary care physicians by 2015 and $32 million to train 600 new physician assistants”
    I sincerely hope your numbers of newly trained PCPs are off by an order of magnitude. 1100 MDs/PA-Cs aren’t going to make a dent in that 21,000 PCP shortfall by 2015.
    Furthermore, spending money on training more PCPs is a waste unless you can guarantee that they will choose primary care as a career. Throwing money at training PCPs is like Abstinence Only Sex Education. I went to the #1 primary care medical school and residency program in the country and the vast majority of my “primary care track” colleagues still chose to enter subspeciaty fellowship training or took hospitalist jobs. (Oh how I envy them today for being wiser than me.)
    The only way to successfully expand the primary care ranks is to change the way we get paid and reduce the exponentially expanding administrative/paperwork/documentation requirements so that students will actually CHOOSE to enter the field because they see it as a rewarding career choice. I have ZERO hope that is going to change any time soon. As such, concierge care and Direct Primary Care models such as Qliance will be the wave of the future. Ironically, this will further increase the PCP shortage because these new forms of primary care have much smaller and more manageable patient panel sizes than a typical fee-for-service PCP.
    I, for one, hope the new Medicare payment cuts go into effect so more doctors will stop seeing Medicare patients. Let’s see how our senior voting block puts up with that and what “Real Healthcare Reform” we can come up with next. The only way true change will come in this society is if the system absolutely crumbles and/or physicians “grow a pair” to start standing up for themselves and their patients. We’re getting closer and closer everyday.
    Burntout PCP

  27. Glenn,
    I appreciate your post. Let’s look at some stark business realities for PCPs. Medicare’s 21.3% cut in physician fees went into effect today retro back to June 1. Many other commercial payors are holding fees flat or actually decreasing them, as well as refusing to pay for chronic care management. United pays well below Medicare for most PCP services, while their CEO got $102 million last year. Other commercial plans persue a “divide and conquer” strategy to keep physicians disaggregated so the plans can dictate fees on a “take it or leave it” basis. Health reform could increase Medicaid rolls by 50%, while in my state (CT) Medicaid pays adult PCPs about 57% of 2009 Medicare fees. Budget cuts and fiscal woes have caused states to reduce or delay payments to commercial carriers managing Medicaid programs, so PCPS and all other docs now have to wait months to collect 57% of Medicare. Yet PCPs are expected to shell out big bucks for most EHRs (unless thet go with Practice Fusion) and maybe they’ll get some addition funds from Medicare and Medicaid. All in all a not too pretty financial picture and one which has physicians voting with their feet, either going into better paying specialties, selling their practices to hospitals or retiring. This new program you mention will train just 1% of the PCPs the USA is currently short of (50,000 est.) by 2015, while we’ll probably lose many multiples of that via retirements alone. Help may be on the way, but it will be many days late and many dollars short of what is needed.

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