Physicians

A Call For a New Primary Care Society

The dream of reason did not take power into account – modern medicine is one of those extraordinary works of reason – but medicine is also a world of power.

Paul Starr, The Social Transformation of American Medicine, 1984

How can primary care’s position be reasserted as a policy leader rather than follower? Even though it is a linchpin discipline within America’s health system and its larger economy – a mass of evidence compellingly demonstrates that empowered primary care is associated with better health outcomes and lower costs – primary care has been overwhelmed and outmaneuvered by a health care industry intent on freeing access to lucrative downstream services and revenues. That compromise has produced a cascade of undesirable impacts that reach far beyond health care. Bringing American health care back into homeostasis will require a approach that appreciates and leverages power in ways that are different than in the past.

But primary care also has complicity in its own decline. It has been largely ineffective in communicating and advocating for its value, and in recruiting allies who share its interests. Equally important, it has failed to appreciate and protect primary care’s foundational role in US health care and the larger economy, as well as the advocacy demands of competing in a power-based policy environment.

The consequences have been withering constraints that have diminished primary care’s value, and that have thwarted its roles as first line manager of most medical conditions, and as patient-advocate and guide for downstream services. Combined with fee-for-service reimbursement and a lack of cost/quality transparency, primary care’s waning influence has precipitated a cascade of impacts, allowing health industry revenues to grow at more than four times the general inflation rate for more than a decade, with unnecessary utilization and cost that credible estimates suggest is half or more of all health care spending.

These impacts have been catastrophic not only for primary care physicians, but for patients, who are routinely exposed to unnecessary medical risks, and for purchasers, who for decades have borne an unnecessarily onerous economic burden. It seems unlikely that these groups’ prospects can improve without a meaningful change in the strategy pursued by primary care’s leading organizations.

The State of Primary Care

Primary care is a demoralized medical specialty. Recent Medscape data show that, on average, generalists make about half what their specialist colleagues do. Other surveys are more pronounced. A 2010 Graham Center study calculated a $3.5 million career income difference between primary care and specialist physicians.

None of this is lost on medical students. Faced with skyrocketing training debt, few now opt to make significantly less, so the percentage selecting primary care has plummeted. Between 1990 and 2007, the percentage of internal medicine residents becoming generalists dropped by 80%.

Then there’s office visit duration. Lower reimbursements and changing health status dynamics have translated to significantly shorter visits with more complex patients. Complicated patients who warrant thorough work-ups will often require more time than is allocated, meaning that they may cost more than they generate. This at least partly explains why specialty referrals have doubled in the last decade. Traditional primary care patients have increasingly become specialty cases, exposed to excessive specialty visits, diagnostics and procedures.

The growing inability of primary care physicians to succeed in private practice has precipitated a wholesale flight to health systems, where many doctors become “feeders” for outpatient and inpatient services. In 2010 the Medical Group Management Association reported that the share of practices owned by physicians had dropped from two-thirds to half in only three years. That trend continues.

Many of these dynamics are rooted in the relationship between the Centers for Medicare and Medicaid Services (CMS) and the American Medical Association’s specialist-dominated Relative Value Scale Update Committee (RUC), which formulates recommendations for the value of medical services. This controversial and opaque process – former CMS Administrator Tom Scully recently described it as “highly politicized” and “not objective” – has overvalued specialty services at primary care’s expense, and inhibited primary care’s ability to hold specialty care accountable. Still, despite the RUC’s ongoing disregard for primary care’s interests and value, primary care societies continue to argue that “being at the table” means having a say.

The Need for A New Organization
Primary care’s second rate status in the US results from organizational structures that are not constituted to cope with American health policy’s power dynamics. Generalists stand no chance against a far larger, wealthier and more influential health care industry that can field billions of dollars to promote ever-increasing health care spending.

At the same time, no single organization represents primary care professionals’ overarching interests. Nor is there one that aggregates their many groups (and their collective influence) to effect policy change that values primary care as medicine’s foundation. Generalists have diluted their modest influence, which derives from about 30 percent of American physicians, by scattering loyalties among six different medical societies. Several of these societies also advocate for sub-specialist interests that, contrary to their protests, may conflict with those of primary care.

Nor does primary care’s policy agenda meaningfully acknowledge that it isn’t only about them. Within health care, primary care’s competitors are the rest of the health care industry, comprising nearly one-fifth of the US economy. But outside the industry, one group, non-health care business, makes up the other four-fifths. Much larger and more influential than health care, non-health care business has suffered significant harm from American health care’s egregious inflation and waste. It should be primary care’s most powerful ally.

A new primary care society could reinvigorate the debate about what kind of health system our children will inherit. It could broaden primary care’s power base by being inclusive, acknowledging non-physician professionals and other groups in service to primary care’s larger missions, unifying it as a specialty, and embracing a 21st century vision of what medicine can be. Support from non-health care businesses and institutions could extend that power base further, re-establishing primary care in policy as the basis of a medical system built around evidence, appropriateness, efficiency, quality, safety and value.

A new primary care organization would not replace existing medical societies. Instead, it would become strong by convening and emphasizing other societies’ most positive attributes, providing a counterweight to the sub-specialists’ perspective. Ironically, the exemplar for this approach is the American Medical Association, which brought together all medical societies in its House of Delegates, then evolved to advocate against primary care and for specialists. This fact is evidenced by its insistence on disproportionate sub-specialist voting representation on the RUC, American health care’s most influential federal financial advisory panel.

Primary care is in decline because it is fragmented, inwardly focused, and structurally incapable of protecting its mission and value in the face of far larger forces. Within the ferocious world of influence, a new society would seek to drive policy that invests in America by investing in primary care’s capabilities.

Success will require primary care to amass much more power, pooling its resources, aligning with other more powerful groups and developing a unified voice under the umbrella of a new society. Only then could primary care’s value be feasibly reestablished within American health care.

Brian Klepper, PhD, is an independent health care analyst, Chief Development Officer for WeCare TLC Onsite Clinics and the editor of Care & Cost. His website, Replace the RUC, provides extensive background on the issue.

Livongo’s Post Ad Banner 728*90

23
Leave a Reply

11 Comment threads
12 Thread replies
0 Followers
 
Most reacted comment
Hottest comment thread
11 Comment authors
Ron Lavine, D.C.Tschwiet MDPeter1Dr. MikeJan Eek Recent comment authors
newest oldest most voted
Ron Lavine, D.C.
Guest

Primary care MDs are logical allies with doctors of chiropractic, who provide another aspect of primary care, also underfunded and under-respected by the system. But primary care MDs, acting against their own best interests, more typically align politically with specialist MDs.

Tschwiet MD
Guest
Tschwiet MD

I have to agree with Brian here- the primary care societies have been left in the dust when it comes to advocating for the success of its members- especially as that success relates to financial gain and job satisfaction. The RUC is just one example of how our leadership failed to (and continues to fail to) identify a critical flaw in driving fair reimbursement. As a primary care doc who too left his extremely busy practice due to increasing demands and growing headwinds that made success simply untenable, I read the posts from Dr. Mike with a sad affirming nod… Read more »

Dr. Mike
Guest
Dr. Mike

It’s bye bye primary care for this FP doc. I could have done so many different things with my life – I was better at the educational system than most of my peers – but I chose FP even before I finished college because I thought that being involved in the health of the whole person and their family would make a difference. But I was misled and betrayed by the society I had hoped to serve. I’ll still be in health care but with a narrower focus and a fraction of the headaches. AAFP and AMA can go to… Read more »

John Ballard
Guest

What a painful comment. And even more painful conclusion. (I’m presuming that FP means family practice, not financial planner — though that may not be a bad alternative.) So what is your Plan B? I’m only a bystander and it’s none of my business, but since this is a public forum you must find it okay to have a conversation about that. Without giving away any secrets, perhaps you can give out a list of alternatives. One that comes to mind is teaching (medical topics, of course — more NPs, nurses, techs). Another is “hospitalist” or other institutional employee not… Read more »

Dr. Mike
Guest
Dr. Mike

It is a matter of being worn down in private practice from the usual suspects – The nearly annual SGR debacle – not being able to take a salary for up to 6 weeks while CMS sorts out congress’s foolishness. The ever increasing pre-authorization hurdles (multiple faxes and 30 min phone calls to get a $4 drug approved). The process of going through meaningful use has been illuminating – stage 1 is a piece of cake compared to what I see coming in stage 2, and it is obvious to me that I cannot sustain even stage 1 meaningful use… Read more »

John Ballard
Guest

Thanks for your candor. It seems you have found a better alternative anyway which is in a much-need area. (From what I’ve heard, be careful of burnout. The substance abuse people can be to medicine what fast food and social work are to their respective fields. Lots more young workers because of burnout.) I have some general questions and since you won’t be grinding an ax your opinion is valuable. ►What difference(s) do you see between traditional Medicare and Medicare Advantage (which is entirely non-governmental)? ►You indicated that the Exchanges were going to be different from the commercial policies. My… Read more »

Dr. Mike
Guest
Dr. Mike

Happy to respond -Patients seem to like the Medicare Advantage plans – they are signing up in droves. They are surprised however when they start having to deal with pre-authorizations and denials. It seems most of the patients end up on the same companies Part D plan as well and suffer the consequences of a severely restricted formulary – seemingly more restricted than stand alone part D plans. I really have no idea as to whether all of this translates into savings or expense for Medicare – but there clearly is some rationing going on just as in most managed… Read more »

John Ballard
Guest

Thanks. You said I expect more than a few patients to lose employer sponsored insurance and in the long run I believe that is correct. That’s part of Dr. Goldsmith’s optimism — that when the consumer becomes the individual patient rather than the company for which he works the dynamic driving both health care and insurance will be changed as a result. One long-standing policy aim of most experts (which nobody wants to speak aloud) is the goal of uncoupling health care from employment. http://www.aei.org/article/society-and-culture/poverty/tax-reform-and-health-insurance/ One of the arguments against ACA has been that employers whose employees are not insured… Read more »

Peter1
Guest
Peter1

“not being able to take a salary for up to 6 weeks while CMS sorts out congress’s foolishness.” “The ever increasing pre-authorization hurdles (multiple faxes and 30 min phone calls to get a $4 drug approved).” “The threat of an RAC/Medicaid audit is always there – they can ruin you over intrepretation of coding that even government coders have been shown to be unable to agree on” “I get blamed for what ultimately is the result of the policies of the insurance they carry. I see this getting worse moving forward, not better.” Why don’t you go all cash? Here… Read more »

Peter1
Guest
Peter1

“But I was misled and betrayed by the society I had hoped to serve.”

Maybe you can be more specific about the misleading betrayal?

John Ballard
Guest

Yo, Ms. Moderator, you getting this?
I promised to be nice. The rest is up to you…

Jan Eek
Guest

If you have something to say to me, just say it. Your condecending reply is not polite.

John Ballard
Guest

Jan Eek, please don’t take offense. My comment was not about you.

Jan Eek
Guest

John Balllard
Sorry, I misunderstood. Good to clear that up. Thank you.

Aaron Wemple
Guest

Rope-a-doped by dopes? Does ‘health care’ oppression = ‘voodoo’ magic justice? Look harder my dear friends. If you were a previous attorney, now president, wouldn’t you create a whole new ‘health care’ market for all of your colleagues to practice in if you could? Or, God forbid, let guns walk and chaotic bills increase if it grew your business? This isn’t rocket science. These are legal malpractice issues. Oppressive corruption at it’s ‘finest.’ The attorney clan will now forever benefit from the recent Supreme Court Health care decision, and remain hidden behind our judiciary and big greedy corporation/banks/etc.. And we… Read more »

Joe
Guest
Joe

If the Supreme Court has decided the Obama Care is really a tax, then isn’t the law null and void, because it did not pass by a 2/3 majority, as required for all new taxes? It was funny watching President Obama’s interview chastising the interviewer for looking up the definition of tax in the Miriam Webster dictionary, and accusing him of stretching it. It was like watching President Clinton saying, “it depends on what your definition of “is” is.”

Mitch Goldman
Guest
Mitch Goldman

One of the reasons primary care is not supported politically is that the benefits of prevention and early intervention are not included in the Congressional Budget Office’s calculations. Every politician worships at the alter of CBO scoring. Primary care lobbyists need to pressinng why CBO scoring is misguided and misleading. For example, the 30% of funding to be allocated to prevention under ACA only includes the cost of prevention programs not the offsetting cost reductions. Also, there was no projected cost increases under ACA is we never address childhood obesity. CBO just does not work when it comes to health… Read more »

SJ Motew, MD
Guest
SJ Motew, MD

I would agree with J Irvine that the onslaught of potential patients tied to the diminished number of primary providers is an arithmetic nightmare. Going even further, reimbursing primary docs based on value, outcomes satisfaction and quality demands more time and effort per patient which further impedes access. It is going to take a total re-engineering of how we deliver primary care with an increased use of nurses, mid-level providers, wellness practitioners etc. acting as frontline care givers (as is done in many countries). Such will leave the higher trained physicians to manage complex conditions, population health and specialized work-up… Read more »

userlogin
Editor

Interesting post. I’ve followed your campaign with interest over the last year. If anything the changes under the first round of health reform look as though they will put even more pressure on primary care docs (add twenty million new patients to the system – many of whom have lived outside the health care box for years – expect a serious, serious set of problems that haven’t been talked about much as the system transitions. ) I’m guessing a lot of docs will agree with you …

John Ballard
Guest

…primary care has been overwhelmed and outmaneuvered by a health care industry intent on freeing access to lucrative downstream services and revenues.

This is the clearest statement of the core challenge to health care as I have read. The sooner primary care returns to the driver’s seat the quicker most of the other challenges will diminish — starting with costs, otherwise known as health care inflation.

Aaron Wemple
Guest

Here’s the major hidden problem: Does ‘health care’ oppression = ‘voodoo’ magic? Look harder my dear friends. If you were a previous attorney, now president, wouldn’t you create a whole new ‘health care’ market for all of your colleagues to practice in if you could? Or, God forbid, let guns walk if it increased your market share and market value? This isn’t a political issue. Politics has become a deceptive rouse. These are legal malpractice issues. Oppressive corruption at it’s ‘finest.’ The attorney clan will forever benefit from the recent Supreme Court Health care decision. And we the people will… Read more »

Jan Eek
Guest

I agree, wholeheartedly. There are so many issues to address here, but I will point to what I think is the basic topic. This is obviously seen from the outside (Europe), but I worked ten years with hospitals, doctors and patients in the US. Discussing the verdict in the Supreme Court is like giving Tylenol to patient with a severe pneumonia. What is so hard to understand for the other Western countries, is the fact that in the US you use an enormous amount of money on medical care (18.2 of the GDP) because the basically privatized health care system.… Read more »

Aaron Wemple
Guest

Yes, yes and yes. Therefore, we absolutely cannot let matters of this magnitude be governed by professional politicians (mostly manipulators.) Why not scientific studies of these issues properly that could only resolve these problems in a win-all solution? Even variable solutions if need be. Not deadbeat ‘laws’ in a deadbeat system governed by a deadbeat practice. It’s stupid for accepting that people who bear false witness for a living have any control over those who have to suffer for them. Therein lies the answers. It can really come for no other place less deceptive & inexperienced. Issues of this magnitude… Read more »