OP-ED

Holier Than Thou Doctors

flying cadeuciiI can recall it like yesterday.  It was 2004, and I had become the CEO of Blue Cross & Blue Shield of Rhode Island.  I was in the middle of my annual physical with my long-standing primary care physician, Dr. Richard Reiter (true).  Dick Reiter is my age and is an old school doc.  He caught my cancer before it got too serious, and had been yelling at me about things like cholesterol, stress, and exercise for years.

During a lull in the exam, I turned to him and asked, “Dick, I’m the CEO of Blue Cross.  What do I need to know?”  He paused, looking down.  Then his cheek started to twitch.  I actually saw him lose his temper for the first time in 25 plus years.  “Jim, you want straight?  What the bleep are you doing to us?  A monkey can do a colonoscopy and yet they make four times what we primary care doctors make.  What you are doing is a disgrace.”  He was some pissed!!

I then had lunch with Dr. Al Puerini, a highly regarded PCP of 30 years with a full practice.  I asked him how much he netted before taxes, and when he told me, I was appalled.  He made some aside about it not being about the money, but it IS in part about the money.  He also told me about how difficult it was to recruit new PCPs in RI.

Those two encounters started me down my path of alarm about the future of primary care.  Rhode Island is a small (40×30 mile, one million population) microcosm of the country.  While we have our accents and quirks, and people still think we’re overrun by the mafia, we’re not all that much different.  Just wicked smaller.  Our PCP population was aging and shrinking rapidly.  The best and brightest from Brown Med School and others of its ilk were decidedly not swarming into primary care.  Practices could not recruit new members.  We were, and still are, in a crisis that is nation-wide.

And it didn’t stop with just the poor PCP reimbursement.  PCPs cannot survive financially without untoward volume.  This has all sorts of negative consequences.  Moreover, on the totem pole of respect, PCPs do not seem to rank high for reasons that I simply cannot fathom.  It seems that the more “miracle machines” a physician uses, the more respect he or she gets.  While the poor PCP does what we in the billing world refer to as “E&M” (Evaluative and Maintenance).  The look-you-in-the-eye, known-you-for-years sort of thing.  In other words, taking basic tests and extrapolating health trajectories.  Wading into gray areas.  Knowing the patient and her family, and making informed prognoses.  All difficult stuff.  Not something that shows up on an LED screen.  Ahhhh….judgment and perspective.

A little aside.  It seems as if politicians, the media, and even participants cannot help but to “cartoonize” the players in healthcare.  Obama and Pelosi did it as a way to get passage of the ACA.  I mean, when the President calls you “evil,” it does smart a bit.  And during my tenure as CEO of a health insurer, I was accused of many things that were rather startling to my family who thought they’d known me better.

Even today when I write articles for THCB and others that are in any way critical of physicians, I get the usual angry knee-jerk response from physicians who absolutely must believe that I have no understanding of the value of physicians and the pressures they operate under.

But my story continues.  Energized to do something on a number of fronts regarding primary care, I called a meeting of my rating group (you know, the actuarial, underwriting, sales, provider “relations”) and I ask them to explain to me why PCP reimbursement was so low.  A variety of non responsive responses were given, and I ended up concluding that it was because we could.  We could keep PCP reimbursement low because most PCPs (at least then) were onesies and twosies with no negotiating leverage, while specialists tended to group together to share “machines” and gain clout.  Sigh.

So then, armed with the knowledge of what PCPs were paid in Massachusetts, our richer neighbor just to the north, I announced that we would achieve “parity” in four years, parity being defined as keeping up with the current Massachusetts PCP rate for E&M codes.  That required us to increase what we paid PCPs almost 50% over four years to cover the historical difference plus ongoing increases.

The pushback I got from my staff was startling.  “That will make us uncompetitive.”  “That is too inflationary.”  “Our job is to keep fees as low as we can so that our premiums are as low as possible.”  Etc.

Finally, having had it with all the negativity, I ordered the trusted actuary who I’d worked with as outside counsel in rate cases for decades to tell me what the impact of such an increase (50%) would be on overall premiums.  The result?  Less than 1%!!!  The moral?  Office visits NEVER break the bank.

Well, we reached parity with Massachusetts after five years (yeah, I know).  We also did major funding, technology grants, nurse practitioner hires, etc., for PCP patient centered medical homes.  While I know there is some controversy about how well PCMHs have done, I remain optimistic, just as I do with ACOs.  And lastly, we funded a loan forgiveness program for PCPs entering their practice in RI.

How much did it help?  Some, I think.  Are PCPs happy today?  In Rhode Island, I think a bit more today.  We have two large practice groups which seem to be thriving, and some smaller regional (if you can use that term for RI) groups who appear to be doing well.  Linkages with hospital systems seem to be taking place.  [About time.]

Yet, unless we can relieve PCPs from the burden of volume, we are destined to have disenchanted, angry, and burnt out PCPs.  The problem is so bad that even YouTube has something on it.

And so, with a dwindling PCP population and ever increasing numbers of newly insureds as a result of the ACA, clearly there is a need.  Likewise, with the aging of the Boomers, we will see more and more patients with 3 or more chronic conditions.  There will always be a need for the PCP, the one who sits face to face with the patient and his family and counsels.  And while nurse practitioners can carry much of the load (I use a NP as my PCP with the VA, but that’s another story for another day), they cannot replace the PCP MD.

Insurers are to a significant extent to blame.  Stephen Schimpff, MD, has run a series of incisive articles on the subject and a book.   It would be well to heed his warnings.  He largely blames payors, and concludes that neither insurers nor the government can (will?) change the current situation.  His primary (so to speak) observation is that we’ve required PCPs to allot too little time per visit to truly be evaluative.  When one has to see 25 patients a day to earn a decent living, one has to cut corners and overuse specialists, with cost consequences.  I would hope that insurers and the federal government both can take steps to change all of this.

There have been articles on THCB on this subject in the past.  As this blog ends, I challenge other contributors to THCB to develop ideas on how we can invigorate primary care and get med schools to produce more top flight physicians who enthusiastically opt for primary care.  This is an almost holy mission, and hence my tongue in cheek title for this blog.

Perhaps Andy Slavitt might have a few words to share with us.  He seems to share my views about primary care.  Actually everyone does, but that hasn’t seemed to have made enough of a difference….yet.

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J Antonucci MDPaul @ Pivot ConsultingLLCMarkAllanVinayPharmD Recent comment authors
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J Antonucci MD
Member

Excuse me. Achieved parity with the miserable pay of other PCPs? What, we should thank this man? Give me parity with the ophthalmologist who will get, himself, $1,000 for a 15 min.operation that takes roughly the skill of shelling out a sebaceous cyst for which I get 70.00. Or of the orthopod 50 min from here who get $1,000,000.00 a year.

anish_koka
Editor

RVU, RUC, reimbursement, DPC, ACA – One begins to forget what lies at the heart of all of this: http://www.nytimes.com/2016/10/06/well/live/a-letter-to-the-doctors-and-nurses-who-cared-for-my-wife.html

Paul @ Pivot ConsultingLLC
Member

I think a more appropriate title of the piece would be “Holier than Thou Insurers”. Yes, I am being a bit snarky, but the insurers hold many of the power cards and while they are sometimes motivated by good (or even holy) intentions, it seldom works out well. I do think Jim Purcell’s contributions are very helpful, shedding light on the perspective of insurers.

Mark
Member

Yea, I’m sorry. While you might “get it,” I’m not sure what good you actually did. As a recent residency graduate, starting salaries in Massachusetts are still 15-25% higher than anywhere in RI. RI is still in the bottom 5 of states for PCP reimbursement. And this PCMH nonsense was apparently heralded into the RI healthcare climate by folks like you. There are virtually no composite studies showing PCMH has any real effect on outcomes or cost. And any small difference it may have are completely negated by continuing to rely on 7.5 minute physician visits and the ~$100k price… Read more »

jamesepurcell
Member

Mark, let’s chat. I’d like to hear your experience and throw it up against mine. I’ve been away frm RI for 5 years, and I know some of my initiatives did not last long. But aside from your ennui, focus on what’s wrong (you do), but also help me with what I do about it. I still regularly talk with the two Als (Purerini and Kurose).

Allan
Member
Allan

James Purcell, I don’t blame the insurers. Their job is to make money for the stockholder. I blame those that make the rules and the insurers who actually use their money and power to influence those rules causing many of the problems we see today. I was a PCP with a subspecialty, but preferred total patient contact rather than dealing with one picture at a time, one dead organ or one live organ. PCP is very rewarding until you guys enter the picture and tell me that I have to write notes on a computer in your bureaucratic fashion rather… Read more »

jamesepurcell
Member

Woof: In response: Denial of treatment as a profit center. C’mon. That was 90’s. The right care at the right time in the right location is what it’s about. You exhibit your ignorance here. Sorry. AMA: I accept that. Now to change that. Mandates? I hate ’em. Heavy handed way of anectdotally driven medicine. Physicians as agents of insurer? You’re kidding me. Organic growth vs. intellectuals: you really think I’m an intellectual. Talk to my wife. I did write that. It’s still true. That simply reflects that physicians do not think much about their patients as customers. This really has… Read more »

Allan
Member
Allan

“ Denial of treatment as a profit center. C’mon. That was 90’s. ” Then you haven’t learned how to understand the incentives that exist or perhaps you don’t even recognize what they are. I’ve seen and worked with them so I have an understanding from ground zero. From your lofty position perhaps you should refocus your telescope. AMA: “Now to change that.” That is not happening anywhere soon. Take a look at the very old suit against the AMA by its own members. Then take a look at what generates money for the AMA. Mandates. You are on track in… Read more »

jamesepurcell
Member

I accept the fact that I will never truly know what a physician experiences. My respect for physicians is actually enormous. Yet, we posit and opine, and sometimes are right, sometimes are wrong. I learn each time. Thank you for reminding me.

Allan
Member
Allan

Jim, I believe you. I think our problems lie in the fact that we rely too much on government and not enough upon ourselves and those we directly deal with. I am sure in a free market where a level playing field exists (reasonable regulation can exist well) you as an insurer can deal with doctors, hospitals, and patients to get the best value for the dollar. That would require utilizing insurance as insurance instead of as an entitlement. I think we both recognize the existence of those that fall through the cracks and may require additional help, but that… Read more »

anish_koka
Editor

Peter- thanks for the data from 1981. Here’s the CMS data from 2014 for those interested. . Link to the full article here: http://content.healthaffairs.org/content/early/2015/11/25/hlthaff.2015.1194.full Regarding physician and clinical services price growth: “For physician and clinical services, growth in both price and nonprice factors, such as residual use and intensity, accelerated in 2014 compared to 2013. Prices increased 0.5 percent in 2014 (up slightly from growth of 0.1 percent in 2013), influenced in part by a Medicare physician payment update of 0.5 percent compared to an update of 0.0 percent in 2013. Nonprice factors also grew faster in 2014—driven, in part,… Read more »

Peter
Member
Peter

I wonder what firefighters or police would get paid if they could set their own wages and what justifications they would make?

Perry
Member
Perry

Firefighters and police have unions to do that for them.

Peter
Member
Peter

Yes, and governments negotiate on behalf of property tax payers for a COLLECTIVE agreement. I’m not sure how physician reimbursement is negotiated between Medicare, various insurance companies and hospitals and groups and hospital linkages – and with the RUC thrown in for good measure.

When a union contract is negotiated all members receive the same contract, not so for health care. I don’t see anyone, except maybe Medicare negotiating for premium payers. Certainly insurance companies don’t care as they just pass on the extra premium. The system is so disjointed that there is no transparency or consistency.

Perry
Member
Perry

Well for Medicare, CMS basically sets the rates or invokes MACRA or MIPS to tell docs what they will pay them and how. Most insurers will contract with docs individually or “provider groups” for discounted fees based on the promise of increased patient on their panels. Societies like the AMA and ACP, do very little to help docs negotiate fair fees.

Allan
Member
Allan

There are both private police and private firefighters.

VinayPharmD
Member
VinayPharmD

Respected members of the healthcare community. Although I am an outsider to the medical side of health insurance and care my unique experiences as a pharmacist who has spent most of my career working on primary care teams with physicians and other healthcare providers has provided me some insight into this maddening world. In response to Jim’s request for innovation, please allow me to pitch my idea and I welcome any and all criticism. My idea involves changing reimbursement for pharmacy and primary care simultaneously. What I can tell is that reimbursement is still primarily based on fee for service… Read more »

Barry Carol
Member
Barry Carol

In any large population of patients, including a state’s Medicaid population, the healthiest 50% account for 4%-5% of costs in any given year. Under your approach, we would be spending $50 per month for both PCP and pharmacist on each of hundreds of thousands of people in a given state who currently cost the system nothing or very little. Separately, I take six maintenance medications for heart disease, all generics. When I need to renew, I send my doctor a note and he sends me new prescriptions by mail for a 90 day supply plus three 90 day renewals. He… Read more »

jamesepurcell
Member

Several last comments. A friend from RI (a PCP) read this and said that my story was incomplete because it failed to mention the efforts of our regulator in RI (the Office of Health Insurance Commission, or OHIC). Chris Kohler was the first such commissioner, and as much as I hate crediting my regulator (that’s a joke), he deserves credit for pushing BCBSRI and United to do much more for primary care, including PCMHs and increasing the proportion of reimbursement PCPs received. Lastly he referred me to this Brown website regarding the new primary care population medicine course. https://www.brown.edu/academics/medical/education/other-programs/primary-care-population-medicine/ We’re… Read more »

anish_koka
Editor

My feeling – I’m a cardiologist who works closely with a primary care physician – an n of 2 multispecialty practice 🙂 is that the discontent doctors feel has much to do with lack of autonomy, and time spent not doing direct patient care as it does with reimbursement/compensation. A couple points on what Jim said 1. Jim seems to applaud ‘linkages’ with hospitals – though I’m sure he realizes these linkages in the last 8-10 years have almost always resulted in a loss of autonomy. Suddenly, non-clinicians who don’t know much about taking care of patients, but have been… Read more »

Barry Carol
Member
Barry Carol

Anish, I’m curious what percentage of the population do you think could afford a $100 per month retainer for DPC on top of their high deductible insurance premium? How many of those would be willing to actually pay it? It’s a very attractive model conceptually but the market opportunity and the ultimate uptake may be a lot smaller than you think especially in a city like Philadelphia with a lot of low to moderate income people.

anish_koka
Editor

50-100/month. We could have subsidies below a certain income level. I can certainly tell you that this model is working right now among a medicaid patient population, undocumented immigrant patient population, etc. Doesn’t have to be a mandate – just allow it as an option, alongside ACOs, PCMH, CPC, etc.

Peter
Member
Peter

” I can certainly tell you that this model is working right now among a medicaid patient population, undocumented immigrant patient population, etc.”

Which Medicaid/immigrant population? If you’re on Medicaid and doing this then how do you get past the income/assets Medicaid rules?

Margalit Gur-Arie
Member

What rules, Peter? As far as I know, people on Medicaid or people eligible for Medicaid or people not eligible for anything, can have $100 per month and can use that money as they see fit, no? Am I missing something?

Peter
Member
Peter

“I’m curious what percentage of the population do you think could afford a $100 per month retainer for DPC on top of their high deductible insurance premium?”

Exactly!

jamesepurcell
Member

Anish: I agree with your concern about PCP involvement with hospitals. I referred to it as”linkages” in hopes that they would foster respect for and involvement with PCPs—not abject dismissal. I’m hopeful the relationship will grow to something better than it is today. I do also appreciate the role of insurers in this mess. We need some game changers here. While the idea of concierge PCP care is attractive, I do not see that as the ultimate answer. It’s a knee jerk reaction to the problem.

Peter
Member
Peter

“How much is the expertise of an orthopedic surgeon with a sterling record of complications worth?”

How much is a PCP worth? How much is the firefighter than saves your life worth?

anish_koka
Editor

Should we pay firefighters and cardiothoracic surgeons the same? Not acknowledging the differential inherent in highly specialized fields that requires many extra years of fairly grueling training doesn’t seem fair either. This debate which gets folks frothing about pay differentials within physicians unfortunately distracts from the real issue. Physician compensation is 9% of the total pie. Divy it up however you want, or reduce it by half – you won’t make any meaningful gains when it comes to the great health care cost debate..

Peter
Member
Peter

“Physician compensation is 9% of the total pie.” Really? Can you link that number? “Spending on physicians’ services currently represents one-fifth of total national health care expenditures. From 1965 through 1981, expenditures on physicians’ services grew at an average annual rate of 12.4 percent, and even larger increases were experienced by the Medicare and Medicaid programs. By contrast, gross national product grew at an average annual rate of 9.4 percent over the same period. From 1965 through 1981, the Consumers’ Price Index (CPI) component for physicians’ fees rose by 7.9 percent per year, a rate 17 percent higher than the… Read more »

Barry Carol
Member
Barry Carol

“Physician compensation is 9% of the total pie.” Really? Can you link that number? Peter – I think Anish is referring to the fact that physician practice expenses account for a bit over 50% of practice revenue. These expenses include office staff salaries and benefits, office rent, equipment, supplies, utilities, etc. and, of course, malpractice insurance. The 9%-10% left after expenses is physician income, or, if you will, the profit generated by the practice. My main beef with the 20% figure in the NHE data for physician and clinical services as a percentage of total National Health Expenditures is the… Read more »

Niran Al-Agba
Member

Gentlemen- please stop this back and forth about specialists and primary care. Both are valuable and absolutely necessary. This is one of the main reasons we are in this mess; not coming to the table as a group and fighting together. Without primary care there would be no congenital heart defects for the cardiothoracic surgeon to repair. Without cardiology or orthopedics, we would have no one to consult on complicated cases where we need help. We must as a group resolve to stop arguing and fighting each other. We want the same things. We want wages that allow us to… Read more »

anish_koka
Editor

Is Peter a physician? I would be surprised based on what’s in his comments – but I am wrong 50% of the time. Niran, I have no beef with you – a primary care physician is a part of my practice and is integral, and on most days does far more effective work than I do. Perhaps an engaged pcp would have been able to avoid the hip replacement all together. I’m a big fan of the Niran’s of the world. But a good way to generate eye-rolls among neurosurgeons and have them not at the table we all need… Read more »

Barry Carol
Member
Barry Carol

Anish, I was just made aware today of a 13 page paper published in Harvard Business Review by Michael E. Porter and Robert S. Kaplan titled “How to Pay for Healthcare.” Their argument is that the best way to create the incentives that would deliver high quality care in the most cost-effective way is through bundled payments. They argue that traditional fee for service is too inefficient and uncoordinated while capitation creates incentives to undertreat patients. I had to submit some personal information (email address, occupation, etc.) to get access to the paper but I hope the link below will… Read more »

Niran Al-Agba
Member

Thank you. You are correct the class warfare between physicians is the wrong debate to be having. Specialists should be defending PCP’s and PCP’s should be defending specialists. I cannot explain Peter’s reference to a firefighter and it is completely irrelevant. However, PCP’s tend to undervalue themselves and he might be doing just that. The neurosurgeon would be right to roll his eyes. DPC has a role, without question, in the future. My concern is that the dreadful Bob Doherty’s of the world (ACP) are laying the groundwork to label DPC’s unethical. Physicians keep getting led around by the nose… Read more »

Niran Al-Agba
Member

Jim – I cannot believe I am going to say this, but you get it! We will continue in crisis (it is about to get much worse) until someone realizes paying physicians by E&M for time is exactly what should change. This is where it MUST start. Lawyers (as you know) are paid this way and I am in the process of setting up my fees along these same lines. We must now charge for phone consults, prior authorizations, filling out forms, writing letters, and 24/7 triage call coverage in order to keep our heads above water. If I could… Read more »

jamesepurcell
Member

Awwww….

Barry Carol
Member
Barry Carol

There are several issues here. Commercial insurance reimbursement rates that you discussed are just one of those. In theory, if higher reimbursement rates for PCP’s allowed them to see fewer patients per day to make a decent living and reduce the current overuse of specialists, total medical claims that payers and members have to pay could decline but we don’t know if that would actually happen or not until somebody tries it. Another problem is that within Medicare, the specialists clearly dominate the Relative Value Update Committee (RUC) and they protect their own turf and reimbursement rates at the expense… Read more »

jamesepurcell
Member

I agree that RBRVS is a major part of the problem, and with your identification of the cause. Now what do we do about it???

Barry Carol
Member
Barry Carol

Jim – If it were up to me, I would like to try the following: First, split the RUC into two committees – one for specialists and one for primary care. Second, hold the specialist reimbursement rates harmless. Third, move the E&M codes partly away from the RBRVS system by supplementing the payment called for by the relative value units with a flat additional payment of somewhere between $25 and as much as $40 for a 99213 office visit. I think relative value units lend themselves better to procedures than to E&M billing codes. The incremental cost will, of course,… Read more »

jamesepurcell
Member

Any referral system that is based on stickiness of relationships and volume is morally bankrupt. We must base our referrals on quality of care, outcomes and cost. Your points are well made, and the issue does remain primarily one of compensation. There is no way around that inconvenient reality. That doesn’t make PCPs any less professional or human.

LeoHolmMD
Member
LeoHolmMD

Thank you. You get it. Primary Care needs to get way more organized. It is not so much about the pay as it is the disparity. It would be interesting to know what the simple action of just raising E&M did in terms of patient care. Time with your provider is highly valued. I have yet to see one metric addressing that. Primary Care can live up to the expectations, but we need the time, workforce, and morale to do so.

William Palmer MD
Member
William Palmer MD

There’s too much to know. Everyone should specialize a little more and the specialists should generalize a little more….so that we have docs more like gynecologists or pediatricians and internists, who know their field thoroughly but also know enough of general medicine to recognize psoriasis and leiomyomas of the uterus, etc., and to be a case manager or gate-keeper for their patients who must occasionally go to outside specialists. The ophthalmologist who doesn’t recognize a basal cell carcinoma on a patient’s forehead is specialized too much. The PCP who doesn’t know that erythromycin prolongs the QT interval or doesn’t understand… Read more »

Perry
Member
Perry

Jim, I encourage you to read Medscape and also take a look at KevinMD website. Pay is only a partial issue for most PCPs. For almost all, it is the constant requirement to spend more time away from treating patients, to feeding the EMR monster with useless information and meeting constantly more “measures”, and the current regulatory quagmire of MIPS, MACRA and so forth. Conversely, my GI guy (who is very good at what he does, and a good doc) can crank through a number of scopes a week and rake it in. I have nothing against him or what… Read more »

RogueRad
Member

Indeed. Mr. Purcell has joined a long line of commentators who have “followed the money” to explain the low morale of PCPs. He might talk to a few PCPs, particularly those who work in rural areas, what ails their souls.

Perry
Member
Perry

Yes, talk to Dr. Al-Agba for one, who posts here and at KevinMD.

RogueRad
Member

It’s not just about the money, PCPs need power (yes, I really mean power) so that their job isn’t simply to satisfy number crunchers and meet (defunct) metrics from organizations like the one you once led. Britain’s model might be one to emulate, as far as GPs are concerned (though I doubt people will be willing to accept the trade-off) https://thehealthcareblog.com/blog/2014/06/21/its-the-gps-stupid-care-coordination-in-britains/ Make PCPs gatekeepers of the system. Raise their pay and responsibility. Have fewer, far fewer, but better paid specialists. Much of the medical management done by specialists can be done by primary care – e.g. management of stable angina,… Read more »

jamesepurcell
Member

I write a lot about workplace wellness and wellbeing, and while compensation IS critically important (after all, that’s why people work), recognition and appreciation rank right up there. Here, with PCPs, we have the confluence of too little recognition, too little time, and too little compensation. And you cannot tell me that the finances don’t drive the small window of face time with PCPs. I grieve about that and understand it; we need to change that. So let’s move the conversation onto change.

RogueRad
Member

Of course compensation is important. But to reduce the cause of low morale to inadequate compensation, if not insulting, is inaccurate. We’re all seeking solutions. How far are you willing to go to solve the crisis? Are you willing to rid PCPs of the measurement mania that afflicts medicine? If not, why not?

Niran Al-Agba
Member

This! As Rogue Rad said… is step #2! The measurement mania and electronic red tape must be eliminated so we can resume practicing medicine. What physicians need is more time to spend with their patients and adequate compensation to feed their children, own a house, pay off student loans, and take an occasional vacation with their family.

Moving the conversation to real change will take an act of Congress, literally and figuratively. Let me know when someone is listening who can actually do something about it. News flash: Its not Mr. Slavitt.!