After an exciting and challenging day of caring for patients and teaching students, a third-year medical student on his family medicine rotation says to me, “I really like what you do, but I just cannot afford to go into family practice.” I realized that by “afford,” he was referring not only to finances but also to the expectations of his parents, friends, and medical school. After spending 35 wonderful years as a family doctor, I have been “dissed’ by a kid who wants to become a dermatologist.
So I am of two minds. Part of me is fulfilled by being needed, loved, and respected by my patients.
Over time, they have increasingly looked to me to diagnosis, advise, reassure, and guide them through a complex healthcare environment in which few others offer them help. Another part of me sees that what I do is increasingly devalued by forces outside the exam room ― those who pay for health care, those who question the “medical necessity” of each test I order or drug I prescribe, and those in medicine who are more likely to know a procedure’s CPT code than a patient’s name.
We are in this position because we have failed to define ourselves, instead allowing others to perpetuate myths about what we do. The first such myth is that what we do is easy. Nothing can be further from the truth. In about 15 minutes, we are asked to treat a long list of chronic problems (e.g., diabetes, obesity, hypertension), resolve a few new problems (eg cough, headache), address preventative health recommendations (eg, smoking, flu shot), integrate the psychosocial issues that impact the patient’s health, and figure out how to get it all paid for by an insurance company using codes that don’t really match either my patient’s problems or the care I provide. Oh, and by the way, can you look at this rash and fill this prescription for my husband? Recent research has shown that an average primary care visit is 50% more complex than a visit to a cardiologist and five times more complex than one to a psychiatrist. So no, it is not easy.
The second myth is that it requires less training than other medical specialties. This has resulted in some assuming that primary care can be left to “midlevel” clinicians. While physician assistants and nurse practitioners can work effectively in primary care settings, it is a mistake to believe that they provide equivalent care to patients with complex problems, and we have suffered by the wide acceptance of this assumption. OR techs can work effectively in an operating room, but no one suggests that they replace surgeons.
I sometimes observe that the only sector of the economy as messed up as health care is higher education, where the US has some great institutions but where costs are incredibly high and have been rising relentlessly for long periods of time. These two dysfunctional systems intersect in multiple places, one of which is the cost of medical school and its impact on the physician workforce.
One of the reasons the cost of health care is so high in the US is the overemphasis on specialists vs. primary care relative to other advanced countries. That overemphasis is a result of multiple factors, including a reimbursement system that favors procedures and the prestige associated with specialties. But another significant factor is the cost and financing of medical school. Average debt levels for graduating medical students are around $150,000. Combine that with leftover debt from college and it’s easy to get up into the $200,000 range. That’s a big nut to pay off in primary care where typical compensation is $150,000 per year or so.
That large debt level certainly encourages graduating medical students from going into primary care. My guess is it also deters some would-be primary care physicians from going to medical school in the first place.Continue reading…
Is economic credentialing — the use of economic factors such as loyalty and utilization rates in the physician credentialing process — a potential tool for primary care physicians to lead ACOs? and reestablish the vitality of primary care in American health care?
Keith Wright and Gregory Drutchas’ incisive article Economic Credentialing: A Prescription To Secure Shared Savings Under Accountable Care provides useful history and context about economic credentialing:
For many years, the use of economic factors by hospitals in making medical staff credentialing decisions has been the subject of much discussion and debate among physicians, groups such as the American Medical Association (AMA), healthcare providers, payors, and attorneys….the implementation of healthcare reform is likely to bring the debate over economic credentialing to the forefront once again.
While economic credentialing has been talked about a lot, it’s rarely been used.
The controversy over economic credentialing arises again with ACO’s…and this time the answer might be different — and opportunistic for primary care.Continue reading…
As a third-year medical student in 1977, I joined the American Academy of Family Physicians (AAFP). In those culturally tumultuous years, it was a way to declare my belief that America needed physicians who cared for the whole person, family and community. It was also a declaration that, in choosing the primary care path in a field ripe with tempting medical specialties, money was not my primary goal.
For much of my 33-year membership, I have considered the AAFP to be “my” organization. However, there is a time when one must step back and declare independence from organizations that have lost touch with their members. The AAFP does much that supports my day-to-day life as a busy family doctor, but for 33 years, its leadership has failed to fix the central problem for primary care in America: poor reimbursement.
I deal every day with complicated health problems of complex patients who are insured by companies singularly focused on limiting even the smallest cost. In return for managing these patients, which often involves critical and life-or-death decisions, I am paid by Medicare 60% less per hour than is a dermatologist, who, for the most part, treats trivial disease that involves no nighttime emergencies and little intellectual challenge.Continue reading…
Starting in 2011 with the regulations required by the PPACA Medicare will mandate copay and deductible free preventative services for our older Americans. This is great news for primary care physicians. I’m a family physician, and have struggled for years with the fact that just about every private insurance plan covers an annual physical exam, but Medicare did not. What this anti-intuitive dichotomy accomplished was bringing in my relatively healthy 30-something patients for a physical exam each year, while for my 70 year old for whom far more preventative services were recommended by the United States Preventative Services Task Force was not covered for a preventative exam ever. Not annually, not every 3 years, just once at age 65 to last their lifetime.
As primary care physicians we tried to our best to squeeze preventative care into visits primarily for other complaints. At a visit of my diabetes patients every 3 months I’d try to focus on the diabetes and save enough time to review immunization status, assure breast and colon cancer screening was up to date, help med decide if they wanted prostate cancer screening, …. I’m looking forward to being able to ask my seniors to schedule a preventative care visit annually now and being able to focus on these issues without having to eke out time in a problem oriented visit.
Still I have to say if the goal is to provide incentive to older Americans to go to their physicians for services that will really make a difference in the health of the Medicare population problems I think congress has it wrong. If we want to prevent unnecessary hospitalizations and expensive complications from neglected medical problems, and have the biggest impact to reduce the burden of expensive medical complications and I believe the most efficacious preventative services we can offer in health care are secondary prevention and disease management. I’d love to think that by primary prevention, education, and physical exams I can help patients improve their health and subsequently reduce costs and get better outcomes. The problem is that there is little evidence that this is the case. This new regulation, offering a free once annual preventative care visit may find some early cancers, improve immunization rates and make us feel like we are being proactive.
I’ve just returned from a few days in London, scoping things out for a planned sabbatical next fall. In what may be a pale echo of the late Alistair Cooke’s always fascinating “Letters From America,” here are a few of my initial observations:
The dominant issue, of course, is the Cameron government’s new austerity program, with its planned deep cuts to government services and benefits. While the program (or programme, I guess I should say) has created some upheaval – witness the recent semi-violent demonstrations by university students, whose tuitions may treble – it has not torn apart the society, the way belt tightening of this magnitude undoubtedly would in America. My sense is that the relative acceptance (yes, I know Charles and Camilla had a frightfully awful limo ride to the West End the other night, but this was, er, theater rather than a defining moment) can be explained the Brits’ stronger trust in their government. It is this same trust that leads to near-universal support for the National Health Service, the UK’s tax-funded healthcare system. This wellspring of support gives the government a little leeway when it says, “We can’t afford to do all this anymore, folks, and we can’t just print money. We must cut programs and benefits.”
In the US, of course, there is no such trust today, nor harbingers of its return any time soon. In a recent issue of Time that outlined this past decade’s mega-trends, Nancy Gibbs observed that the cumulative effect of 9/11, Katrina, BP and the subprime crisis was to markedly shrink Americans’ already scanty faith that their government can do anything competently. So our response to the recent announcement that Chinese kids are shellacking us in educational achievement is hand wringing and statistical nitpicking, not the call for vigorous government action that characterized our nation in the Sputnik era.
This is a story about consumer choice using publicly available information. Unfortunately, it is also about the power of suggestion as used by an incumbent provider organization.
The friend who sent me this note is a research fellow at one of the Boston teaching hospitals, so I guess he is more likely than most to do the kind of research he summarizes. Most people would have taken the referral advice offered without question. If they ever did ask to see a different doctor, most would never get past the “need” for asking for “special permission.”
I had a strange encounter, and I was wondering if you could tell me if this is normal.
A few months ago my primary care physician recommended I see dermatology for my eczema. His clinic recommended the names of two dermatologists within the same health care system. I looked up both dermatologist on healthgrades.com and found that their patients had given them luke-warm reviews. (There were many reviews, so this wasn’t a sampling problem). Also, I have been reading the medical literature about eczema, and knew there were a lot of recent advances, so I wanted somebody who had published and was familiar with the research.
I found another dermatologist, Dr. Caroline Kim. Her patients loved her (according to healthgrades.com), she had published articles in dermatology research (from scholar.google.com), and she trained at top institutions: Harvard Medical School and MGH. I made an appointment with her.
Remember the penguin problem described by economists?
No one moves unless everyone moves, so no one moves.
Overcoming the penguin problem has a lot to do with creating expectations. A recent writing by Dr. James O’Connor in Physician Practice expresses a voice from the physician community that I’ve never heard before. His essay is entitled “Meaningful Use — Doctors Have No Choice”.
Physicians Have No Choice Other Than to Adopt EHRs?
Dr. O’Connor argues that physicians are effectively being forced into adopting EHRs. He cites facts and reaches a powerful conclusion:
1. CMS penalties begin in 2015.
2. What if you won’t or don’t accept Medicare/Medicaid patients (13 percent of practices in 2009, up from 6 percent in 2004? In August, four major insurers (Aetna, Highmark, United Health Group, and Wellpoint) announced that, at a minimum, they will link their pay-for-performance programs to federal meaningful use criteria. Other insurers are likely to follow.
3. Do you run one of the increasing number of “boutique” or VIP practices that work on a cash-only basis? The American Board of Medical Specialties (ABMS) released a statement in August saying that they intend to link meaningful use of health information technology into the ABMS Maintenance of Certification© program.
4. You don’t care about being board certified? (Sound of crickets chirping.) The Final Rule gives states the authority to impose additional requirements that promote compliance with meaningful use. As reported in Physicians Practice, the state of Massachusetts may take away your license to practice medicine in 2015 unless you demonstrate meaningful use of an EHR system. In Maryland, private insurers will be required to build incentives for acquisition of EHRs and penalties for not adopting them into their payment structure.
OK, so technically, we do have a choice. We could stop taking Medicare and Medicaid patients, accept cash only, give up our board certification (and thus usually hospital privileges), and move to a state (or country) that doesn’t impose EHR requirements. But is that really a choice? No.
On October 18 2010, Dr. Blumenthal published a letter to EHR vendors titled "Health IT and Disparities" urging them to “include providers who serve minority communities in their sales and marketing efforts”. Reiterating the assumed benefits of Health IT to both quality of care and efficiency of care delivery, the National Coordinator for Health Information Technology stressed the importance of EHR vendors working together “to provide EHR adoption opportunities for physicians and other healthcare providers working within underserved communities of color”. This is obviously an important and welcome appeal. Physicians who provide care for impoverished minority communities usually lack the means to purchase EHRs and perhaps some EHR vendors will heed Dr. Blumenthal’s request and make special arrangements for these doctors and their clinics. The stimulus incentives may also help. But how about those who serve equally impoverished populations and are practically barred from incentives?
In my home State of Missouri there are about 350 Rural Health Clinics (RHC) serving a state which with very few exceptions is one big Medically Underserved Area/Population (MUA/MUP) which is a geographical area or a population designated by the Health Resources and Services Administration (HRSA) as having: too few primary care providers, high infant mortality, high poverty and/or high elderly population. For the uninitiated, RHCs are designated by CMS and have to meet certain requirements. The practice has to be located in a rural area and it has to provide team care, which is all the rage now, meaning that a Nurse Practitioner or a Physician Assistant and a Certified Nurse Midwife have to be on premise and team up with the physician in providing patient care. RHCs can be independent practices or they can be owned by rural hospitals. Either way RHCs are paid by Medicare differently than a practice without RHC designation. RHCs are required to submit reports of their operational costs and their total number of visits. Based on these two parameters the reimbursable cost per visit is calculated by Medicare. The entire process is complex and subject to rules, regulations and caps. The main point here is that RHC providers are not reimbursed according to the regular Medicare physician fee schedule and therefore will be unable to receive EHR incentives under Medicare. A few RHCs may qualify for Medicaid incentives, but in most cases they don’t have the prerequisite 30% Medicaid patients.
Hey there, big, smart, good-looking doctor….
Are you tired of being snubbed at all the parties? Are you tired of those mean old specialists having all of the fun?
I have something for you, something that will make you smile. Just come to me and see what I have for you. Embrace me and I will take away all of the bad things in your life. I am what you dream about. I am what you want. I am yours if you want me….
Seduce: verb [ trans. ]
attract (someone) to a belief or into a course of action that is inadvisable or foolhardy : they should not be seduced into thinking that their success ruled out the possibility of a relapse. See note at tempt .
(From the dictionary on my Mac, which I don’t know how to cite).
If you ever go to a professional meeting for doctors, make sure you spend time on the exhibition floor. What you see there will tell you a lot about our system and why it is in the shape it is. Besides physician recruiters, EMR vendors, and drug company booths, the biggest contingent of booths is that of the ancillary service vendors.
“You can code this as CPT-XYZ and get $200 per procedure!”
“This is billable to Medicare under ICD-ABC.DE and it reimburses $300. That’s a 90% margin for you!”
This is an especially strong temptation for primary care doctors, as our main source of income comes from the patient visit – something that is poorly reimbursed. Just draw a few lab tests, do a few scans, do this, do that, and your income goes up dramatically. The salespeople (usually attractive women, ironically) will give a passing nod to the medical rationale for these procedures, but the pitch is made on one thing: revenue.