On Primary Care in America
Our talks of retainer medicine became more general talks about primary care, which is a great segue. A classmate emailed me his own sentiments:
I think you’re underestimating how screwed primary care physicians are… Primary care is royally f’d, and I don’t think its fair to pretend that their problems will magically get fixed by universal heatlhcare. As a lot of primary care’s f’d-ness has come at the hand of specialists.
As others have said, priarmy care is in trouble in this country. And I agree. Some of it is due to the lack of reimbursement compared to specialists; some of it is due to the lifestyle–seeing 8 patients an hour, including documentation and all that’s required for a patient visit–and the inability to properly care for a very sick patient with multiple medical problems in 7 minutes. (I do not ever mean to give the impression that “universal healthcare” would magically fix all these problems, just that I would rather deal with the problems in a fairly logical, rational, planned-out system than the patchwork disaster we have today.)
I’m going to attempt to discuss some solutions to the problems–both for an individual physician and health care/society as a whole. (While when I’m working as a clinician, my goal is the best care for my patients, when I discuss health care reform, I think it makes no sense to ignore the ramifications of a change to society as a whole.) If you solution is “people need to take more responsibility for their health and behaviors,” that’s a sentiment I whole-heartedly support, but if you think that’s sound health policy, Do Not Pass Go, Do Not Collect $200.
- Income. Perhaps the biggest issue for most is the lack of reimbursement when compared to other specialties.
By having a system that so heavily reimburses procedures over primary care (I wish I could remember where I read about the history of the RVU, Medicare’s unit of measure for determining who gets paid what for everything they do), you by default inequalize the playing field, and Sutton’s rule applies. One decent tutorial is from The Happy Hospitalist, “That’s Less Than Burger King Pays”, minus one gaping error of ommission:
Imagine for simplicity that an internist has an all Medicare practice that generates $360,000 a year in clinic revenue. Let’s imagine the overhead is 50%.
(I assume by “overhead” HH means expenses.) Overhead is 50%? Why not try to take a piece of this pie back? Administrative costs are a fierce proportion of total health care spending, even if you don’t like the numbers proposed. You do, of course, realize that in other countries, solo physicians can literally be solo physicians because they submit one form for their services, and get paid, right? And they certainly jump through fewer hoops with HMOs getting follow-up colonoscopies approved, or writing letters to non-medically-educated administrators to get treatment approvals, right? All of those things cost money.
So we could certainly get money back into everyone’s pockets if we simplified the billing and administrative systems in the US, but I also think the RVU system needs to reward primary care work more and reward some procedures less. This would encourage more people to go into primary care and keep more people in primary care as well.
- Lifestyle. Two big parts to this (correct me if I’m missing more)–time and paperwork. Panda sums up the former pretty well, and how the lack of time contributes greatly to costs (although he doesn’t mention costs specifically):
The typical elderly patient who needs anything more than a routine physical exam cannot have her problems addressed in a fifteen minute visit, much of which is taken up by compliance and admininistrative tasks. Consequently, there is a disturbing tendency to consult specialists for every medical problem that will take more than fifteen minutes to address (a tendency that is completely separate from the legal imperative to fend off the predatory plaintiff’s attorneys). The result of this is that you have three or four doctors doing the work that one could do with all of the lost time and inefficiency that this entails. Additionally, under the theory that to the man with a hammer everything is a nail, when you send a patient to a specialist they are going to use their signature procedures to the full extent allowed by reimbursment and ethics. In other words, the default position of a gastroenterologist is to perform the colonoscopy because short of this, he may be adding nothing of value to the patient’s care. Now, I’m not saying that there is no use for specialists, just that sending a patient to a specialist to confirm something you already know or to implement a treatment plan that you would start yourself is a waste of money…except that the economic realities of primary care make it impossible not to use them like this.
Many specialists are used as nothing more than physician extenders, kind of like mid-level providers if you think about it, for busy primary care physicians who know what to do but don’t have the time.
Time. I’ve commented on this before, but it seems silly to give specialists more time with patients than primary care docs. Sure, primary care-ists see more acuity and less chronic disease, but that’s becoming less and less the case. Taking a page from the retainer medicine book, what if new standards were set for a patient based on the patient’s comorbidities? The annual diabetic exam gets 30 minutes at a minimum. The seemingly-refractory hypertensive patient gets half an hour so you can figure out what’s really going on. (Probably compliance.)
Paperwork. Documenting is important — and not just for medico-legal blah blah blah. The US health care system is confusing and complex (and could certainly be simplified by health care reforms), but say we started paying doctors for their time–all their time. And perhaps to incentivize primary care, we only pay primary care doctors for all of it. That people practicing primary care can get reimbursed for their time on the phone, the paperwork they fill out–all of that. (Yes yes, I know this would create other incentives to send more paperwork to the PMD, but I’m brainstorming here, people.) I will also quote a poll that I can’t find right now stating that two-thirds of physicians would be willing to take a 10% pay cut for a significant reduction in the amount of paperwork they have to complete.
Look, to all of those who think retainer medicine will fix primary care, think again. It will fix primary care for individual physicians, but not for society as a whole. I’ve run the numbers. We need something in-between: something that encourages providers to stay in (and go into) primary care with better lifestyle and reimbursement, but that still allows them to see more patients than in a retainer practice.
I welcome your comments and criticisms, but I’m brainstorming solutions that would help both individual physicians and society, not one or the other. Offer something constructive–it seems like most people are happy to poo-poo an idea and complain (maybe that’s what the blogosphere is good at), but not to offer up their own solutions.
In our group we contract out billing. I don’t know what the industry average is, but generally speaking it ain’t more than 10%.
If you cut that in 1/2 with single payer, you save at most $18,000 in administrative costs.
Not a big incentive to enter primary care.
The incentive won’t come from cost cutting as most offices have fixed costs of capital expenditures, rent, electricity, gas, nurses, secretary, social security, retirement, ***health insurance***
Are you going to cut all that out?
I also think the RVU system needs to reward primary care work more.
Graham, you’re ignoring the elephant in the room. The solution isn’t an adjustment in the RVU system. The solution is to abandon it altogether.
The RVU system is a textbook demonstration of what happens when a group of “experts” attempt to outsmart the market by setting the “appropriate” price.
While I don’t support Medicare For All, I have to wonder about *one* aspect of it that might be worth pondering….
Would using the Medicare FI-style system, where all claims, regardless of who the secondary is, get submitted through one entity, make a substantial difference? It seems like a goodly portion of the overhead associated with billing (provider end) and submission entry (payor end) could be reduced, and the infrastructure is already in place and presumably could scale.
To me, of course, the Big Answer is to start by fixing healthcare finance in ways that mandate getting young healthy people paying “their share” forward (ie, an individual mandate), insurers taking all comers, etc.
But let’s think small. It’s 2008, and we can do better than the HCFA SuperBill.
Graham, I posted this on Medical Rants, and I am copying it here. The main point: retainer medicine is an indication of a serious problem, and an indication that people actually value primary care. It should be looked on as a symptom, not a treatment.
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[As posted on MedRants:]
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It strikes me that the increasing popularity of retainer practices suggests that people highly value care given by generalist physicians who have enough time and interest to take truly comprehensive care of them. They value this care so highly they are willing to pay for it out of pocket.
It also strikes me that the main reasons such care is not available to all people are that:
1) The reimbursement given to most generalists is inadequate to pay for such care. This reimbursement has been de facto dictated by Medicare, and in turn is determined by the secretive and unrepresentative RUC (see previous posts on this blog, Health Care Renewal, http://hcrenewal.blogspot.com/, and other blogs).
2) Most physicians’ office practice costs are driven up, and time is further wasted by numerous bureaucratic requirements imposed by Medicare, managed care, regulators, accrediting agencies, etc, etc.
These conditions seem to have developed because managers and bureaucrats believed that the practicing physician, particularly the generalist, is the cause of rising medical costs. Or maybe they just thought that the generalists were an easy target for cost cutting.
Meanwhile, the costs imposed by excessive bureaucracy, overpaid management, conflicts of interest and corruption in health care organizations go on and on.
The rising popularity of retainer practices should not be blamed for the current health care mess. It is an indicator how much people value comprehensive, generalist care, the sort of care that is now being stamped out by the bureaucrats and managers who run health care, often for their own personal benefit.
What a great framework and lens through which to view the movement, Roy. Thanks.
Eric–yes, you’re absolutely right that there’s enormous duplication of effort (read: waste) by all the different billing systems in the US.
Catron–love your humor. Market principles don’t apply in a system where supply creates demand!
i disagree with hh: i do not believe the vast majority of practices are outsourcing their billing. rather i think they have 1-1.5 fte’s trying to collect. i think most would save signficantly more than 18k. at almost every practice, employees are the biggest expense. additionally it appears that a lot of this is inefficiently done by people not properly educated on how to do it, or by a spouse also not educated on how to do it.
i also disagree somewhat with panda’s assertion that specialists are doing more procedures because patients are quickly referred to them. most of the experienced primary care docs we see send patients earlier on in their workup, recognizing that eventually they will need a procedure or test. that is efficiency for them. lastly, of course more procedures are being done than before, that’s better living through better technology and that is what patients want.
Market principles don’t apply in a system where supply creates demand!
The “supply creates demand” meme is popular among single-payer types, but it’s a myth based on a misrepresentation of Say’s law. If the market doesn’t work for health care, how do you explain the declining price of laser surgery, one of the few medical procedures that CMS allows to exist in an unfettered free market?
Okay, you got me there, in fully elective procedures like Lasik and breast augmentation, you’re probably right.
But when a hospital goes from 1 CT scanner to 2, you honestly don’t think more people are going to get scanned in that hospital?
Besides, Lasik is a procedure where people can find out all the information they want. That certainly doesn’t work in acute medicine, and often doesn’t even work in subacute or chronic disease, either.
But when a hospital goes from 1 CT scanner to 2, you honestly don’t think more people are going to get scanned in that hospital?
It usually works the other way around in my experience. At my hospital, for example, we recently added another CT because the medical staff pressured us to do so. They were already ordering the tests and wanted us to reduce the patient wait times produced by pent-up demand on our single machine.
Here’s how the analysis of the “supply drives demand” crowd goes off the rails: They would observe that more CTs are now being performed per day and conclude that the new machine produced the demand. But they would be committing the post hoc fallacy. In reality, the demand was already there. We just expanded capacity to accommodate it.
[...] a comment is so good it deserves highlighting. This comment by Dr. Roy Poses of the Health Care Renewal blog is one such comment. His first statement is a perfect summary: [...]