Thursday, August 16, 2007

Doctor "Pam" Comments on the Crisis in Primary Care

A comment from an anonymous family physician named "Pam" on a recent post about the declining popularity of primary care among medical students is worth publishing on its own (slightly edited).

I'm a family doc who took time off for heavy family responsibilities and am now wanting to go back to work. The environment in which I can practice my skills as a communicator, healer, educator of patients, manager of problems, etc has become toxic, antagonistic toward its nominal aim.

When I left medicine, 5 years ago, I had a thriving solo practice and yet was having trouble getting paid and in turn paying off the bank. Looking at the field now I see all of the same problems (many of them worse) as when I left.

I would hate to discourage an intelligent, idealistic, empathic young person from going into primary care. But the road has become too treacherous.

As for me, I don't know whether to open a boutique practice in my upscale town or do a fellowship leading to specialization, or what. I know I can't practice medicine in the way it's currently prescribed. (I suppose that makes me "noncompliant" in the parlance of the field, though I've caught wind that the new word is "nonadherent." Whatever.)

The root of the problem is political, as you've described in your other posts. As Kevin Grumbach noted in a speech to the Society of Teachers of Family Medicine this year,

". . . fees are not the product of free-market supply and demand. Rather, they are the result of a mechanism for determining relative value units for physician services—which in turn determine fees for Medicare and other third party payers --that is largely controlled by a committee [the RBRVS Update Committee, or RUC] under the auspices of the American Medical Association. . . ."

"This committee has 26 voting physician members nominated by specialty societies; only 3 of these members are primary care physicians. In addition to exerting disproportionate influence over policies such as Medicare fee updates, specialists have the added advantage of having much of their practice costs subsidized."

As they say, go and read the whole thing (or listen to it on your iPod.)

Thank you for your blog.

As we have noted before, primary care and "cognitive" physicians are having a very tough time, mainly because reimbursements are low, and not made for many of the tasks they do to provide coordinated, continuous, comprehensive care, especially for patients with chronic diseases. Meanwhile, they bear a heavy and increasing bureaucratic burden imposed externally, mainly from the govenment, e.g., the Medicare and Medicaid programs, and private health care insurers and managed care organizations. "Pam" makes these points again, vividly and personally.

All this results in pressure to see too many patients in too little time to cover overhead costs.

The practitioners who ought to have enough time to talk to patients, think about their problems, obtain more information about patients or their diseases and complaints, and communicate with other physicians, don't. We know from decision psychology that people subject to time pressure make less optimal judgments and decisions, mainly because they simply don't have time to think enough about alternatives, or the data they have. Thus, handicapping the professionals who ought to provide patients with their "medical homes" likely is a major cause of increased cost, decreased access, and sub-optimal quality.

Yet whenever there are costs to be saved, the first target seems to be primary care physicians. What's wrong with this picture?

I also thank "Pam" for the link to Kevin Grumbach's talk in which he mentions the still not very well known contribution of the RUC to the current reimbursement problems in primary care. We have posted about this here and here. This again raises the question of why the AMA, an organization which professes to represent all physicians, seems to be supporting federal reimbursement policies that are so bad for primary care and cognitive physicians?

Thanks, "Pam." Hope to hear from you again.

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