Primary Care and the HC Renewal RUC-kus

Dr. Richard Baron, a Philadelphia internist who's unusual in that he's both a private-practice clinician and a well-published and -respected academic (he was recently ABIM Chair), has been mixing it up in the pages of the New England Journal.

To readers of this blog, it'll be useful armchair review: not just because the theme of generalist clinicians' decline should concern us, but because the blog itself comes into play!

The topic of the day: why primary care doctors are in trouble. Why they're (my words, perhaps, not his) so prone to burnout. And why they're not replacing themselves.

In his original April 26, 2010 article, Baron provided a "snapshot" from his own group practice to address the question, "What's keeping us so busy in primary care?" The piece repays reading if one wants the gory detail on just how tedious and time-consuming the "long tail" of primary care has become.

Largely because of demands of third parties, primary care providers are mired in the briar patch of making money for other people instead of themselves, through myriad pre-authorizations, forms, renewals, and all the other parts of the glue that keeps health care going.

We already knew a lot of this, at least tacitly. But what's wonderfully useful about Baron's above piece was that (a) he spelled it out crisply, (b) he did so with lots of numbers people could cite, and (c) did so in such a highly visible and prestigious venue.

Now, in the latest number of the NEJM, Baron mixes it up with a couple of critics.

First I have to wonder aloud, just how did the journal pick these particular two letters? (Or maybe the author did? Hard to believe they were the only two.) Typical--and this is something else it would be easy to measure in the Journal's correspondence pages--in that they both come from the ivory tower, not the trenches where Baron himself labors.

The first letter, from a non-clinician at the Palo Alto Medical Foundation Research Institute, lamely posits the value of the electronic health record in identifying staffing needs for primary care. We happen to know not only that Baron's practice was a very early EHR adopter, but Dr. Baron himself has published eloquently on the sundry limitations of the EHR.

In response, Baron gently reminds the Palo Alto ivory tower-dweller that very few practices can afford a registered nurse--even if the EHR could somehow magically discern the need for such a presence.

A second writer chimes in from the equally rarefied reaches of the AMA's Relative Value Update Committee, or RUC, "appointed by the American Academy of Neurology." This writer avers that "the value assigned for evaluation and management is the same for all specialties," which clearly is the RUC's take on things but is fairly jaw-dropping to the rest of us.

In response, Baron cites R. M. Poses, MD, moderator of the present blog, and a June 1, 2010 HCRenewal offering--Poses has in fact given us many such offerings on the RUC--regarding the "significant structural and political issues" surrounding that body's untransparent deliberations.

Usefully, Baron finally joins others stepping outside the visit-oriented physician payment schema, urging a paradigm shift in which he urges "systems that encourage and support services of high value ... rather than anchoring payment to visits."

This exchange is telling in a number of ways. It shows up the lack of sync between the basic understandings on the part of health policy's chattering classes--those prone to publish and write letters to premiere journals--and of those actually doing the work of primary care.

It also, I'll venture to say, shows up something more elusive about why this predicament is so difficult to fix.

That is, we have, almost uniquely in this country, an imbalance--the imbalance in numbers, slowly evolving over the past century, between generalists and specialists--that's been around so long it's become part of the warp and woof. Something like ubiquitous guns or illicit cannabis, something very difficult to even think of getting beyond.

We've written in this blog about the anechoic effect, how so much of what happens in health care (corrupt executives, nontransparent RUCs, etc. etc.) barely stirs a ripple in the public consciousness. Why that is we'll leave for another day, but it's been lately of interest to more and more folks. (For starters, just plug the term "anechoic" into the HCRenewal search box.)

Add to this, now, what one might call the reverse Robin Hood effect. The result of such an effect is how the RUC and others--many others, in government as well as in industry--have managed to set in motion a specious reasoning process, a process that allows decision makers to justify robbing from the poor to give to the rich.

Understandably, Baron does not go beyond the bland statement that such a process has "militated against appropriate updates for primary care services." But imagine what would happen if the RUC were suddenly, in what really boils down to a matter of power, dominated by people from primary care. Imagine what would then happen not only to reimbursements for cognitive services, but also to practitioners' morale, and to recruitment of medical students into primary care.

History, both recent and not-so-recent, bears out such an assertion. When the UK increased the value of primary care a few years ago, in terms of pounds sterling, it had a salutary effect on non-fiduciary metrics such as recruitment. To quote Gomer Pyle, "surprise surprise surprise."

Indeed, as the Economist reported five years ago (the preceding link may require subscription or library access), price signals worked wonders in making the primary care role more attractive.

Further back, ironically, when procedural specialties had lower status than cognitive specialties--we're talking a couple hundred years ago, now--this controversy would have been simply incomprehensible to patients and clinicians alike.

For those who'd respond, "but back in the wayback, we didn't have all the fabulous benefits of modern procedures," the simple response is, well, stuff and nonsense. The rising tide of science has raised all boats. Not a week goes by that the evidence base doesn't provide new reasons to assay minimally- or non-invasive technologies that are devolved to primary care physicians.

No, underlying Baron's plea is the reverse Robin Hood effect and a simple matter of power. In fact, it's a phenomenon exceedingly well known to sociologists ever since Robert Merton in the 1960s. They call it the "Matthew Principle," after the Gospel of St. Matthew. "To him who has, it shall be given."

But in the US such a system, like that of sub-prime mortgages earlier in the present decade, has finally become so over-evolved it's threatening to topple over of its own weight.

Thus, lobbyists are just now fighting the recess appointment of Dr. Don Berwick not because they think he doesn't understand how these processes work, but because they know that he does. Wish him, and Dr. Baron, luck.