Tuesday, April 05, 2005

The Primary Care Squeeze: Who Will Be Part of the Solution?

In stark contrast to stories of ever more expensive drugs for ever more expansively defined ills, government research leaders getting six figure consulting fees, and multi-million dollar CEOs, ... primary care is in progressively worsening crisis.
Last week the American Medical News reported that family medicine has seen its eighth consecutive yearly decline in the number of US medical students matching to its residency positions. Since 1997, the number of US students going into family medicine training has dropped from 2340 to 1117, more than a 50% decrease. Fewer US students have matched in all primary care fields over the last 5 years.
This data still seems to puzzle the leadership of major US medical organizations. For example, the article quoted Steven F. Weinberger, Senior Vice President of the Medical Knowledge and Education Division of the American College of Physicians, "There's a concern that being the physician responsible for the ultimate care of the patient means life becomes a little more unpredictable in terms of hours. But there are wonderful ways to build models of practice to counter that." Furthermore, he said "another important issue is giving students the sense of the long-term gratification of the longitudinal care of patients." This is similar to previous comments made by him, and by leaders of the American Association of Medical Colleges (AAMC) and the American Academy of Family Practice (AAFP), (see this post) suggesting that the main reason that students were not going into primary care is that they hadn't learned about all its positive aspects.
I certainly agree that there are intellectual and emotional benefits to primary care practice. Maybe we aren't adequately teaching students about them. But it seems as if some of the folks leading large organizations like the ACP don't understand just how grueling primary care has become.
One way to understand its challenges is simply to page through some of the stories on Health Care Renewal.
On the other hand, see two articles from the Miami Herald last week. The first, "Primary Care MDs Under Pressure," described anecdotes of primary care doctors leaving practice "because they couldn't overcome the squeeze between low fees from insurers and soaring costs, or they refused to survive by cutting their time with patients." Ted Fisher, of the Florida Academy of Family Physicians, said as a result, "we see a big shortage coming in Florida...." The article included figures that primary care reimbursement has gone up 4.4% annually, while primary care overhead costs have gone up 7.7% annually. Discussions with physicians here in Rhode Island and southeastern Massachusetts suggest that we are being squeezed just as hard.
Why this story hasn't reached the leadership of the ACP, the AAMC, and the AAFP is not clear.
Robert Forster, Vice President, Health Care Services, and Medical Director of Blue Cross Blue Shield of Florida, was quoted as acknowledging that reimbursement to primary care physicians has not kept up with inflation, much less their rising costs. However, in the second article ("Primary Care is Often Undervalued"), he blamed it on society: "The importance of the primary care doctor doesn't have societal backing. The problem is that it's hard to measure the value of talking to a patient." Furthermore, "since the 1950s, American medicine has emphasized specialties and procedures over primary care. It's going to take some major changes in our society and our thinking to turn that around." Of course, "society" may be enchanted by the marvels of high-technology, sub-specialized care. However, in 2004, Blue Cross Blue Shield of Florida announced it has 28% of the Florida market, more than twice the share of any competitor. Why its Vice President, Health Care Services and Medical Director denies any personal or organizational responsibility for inadequate reimbursement for primary care is not clear either.
In summary, primary care is under seige by progressively rising costs and lower reimbursement. Since this seems to be public knowledge, it shouldn't be surprising that medical students are increasingly going into other fields. What is surprising, and troubling, is that leaders of major medical organizations either fail to recognize how hard it is to practice primary care, or recognize it, but fail to acknowledge any responsibility to do anything about the problem.
By avoiding any responsibility for the solution, such leaders become part of the problem.


Cetona said...
This comment has been removed by a blog administrator.
Cetona said...

As someone who soldiers on, about half time, doing primary care, this thread really hits me where I live. At this point in my life--pretty late to be expanding, not slimming down, one's primary-care patient-care hours--I find myself going in to the office and both hating and loving it.

That's the visceral part. Here's the analytical part. It's absurd for everyone to be passing the buck and blaming "society." The notion that society does not value talk--and let's not forget, it is far more than just talk, it's major-league decision-making--is ridiculous.

Proof of this assertion: my many conversations on the subject with my attorney. His son recently became a house officer at a Harvard teaching hospital. From that, said attorney notes, he really began to see the picture.

Now, this is a guy (the father) who makes his living--handsomely, I do believe--from talk and decision making. He looks at his son and me and says: "you guys are nuts."

And, indeed, we are. The irony is, the Bill Frists of the world--physicians who've ascended to power--are docs. But the last thing they can be counted on to do is help their brethren in primary care.

As a sidelight, there's an interesting historical irony in all this. Two hundred years ago the shoe was on the other foot. "Physicians"--docs not given to procedures and sharp objects that sliced bodies--were on top. At one particular time and place, for contingent and local reasons, they became ecumenical and welcomed in their proceduralist brethren.

Thus the question: what contingent and local conditions may occur that will allow them to return the favor, now the shoe is decidedly on the other foot. We could start by asking Bill Frist, "do you really want to preside over the extinction of the primary care physician?" (The likely answer's not at all obvious: much savings can be effected by turning primary care over to lower-cost [for now] providers. Do we have the foggiest idea whether there'd be any "quality leak" were this to happen?)

[This replaces a near-identical earlier version of comment.]