The Primary Concern With Health Care Reform

The need to enhance the delivery of primary care is not a new dilemma, although there has been a renewed recognition of the necessity to do so in any current health care reform debate. As it now stands, the lack of a strong primary care infrastructure will only be exacerbated as the population ages and the need for up to 44,000 more primary care physicians by 2025 has been reported (http://www.sciencedaily.com/releases/2008/06/080617111826.htm).   

The reason for the decline in medical students entering primary care has been debated for many years. Some of the causes are obvious, such as lower reimbursement. In fact, it has gotten so bad in some areas of the country that well known practices are no longer accepting Medicare reimbursement as they struggle to survive economically (http://www.bloomberg.com/apps/news?pid=20601202&sid=aHoYSI84VdL0), (http://www.foxnews.com/story/0,2933,306439,00.html. ). This does not even address the issue of Medicaid reimbursement a focal point for expanding coverage and reducing cost in congress.

One very often overlooked issue that contributes significantly to the strain on our primary care system is lifestyle and practice environment.  Primary care physicians must see more and more patients with ever increasing chronic conditions and do so in less time than ever before (http://www.nejm.org/perspective/primary-care-video/). This phenomenon is often referred to by primary care doctors as running the “hamster wheel”.

Volume alone is a problem, but practice hassles exacerbate that ten fold. It is not uncommon for a diagnostic procedure or treatment plan that would be approved by an insurer if ordered by a specialist, be denied when ordered by a primary care physician. This then triggers the time consuming appeals process. Recently, a patient of mine was denied a prescription for her angiotensin receptor blocker (ARB). This was originally prescribed by her cardiologist, and I was simply refilling the prescription. It was denied. Despite the fact that I personally called and spoke with the pharmacist and explained why the patient needed the ARB as well as the fact that it was chosen by a cardiologist because it had been determined that given this patients condition that the patient would particularly benefit from this drug. When the cardiologist had his staff call, it was approved immediately.

I won’t continue with the laundry list of hassles (I haven’t even gotten to insurers telling my patients I coded their visit wrong and that is why they won’t cover it, the family medical leave act forms, and every other form that employers, schools, insurers, home health companies, durable medical equipment companies, and the like require that I fill out). I am sure you get the idea.

Despite all of these barriers which negatively impact patient care, primary care delivers a good return on investment. Starfield et al found that: “The contributions of primary care to improvements in many aspects of population and individual health are well documented. In addition to the health benefits, there are reductions in health system costs and reductions in disparities in health across population sub-groups. These findings are robust over time and across areas and health systems.  International comparisons show that countries with health systems based on strong primary care have better health at lower costs” (http://www.jstor.org/stable/30045625?seq=1. ).

Imagine what a robust primary care workforce could provide to improvements in patient care.

-Randy Wexler, M.D.
Assistant Professor of Clinical Family Medicine

4 responses to “The Primary Concern With Health Care Reform

  1. My spouse and i never thought of this in that , light. It is pleasurable to view stuff coming from a diverse standpoint. Interesting understanding in addition to – Have them arriving!

  2. Mark and Randy, much has been written about the shortage in primary care physicians and general surgery. Attention to this chronic and worsening problem is welcome, particularly by those of us who practice in generalist fields. A sense of urgency has emerged because of concerns that when health care reform improves access, there will not be the work force to meet the needs of the population. Like many major and complicated social problems, people want a quick fix and their attention turns to the educational arena. The chorus of legislators in Congress and State government are singing the refrain “there would be no shortage of primary care physicians if:
    Medical schools would recruit people from underserved areas;
    Medical schools would stop recruiting people interested in lifestyle careers, the right people;
    Medical schools would expose their students and trainees to the office based practice;
    Someone would pay back the loans of students entering primary care careers.”
    You get the picture.
    None of these solutions will work in isolation and it is doubtful that all of them together will be sufficient to solve the problem.
    It is the American way to use education as the ticket out of poverty; thus, while some students from socioeconomically disadvantaged backgrounds will return to their communities of origin to practice, others will see the MD degree as a means for leaving. We should not put the burden of serving the underserved on the backs of the underserved.
    There may be too many people entering medical school with an eye towards an easy lifestyle. Some physicians may want a lifestyle where they make a lot of money, work regular hours, and never take call. But the term lifestyle has been used to trivialize valid concerns about sustainable work environments. Is it fair to say that physicians who eschew positions as the sole physician in a rural community, required to be on call 24 hours a day, 7 days a week and 365 days per year are interested in lifestyle? Must a career in medicine involve such personal sacrifice that burnout is inevitable?
    Medical schools have been exposing their students to primary care offices as part of their medical education for almost two decades and yet no shift in interest has resulted. Why? A medical student may admire the ability of a generalist to manage a wide variety of undifferentiated conditions and long to have the types of warm relationships that are demonstrated by the physician during this exposure. But their admiration may be coupled with a fear that these careers require superhuman knowledge and heroic commitment. They may not be able to envision themselves in that role—it may seem too overwhelming. During a month in a typical primary care physician’s office, the average student will personally experience the hassles of generalist practice (such as those described by Dr. Wexler) but will only be able to experience the tremendous rewards (relationship building, intellectual satisfaction) vicariously. These experiences are as likely to immunize the early medical student against primary care as they are to foster a desire to pursue a similar career.
    A student choosing a lifelong career in a primary care specialty rather than a medical or surgical subspecialty will be leaving approximately $3.5 million on the table. Loan forgiveness and attention to student indebtedness is a good idea but it really doesn’t offset this “primary care tax”.
    How do we solve this problem? First, we need to acknowledge that this is an adaptive challenge. Technical solutions like changing medical school admissions, eliminating debt, and requiring rotations are unlikely to be sufficient and may distract us from pursuing more challenging and perhaps unpopular interventions. Adaptive challenges require the willingness of all who create or sustain the problem to work on it together, not relegate it to the next generation. Complex adaptive challenges do not respond to off the shelf solutions but instead require new learning. Where do we start?
    We can learn from our colleagues in medical scientist training programs. They know that exposing a medical student to a month of research is as likely to turn them off from research as it is to turn them on. They need to experience research over a long period of time (more than a year) so that they have the opportunity to balance the inevitably frustrating experiences with moments of exhilaration. The government knows that the country will benefit from a steady pipeline of physician scientists so they have set up stable system to support this prolonged and economically challenging process through NIH funded programs. A similarly prestigious, federally funded generalist practice track could be designed. Students who are interested in careers in community based practice could be recruited and then immersed in community practice from day one and continuing throughout their training. This type of a program could give them the opportunity to learn if the joys of this type of a career could outweigh the burdens.
    We can learn from other countries. If a primary care shortage is bad for the nation, then we need a national solution to the problem. Other countries mandate practice in underserved areas in exchange for the privilege of pursuing a career in medicine, a career which, in the US, is at least partly supported with federal and state monies. Expanding the voluntary public health service may work but perhaps it is time to consider requiring all residents to practice for some time in their first specialty (whether that is general surgery, general internal medicine, general pediatrics, general ob/gyn) before they pursue fellowship training. This would not be a popular suggestion unless coupled with economic relief from debts incurred during medical training. It would not work unless there was no way to “buy out” of your service obligation.
    We can learn from other industries. Highly effective companies look carefully at matching skills and knowledge with the jobs required. Rethinking who delivers what aspects of primary care (what could be done by community health workers? by nurses? by nurse practitioners?) and what needs to be done by physicians would be a first start. The personalized health care that everyone wants (both Democrats and Republicans) starts with a physician who has the time to develop a relationship with her patients and to think about what is right for the patient in front of her.

  3. Mark, one option would be to proceed with refinement and implementation of the Patient Centered Medical Home (PCMH). This team based approach to enhanced chronic care management, prevention, and care coordination is designed to free up time for patients and physicians to spend more time face to face on complicated matters, while communicating through evisits, and email for more routine care. The current roadblock is that today’s reimbursement system is office based. As such, insurers would have to pay for things that they currently do not. It also involves a care management fee on a per member per month basis to compensate for the ever increasing amount of admisntrative work (currently not compensated but requiring a lot of time). The idea is to see less patients face to face, but spend more time with them, while providing other care by electronic means. As a colleague of mine from cincinnati once said’ “I am not asking for increased reimbursement to make more money, I am asking for increased reimbursement so I can see 20 patients a day instead of 30, spend more time with them, and provide them the care they need”. Most studies on the PCMH concept show that both patients and physicians are more satisfied and happier. Outcomes are better too.
    Other incentives which would have a quicker and more direct effect would be loan forgiveness for those entering primary care, tax incentives for primary care practice, as well as scholarships for medical students who enter medical school agreeing to enter primary care.
    Finally, the one variable which correlates with a student entering primary care is having grown up in a rural setting. Modifying admission policies to increase enrollment of students with such a background would also help.

  4. Randy–I would agree that primary care physicians provide a strong return on investment and are essential to successful healthcare reform. You seem to maintain a positive perspective despite the many challenges you face, but I am concerned it is these very challenges that may discourage some medical students from pursuing careers in primary care. I would be interested in hearing your thoughts about a future practice model that would address these challenges and other possible “incentives” to encorage students to pursue primary care careers.

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