Tuesday, March 15, 2011

Reconsidering Reimbursement

The image and role of the family physician in American medicine has shifted from the house-calling doctor with a black handbag to the integrated coordinator of patient care. Despite this, reimbursement remains largely unchanged, with fee-for-service the dominating payment structure. The modern health care climate demands a robust health policy strategy that restructures these outdated reimbursement schemes. Realigning appropriate payment would address issues with ongoing care for patients with chronic conditions and continuity of treatment. Further, restructuring reimbursement would have an effect to revitalize interest and incentive for medical students to enter the field.

Primary care physicians (PCPs) are recognized as family physicians, general internal medicine practitioners, general pediatricians, and obstetrician/gynecologists. As a group, PCPs are often the first point of physician contact for patients with new health issues. PCPs typically serve as coordinators of comprehensive care, and as mediators between specialists. Studies show that one-fourth of Medicare beneficiaries sees an average of 13 physicians each year, and fills 50 prescriptions in that time. PCPs are the primary point for consistent medical contact for these patients – the proverbial glue that holds the pieces together. These are the doctors that are at the front lines of medicine, but who also work in the trenches of prevention and management of chronic care.

While new models for health care are continually considered, such as the Accountable Care Organization (ACO) and the Patient-Centered Medical Home (PCMH), the common theme among all is the central role of the primary care physician. The fundamental key lies in placing the PCP as the coordinator for a patient within a system of care. This is particularly important in rural or underserved areas. PCPs are called not only to treat patients at point-of-care, but also to manage and facilitate physician extenders.

One of the foundational problems in fee-for-service is that it essentially encourages payment for sickness. Through the course of a year, a diabetic patient may see a PCP for a total of two hours. Yet that same patient has to manage their disease for 8,765 hours in that year. The PCP is reimbursed for the sum of two to three visits of point-of-service care, but the disease is ongoing. This would be akin to having a leaky kitchen faucet and asking a plumber to come look at it twice a year, paying for those two visits, but never having the leak quite fixed. While it remains impossible to completely “fix” a diabetic patient, reimbursement must be restructured to account for ongoing and chronic care. The existing plan provides compensation for volume of care. This model must be updated to consider compensation for counseling, diagnosis, and continuity. Moving away from fee-for-service would shift the perspective of reimbursement from one that pays for sickness to one that encourages payment for healthiness.

Finally, shortages in primary care medicine, long considered the gatekeeper of health care, are now threatening national access to care. Studies show that over 60 million Americans, or nearly one in five, lack access to primary care due to shortage in their communities. Meanwhile, only 8% of the nation's medical school graduates enter family medicine. This compares to 14% of the same graduates in 2000. Restructuring reimbursement would have a profound impact on the incentive for students to enter the field of primary care medicine.

It is often said that an ounce of prevention is worth a pound of cure. This analogy certainly has profound implications for our modern health care system. Primary care physicians, the vanguards of preventative medicine and caretakers of chronic disease, should be reimbursed for the broad level of responsibilities they conduct. Our nation must undertake a sincere evaluation of our reimbursement models and engage in the development of a more robust payment scheme for primary care physicians.

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