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 The modern health care climate demands a robust health policy strategy that restructures these outdated reimbursement schemes.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.

Does Building a Primary Care Workforce Start with Medical School Admissions Committees?

Between COGME’s 20^th report recommending expansion of the nation’s primary care workforce (see 1/28/11 post) and the health care rhetoric and legislation coming out of Washington over the past few years, it seems that those in health care industry and policy are in full agreement that a primary care shortage exists in the United States and that the number of primary care physicians we produce in the coming years will have a significant impact on both cost of and access to quality care.

But how do we as a nation produce more primary care physicians? And is setting a numerical goal (i.e. 40% of physicians will be primary care physicians by 2020) enough?

Assuming we can improve reimbursement for primary care physicians (both male and female – see 2/3/11 post on gender-based physician salary gaps) such that family medicine becomes a more desirable financial option for those students who see reimbursement as a barrier to a primary care career, we will still have to address the disparity in access to primary care that occurs between geographical boundaries in the U.S.

In 1970, the federal government created the National Health Service Corps (NHSC) in an attempt to combat the changes in access to care that had begun over the prior two decades as rural physicians retired or moved to cities, where medical practices offered higher salaries and job opportunities for spouses. With the passage of the act that created the NHSC (and its subsequent amendments), the government recognized that proportion of patients living in areas with a population to practitioner ratio of 2,000:1 as “underserved.” These geographical areas were termed Health Professional Service Areas, or HPSAs.

Currently, the Health Resources and Services Administration (HRSA) website states that

“As of September 30, 2009, there are 6,204 Primary Care HPSAs with 65 million people living in them. It would take 16,643 practitioners to meet their need for primary care providers.”

Although over the past two years President Obama has reversed a trend in dwindling HRSA funding and expanded HRSA health workforce programs (including doubling NHSC funding to $300 million in the fiscal year 2010 budget and increasing that number by an additional $27 million for 2011 along with increasing funding for community health centers), we have to realize that more federal funding alone isn’t the panacea for curing the problem of geographic health workforce disparities.

A study published in the November 2010 issue of the American Journal of Public Health analyzed interview responses from primary care physicians in Los Angeles County, California concerning their reasons for practicing in their particular geographic location¹. Only 24% (5 of 21) of interviewees practicing in underserved areas in the county chose their practice location because of loan repayment obligations, which seems to indicate that federal funding is a minor player in the eventual retainment of primary care physicians in such areas. Compare that to the 19% (4 of 21) of physicians in nonunderserved areas serving in their respective areas due to loan repayment obligations, and one starts to wonder whether loan repayment money really has an impact at all.

Digging deeper into the numbers of the study reveals that those physicians working in underserved areas were most likely to do so because of mission-based values (a “sense of responsibility or commitment to a particular community, a defined patient population, or a moral obligation”) and self-identity (including “language, personal, family, cultural, socioeconomic, and geographic backgrounds”). A 2003 study of a rural physician workforce in Florida provides similar insight, noting that physicians from rural backgrounds and physicians who were exposed to rural experiences in medical school and residency were more likely to practice in underserved rural areas². To further the connection between training and practice, a 2009 study in the Annals of Family Medicine looked at training residents in community health centers (CHCs) and found that family medicine residents who trained at CHCs were four times more likely than their colleagues to go on to practice at CHCs³.

In addition, among primary care specialties in the L.A. study, the vast majority of physicians practicing in underserved areas were family physicians, whereas internal medicine and family physicians shared an equal percentage of the total in the nonunderserved cohort.

So what does all this mean? It would appear that prior experience in an underserved community and a sense of responsibility to that community is truly the major motivator in where a primary care doc practices. It means that medical schools and residencies need to partner with CHCs to encourage graduates to work with the kinds of populations that frequent them. Even more importantly, it confirms what we should have known all along: the best medical school candidates are those who already enter with mission-based values and who self-identify with those communities that most require family physicians.

Easier said than done, but we can’t hope to rely on loan repayment opportunities and training alone to funnel more students into family medicine. Opportunities to train with an underserved population best stimulate those who already want to work in that setting. It’s up to medical school admissions committees to select medical students who fit that bill.

The Robert Graham Center (RGC), with private foundation money, is already producing objective data on how well medical schools and training centers are fulfilling their “social mission” (that is to say, how well they are meeting the health care needs of the public)⁴. The RGC uses geographical information systems mapping tools to display these results visually. The only limitation of this data is that it is elicited from the American Medical Association Physician Masterfile which, although fairly comprehensive, still is prone to a small amount of error.

Knowing that, I propose a more effective use of federal money to improve the primary care services in the United States: create a national database of registered physicians and their specialties and locations of practice; then, instead of tying the majority of a medical school’s funding to the amount of research it produces, tie a large portion to the percentage of each school’s graduates who end up working as primary care physicians in underserved communities.

It would be a carrot approach, much like President Obama’s “Race to the Top Fund” for improving primary school education, and perhaps it would create an incentive (to compete with incentives from research funding and alumni donations) for admissions committees to take a closer look at the values of their applicants.

References:

1. Odom Walker K, Ryan G, Ramey R, Nunez FL, Beltran R, Splawn RG, Brown AF. Recruiting and retaining primary care physicians in urban underserved communities: the importance of having a mission to serve. Am J Public Health. 2010 Nov;100(11):2168-75.
2. Brooks RG, Mardon R, Clawson A. The rural physician workforce in Florida: a survey of US- and foreign-born primary care physicians. J Rural Health. 2003 Fall;19(4):484-91.
3. Morris CG, Chen FM. Training Residents in Community Health Centers: Facilitators and Barriers. Annals of Family Medicine. 2009 7:488-494.
4. Bein, Barbara. Robert Graham Center to Study 'Social Mission' of Teaching Hospitals, Health Centers. AAFP News Now. 27 July 2010.

Gender-Based Income Gap for Docs Should Elicit Call To Action

As the only female contributor to this blog, it seems only appropriate that for my first post I tackle some gender issues. The February 2011 Health Affairs Table of Contents came out today and the very first article I noticed was “$16,819 Physician Gender Gap”. This sort of article occasionally appears, long enough to elicit some guilty feelings and an apathetic hope for change, then disappears quietly until the next round.

In a world where over half of entering medical students are female, and a disproportionate amount of those are pursuing careers in primary care, the gender-based income gap is a huge workforce issue that we never really address. We’ve paid a lot of attention to disparate salaries across specialties, but not within our own profession. It’s something we toss out to the free market, assuming that the gap will close under the appropriate conditions. Some of us may even silently think things are fine as they stand.

This is issue is not unique to the specialty family medicine, and it is certainly one that appears across many non-medical professions. According to this graphic from the New York Times, physicians are actually at the bottom of the barrel where the income gap is concerned – that is to say we’re doing worse than lawyers, pharmacists, medical scientists, teachers, postal workers, and pretty much everyone else.

Lest you think I’m approaching this from a purely feminist angle, I have considered the free market argument potentially justifiable. I mean, women in medicine choose primary care careers, and take time off for children, and spend more time with patients for lower total reimbursement, right?

Wrong.

Let me rephrase – all of those points are true. However, these classic rationalizations have been proven inconsequential by the authors of the Health Affairs article. Men simply make more money than women for the same work.

The authors used survey data from New York State to examine salary trends from 1999-2008. Their data not only shows that an income gap exists, but that it has grown almost five-fold in the last 10 years, from a gap of 12.5% to 17%. To avoid confounders of experience and rank, they only looked at starting salaries. More importantly, this study is the first to my knowledge to show that disparities exist across specialty, practice type, and work hours. Controlling for these and other factors slightly reduces the gap, but does not eliminate it entirely.

The high prevalence of women in primary care has often been cited as a reason for the income gap; however, a decreasing proportion of women are choosing primary care. As the authors point out, this argument would predict the gap to decrease, rather than increase as it has in recent years. A stratified analysis of primary care versus non-primary care specialties revealed similar results – unfortunately, the analysis lumped family medicine together with pediatrics and internal medicine, three specialties that have very different post-residency workforce dynamics.

The vague concept of “productivity” has been another rationale for the discrepancy, often as measured by patient visits over time, rather than on the more clinically relevant measures of quality or outcomes. Results presented at the WONCA 2010 Conference show that among Canadian physicians, women spend more time with patients (17.8 minutes vs. 13.3 minutes), are more emotionally engaged, and allow more time for discussion and questions. Unfortunately, these women also report more signs of burnout and physical stress. Ultimately, studies regarding productivity have been mixed.

“Quality of life” is often used as a euphemism in these discussions to reflect the part-time and re-entry options available to balance family and work obligations. The authors postulate that quality of life may be a direct cause of the discrepancy. As more practice options become available, “female physicians may be seeking out employment arrangements that compensate them in other – nonfinancial ways.” Women are the typically beneficiaries of these changes, but men are increasingly attentive to quality of life concerns as well. I remember a professor of mine, a retired physician, who recalled (with a smile) a successful presentation at rounds some fifty years ago because he chose to stay at the library all night instead of returning home to his wife and newborn. It is fair to say this is not the current day expectation. And no, he was not a family physician.

While causality data for the gap is patchy and contradictory, evidence does exist that debt load and anticipated future income affects specialty choice. The average debt for a medical senior graduating in 2007 was $145,000 for public schools and $180,000 for private schools, and over 23% of students had debt above $200,000. Less than 8% of those students are pursuing careers in family medicine, a majority of them women.

The COGME Report included a recommendation to increase primary care physician income to 70% of the median level of specialists. I propose we pay equal and special attention to the less discussed income gap in medicine that exists along gender lines. With women as a historical majority of the primary care workforce, and female graduates increasingly choosing subspecialty fields, income discrepancy may be contributing more to workforce dilemmas than we realize.

With that said, I challenge to you to think about this - what can family medicine do to lead the change?

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References:

(1) Sasso AT, Richards MR, Chou C, Gerber SE. The $16,819 Pay Gap For Newly Trained Physicians: The Unexplained Trend Of Men Earning More Than Women. Health Affairs, 30, no.2 (2011):193-201.

(2) Palmert M, Pipas C, Wadsworth E, Zubkoff M. Economic Impact of a Primary Care Career: A Harsh Reality for Medical Students and the Nation. Academic Medicine, 85, no.11 (2010):1692-1697.

(3) Sullivan MG. Women Physicians Connect Emotionally With Patients, But Are More Stressed Out. Elsevier Global Medical News. Published online on June 29, 2010. Available at http://www.medconnect.com.au/tabid/84/s22/Neurology/ct1/c337421/Women-Family-Physicians-Connect-Emotionally-With-Patients-But-Are-More-Stressed-Out/Default.aspx. Accessed February 3, 2010.

(4) Why Is Her Paycheck Smaller? New York Times. Published online May 18, 2010. Available at http://www.nytimes.com/interactive/2009/03/01/business/20090301_WageGap.html?src=tp. Accessed February 3, 2010.

Access to care following health care reform: Lessons from Massachusetts

In March of this year, President Obama signed into law the Affordable Care Act. In 2006, Massachusetts enacted state health reform that included some similar elements to decrease the number of uninsured in the state including increased coverage and the individual mandate.

We are now 4 years status-post the passage of the health care legislation in MA. What lessons can we learn for the national health care reform from Massachusetts?

430,000 uninsured Massachusetts residents have now been granted insurance since 2007 when the law came into effect. However, access to primary care remains a huge problem in Massachusetts especially in the more rural areas of Western Massachusetts. Data published by the Massachusetts Medical Society in October show that 54% of Family Physicians and 49% of General Internists in the state are not accepting new patients. The average wait time for an appointment with a new primary care provider is 44 days.

Anecdotally, as a medical student in Massachusetts, I have witnessed the family medicine clinic attached to the main teaching hospital (incidentally, where my personal PCP is) cut evening and weekend hours due to a shortage of physicians. Earlier this year when I called to make an appointment for an acute problem, I was offered a visit in 2 weeks. [Side note: I grew up in Canada and, when I was sick, I frequently called at 9 am when my family doctor's office opened to receive an appointment later that same morning. ]

I emailed my physician instead... but, how many people in the same situation, would go to the Emergency Room?

In Massachusetts, we have witnessed an increase in emergency room and urgent care utilization following the passage of health care reform. This not only increases costs but also undermines doctor-patient continuity and fragments care. This situation is even more acute in the rest of the nation. Massachusetts has the 3rd highest PCP to population ratio with 107.8 PCPs per 100,000 vs. an average of 79.4 per 100,000.

So, what can we do?

Can we rely on IMG grads to provide where US grads will not? How can we collaborate with other medical staff like nurses, MAs, and PAs, to increase efficiency and provide better care to more? Are PCMHs or ACOs the answer? We are increasing PCP payment and increasing PCP and underserved residency slots but is this enough and is it timely (given that it takes almost a decade to train a physician)? These are all questions we need to answer if national health care reform is to be effective...