DrRich’s Advice to Primary Care Physicians

Posted on November 24, 2008
Filed Under Primary Care in America |

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Senator Baucus’ splashy “call to action” for healthcare reform  last week accomplished several things. It served notice to the few remaining Republicans that a little thing like a generalized economic meltdown isn’t going to stop the Democrats from tackling the number one item on their domestic agenda.  It served notice to President-elect Obama that his new administration is not going to be running roughshod over Congress, and will not be dictating the terms of healthcare reform. (Baucus is senior enough to have been around the last time a President - and spouse - made a major push for healthcare reform, and remembers what it felt like to be a mere Senator in those times.) And it served notice to all the other uncountable would-be leaders of healthcare reform in the party (such as Wyden, Kennedy, Clinton, Waxman and Daschle to name just a few) that they’ve got to take the Chairman of the Senate Finance Committee into account before they get too carried away with any specific plans, promises or pontifications.

But to American doctors, the main import of Sen. Baucus’ broadside was his explicit recognition that more emphasis needs to be placed on shoring up primary care in America, and that corresponding steps need to be taken to reduce spending on “overvalued services” (by which he means specialist physicians).  In other words, his position paper called for taking some of the money now being paid to specialists, and giving it to primary care practitioners instead.

In effect, Sen. Baucus stood with one arm around the PCPs and one arm around the specialists, and said, “Now boys, let’s you and him fight. I’ll hold your coats.”

And indeed, it appears that the battle has been joined. And DrRich finds, sadly, that some of his very good friends in the medical blogosphere are on opposite sides of the battle. The venerable Robert Centor hopes that Obama listens to Baucus  and takes steps to pay primary care docs more in line with what they’re worth, even at the cost of reducing payments to specialist physicians. Kevin, MD seems to agree.  On the other hand, Dr. Wes  takes strong objection to the notion that Baucus (or anyone else) considers his specialist services to be “overvalued,” and most especially he (Joe-the-plumber-like) objects to the idea that the government will decide to just go ahead and spread the wealth around.

So, the early indications are that Sen. Baucus will get what he probably wanted - the spectacle of doctors loudly engaging in internal warfare over money.  Such a spectacle, obviously, plays into the public perception that doctors, whatever their specialty or their specific reimbursement levels, are handsomely paid already and generally are too greedy. For PCPs and specialists to openly fight over money can only make it easier for the central authorities to get away with whatever it is they decide to do to doctors as they “reform” American healthcare.

DrRich’s own sentiments in this matter favor the PCPs. DrRich practiced for a while in the 1970s as a general internist himself, before spending the next 20 years as a subspecialist (the same variety of specialist as Dr. Wes, as it happens).  And even though DrRich worked very hard and became quite well-known and highly regarded in his specialty, in retrospect he believes that nothing he ever did was more challenging, difficult, or worthwhile than the years he spent as a primary care doctor.  Add to that the fact that since leaving medical practice several years ago, DrRich’s only real encounters with the healthcare system have been as a patient; and it is as a patient most especially that DrRich recognizes the value of a good PCP.  Finally, DrRich cannot overlook the fact that the specialist-laden RUC (the agency that Medicare relies upon to determine physician reimbursement) has been completely screwing PCPs for decades. So DrRich’s prejudice, if we accept the premise that there’s only a fixed pool of money with which to pay doctors, is that it’s time to tip the scales in favor of PCPs.

But DrRich, the starry-eyed idealist you all know him to be, would be greatly disappointed to think that the only reason - or even the main reason - that nearly 50% of American PCPs want to leave medical practice today is because of low pay.  The pay is indeed too low and needs to be raised.  But if raising the pay of PCPs, even quite substantially, would cause the majority of them to suddenly become delighted with their jobs, then DrRich would be plunged into the depths of despair, his trust in humanity, his belief in progress, his conviction that reason and goodwill can address any problem, and even his love of puppies, would be utterly destroyed.

The reasons primary care medicine has been wrecked in America has only a little to do with low reimbursement. As DrRich has pointed out many times before, our healthcare system has taken exquisite pains to make primary care medicine an untenable proposition for American doctors, notwithstanding the crocodile tears now being shed for PCPs in so many quarters.

Observe:

Their pay is determined arbitrarily by Acts of Congress, not by what they’re worth to their patients or to the market, and indeed in this way PCPs have a lot in common with workers in the old Soviet collectives.

They are directed to “practice medicine” by guidelines and directives which are handed down from on high; guidelines which, being forcibly based on what is called “evidence-based medicine,” necessarily address the average response of some large group of patients to the treatment being considered and do not allow much if any latitude for an individual patient’s needs; and which are often promulgated less to assure the excellent care of patients and more to further the agenda of various and competing interest groups, professional, governmental and otherwise.

They are limited to between 7.5 and 12.5 minutes per patient encounter (depending on the third party that controls a given patient’s medical care), and the content of what must occur during those 7.5 minutes is strictly determined by sundry Pay for Performance checklists, so as to strictly limit any interchanges between doctor and patient that do not meet the approved agenda for such encounters.

Their every move must be carefully documented according to incomprehensible rules, on innumerable forms and documents, that confound patient care but that greatly further the convenience of  healthcare accountants and other stone-witted bureaucrats who are employed specifically to second-guess every clinical decision and every action the PCP takes.

They are expected to operate flawlessly under a system of federal rules, regulations and guidelines that cover hundreds of thousands of pages in immeasurable volumes that are never available in any readily accessible form. If they do not operate flawlessly according those rules, regulations and guidelines, they are guilty of the federal crime of healthcare fraud. Furthermore, the specific meanings of these rules, regulations and guidelines are not merely opaque and difficult to ascertain, but indeed they are fundamentally indeterminate - that is, no individual or group of individuals in existence can say what they mean. So, PCPs operate under a massive quantum cloud of rules as best they can, but their actual status (regarding healthcare fraud) is, like Schrodinger’s cat, fundamentally unknowable - until the “box is opened” (typically through criminal prosecution), whereupon the meaning of the rules is finally crystallized in a court of law, and doctors who had been practicing in good faith find that they have at least a 50- 50 chance (like the cat) of learning that they are actually professionally dead.

Worst of all, PCPs have been charged with the duty of covertly rationing their patients’ healthcare at the bedside, and they have been pressed to nullify the classic doctor-patient relationship, by the healthcare bureaucracy that determines their professional viability, by the United States Supreme Court, and by the bankrupt, new-age ethical precepts of their own profession.

As much sympathy as DrRich may have for medical specialists, having been one himself for 20 years, any objective observer must admit that this litany of professional travesties has been visited upon the primary care doctors far more than upon the specialists. Indeed, DrRich was astounded to learn last week that 50% of PCPs aren’t looking to leave medical practice. His deep admiration of these dedicated individuals was only reinforced.

DrRich finds absurd the notion that merely increasing the pay of PCPs would override all these other considerations, and suddenly make these doctors satisfied with their lot. DrRich sincerely hopes that PCPs, if they choose to fight at all (instead of just quietly walking away from their profession) will fight for the things that really matter, and not just fight the other dogs for a bigger share of the carcass that their masters have thrown into the cage for their own amusement.

He further urges his PCP friends to remember that they - in clear distinction to their unfortunate specialist counterparts, who have largely become utterly dependent on third party payers - have the opportunity to walk away from the designated healthcare system altogether, to hang out a shingle, and to go back to work directly for the people they originally went to medical school to help. They will of course be loudly criticized, ostracized, and castigated, like any iconoclast. But there may be no other way for them to salvage their professional standards, to place their patients first, to reestablish their professional autonomy, or to restore themselves to a position of honor and self-respect, while still remaining primary care physicians.

Mr. Baucus won’t tell them that. Neither will Ron, Ted, Henry, Tom or Hillary. Not even Mr. Obama will tell them that. Only their friend, colleague and patient, DrRich, will tell them this truth. They are, of course, welcome.

Comments

10 Responses to “DrRich’s Advice to Primary Care Physicians”

  1. Dr. Wes on November 24th, 2008 8:07 am

    DrRich-

    The documentation requirements for subspecialists are equally daunting. Just witness the 900-page, 22 chapter guidelines for antithrombotic therapy or varios performance measures. Sheesh.

  2. Red Baron on November 24th, 2008 12:16 pm

    Nice post.

    The only think I might add is that mid-level providers have made serious inroads into the primary care market space in a ways they have not with traditional sub-specialists (i.e. now a day you get your HTN check with an NP or PA).

    Until the appropriate MD-MLP ratios are worked out (and I really hope this is not done thru act of law as it is always specific to a particular practice), primary care physicians are going to continue to see an inability to get traction on their pricing power.

    What we really need to do is teach MLPs how to perform a lot more subspecialty procedures. There is no reason they should not be able to perform colonoscopies or angioplasties.

  3. Dr. Bobbs on November 24th, 2008 8:26 pm

    Interesting post.

    I firmly believe primary care medicine is going to make a big comeback. The specialists do a good job. Firefighters do a good job, too. But if you find yourself having to employ the services of the fire department repeatedly, you’re doing something wrong.

    While I think paying primary care docs more money would go a long way toward patching up America’s imploding health care system, I don’t care much for the “gubmint” deciding who should get paid what.

    Most primary care office visits are not very expensive. It’s catastrophic stuff, like MIs or severe MVA-related injuries, for which you need third party payors. Primary care can potentially operate by and large outside of the third party payor system. I think that eventually — and I concede that “eventually” may be measured in decades — it will.

  4. Oskie on November 24th, 2008 10:58 pm

    The best long-term solution is too keep specialist reimbursement commeasurate with specialist skills and training and outsource primary care to more PA’s and nurse practitioners.

  5. Annie on November 25th, 2008 9:34 am

    DrRich, your argument is so compelling, if depressing.

    I wonder if you’ve ever worked in an interdisciplinary team environment, such as a community health or ambulatory clinic which uses baccalaureate prepared nurses as case managers in that they carry their own patient case loads and work in concert with the primary care physicians around preventive care, disease management and the like?

    It seems to me that we are missing the boat if we don’t at least consider a way to nose back into some sort of model which provides for higher quality and more sustainable therapeutic relationships with patients.

    Having physicians partner with nurses (I’m not speaking to advanced practice nurses and PAs here as that’s a somewhat different issue of extending physician services instead of enriching by collaboration)seems to me to have several advantages:

    increasing efficiencies in addressing preventive care metrics for all patients in the practice

    increasing physician and nurse satisfaction around patient relationship sustainability

    improving targeted patient outcomes around managing chronic diseases by using nurses to counsel, provide education and bridge the health settings to home gaps of health management by patients

    united front with higher numbers of providers to advocate for patient workload, reimbursement and preferred practice conditions, as well as to advocate for patients

    What’s happening to physicians - the divide and conquering by internal warfare - is, in my view, one of the principal reasons that professional nursing is so weak and ineffective. Nurses, who practice overwhelmingly as employees, depend on employers for their livelihoods. So instead of advocating without self-interest for patients, they suffer the problems without speaking up for patients since their livelihoods are endangered.

    Physicians are finding that as they become employees as hospitalists, ED physicians, intensivists, etc., that their ability to advocate is also impinged and that they are also pitted against their colleagues by external non-physician third parties.

    If nurses and physicians came together and reached consensus on some form of practice collaboration and patient advocacy, I like to think that the impact would be much more powerful and the effects much more beneficial to all.

  6. S Silverstein on November 25th, 2008 2:40 pm

    See my Open Letter to en. Baucus on Health IT.

    It’s not as easy as he thinks.

    link

    – SS

  7. Dan on December 7th, 2008 8:19 pm

    So, You Want To Be A Doctor…..

    In recent times, others have appeared to express concern about the apparent shortage of primary care doctors in particular- both presently and in the future they speculate that the shortage of doctors will continue to exist or progress to even greater shortages of PCPs. Typically, the main reason believed and speculated by others for this decline of this unique health care profession specialty that historically has been the apex of our health care system is lack of pay of PCPs, which is the second lowest medical specialty next to pediatrics, it has been reported.
    Once viewed as a vocation with great esteem and respect, a desire to be a doctor may not be desired as a career path by many. While this profession requires admirable commitment and dedication, as reflected in their training regimen in the U.S. that consumes about a third of their lifespan, the complications associated with practicing medicine in many situations presently may be why others are not seeking this profession. Such complications may include:
    Primary Care Doctors perhaps more than other physician specialties seem to be choosing to practice medicine under the direction of health care systems for financial security, primarily, as the cost involved with running a medical practice is quite expensive. These regional and nationally created healthcare systems are typically composed of numerous hospitals and clinics in a certain geographical area.
    The often monopolizing nature of the business models of these health care systems of increasing growth is not necessarily a desired method to practice medicine as a primary care physician in particular. Often, these often large health care systems employ their authoritarian stance by limiting as well as dictating how their health care providers practice medicine. This is further aggravated by possibly unreasonable expectations of their health care system employer- such as mandating that doctors they employ to see as many patients as they can in a full day. There actually have been cases of physicians being fired by a health care system for lack of patient volume that they have in their practice. Conversely, there are instances where health care providers receive financial rewards for seeing more patients a day than what is determined as average visits by the health care organization, it is believed. Such requirements likely and potentially affect the clinical judgment that is determined by physicians employed in this manner, as well as the quality of care the doctors provide their patients. Medicine should not be viewed as a profession of speed and volume.
    Another reason may be due to the increasing premiums for their mandatory malpractice insurance, which may make doctors financially unable to work independently due to such factors involved with practicing medicine presently. In regards to malpractice insurance for physicians, many doctors find this type of insurance in need of reform for a variety of reasons. These premiums become more costly for doctors as it relates to their chosen specialty as a health care provider. For example, the malpractice insurance premiums of an OB/GYN doctor are usually higher than one of a specialty viewed less risky for lawsuits, such as Dermatology, perhaps. With malpractice cases that are initiated, those who initiate a lawsuit against a doctor win about 25 percent of the time, with monetary awards averaging nearly a half a million dollars for these who sue doctors and win. Around 95 percent of these cases are settled out of court, it has been reported.
    In addition, the issue of medical malpractice is also frequently a catalyst for a doctor to practice what has been called defensive medicine. This basically means that the health care provider is prohibited from relying upon their subjective factors in their assessment of their patients, which in itself raises the question of what the point was of all of their training in the first place. They are compelled to order perhaps unnecessary diagnostic testing to rule out medical conditions or disease states that likely such patients do not have. This practice of defensive medicine may be encouraged by the health care systems that employ such doctors as well. This waste of medical resources is further validated by the legality reflected in the tone of the notes a doctor usually annotates or dictates with their patients after they see them for treatment. So one could argue that over-treatment is as common as under-treatment of patients in today’s health care system.
    Such excess and limitations imposed on today’s primary health care provider are usually not fully illustrated during their training for this profession, which is one that has been viewed as one that is quite noble and of great responsibility. This may be why this medical profession may no longer be viewed as distinct from other vocations as it once was, or one that has been desired more than apparently it is now. Some claim that doctors are somewhat understandably more cynical and demoralized than they have been in the past, which may be replacing the pride and responsibility that they historically have had with what they believed were their callings as doctors, as well as the perceptions of patients in the U.S. Health Care System.
    Further complicating and vexing to these restrictions is the usual financial state of the individual physician after their training, as many have debt that may exceed over 100 thousand dollars. This is much more debt than what doctors experienced after their training only a few decades ago, it has been said.
    Conversely, there are obviously some others who believe that doctors in the U.S. are over-paid and greedy. In spite of how they are judged, physicians are likely not absent of financial concerns as with many other people, yet the situation with doctors may be of more of an issue than many other professions, comparatively speaking, in addition of taking on more responsibility that is of greater importance compared with other vocations, one could argue. Such realistic variables should be factored in when one chooses to judge the profession of a physician. On the other hand, no physician should view their jobs as no different from any other venture capitalist when rationalizing their income and motives related to this exceptional vocation as a doctor, as others are more dependent on their judgment for the restoration of their health.
    It has been determined by others, and suggested often and lately, that many of today’s physicians practicing medicine in the United State do not recommend or speak favorably of their professions compared with their typical views of their profession in the not so distant past. While this self-perception physicians may have of a negative nature may be somewhat understandable, it is also unfortunate for the health of the public in the future, and the perception normally associated with the medical profession which could deter ideal medical care for others.
    There have been cases where doctors do in fact change careers, and get into vocational fields such as medical communications or corporate medical companies. Also, expert witnessing is another consideration for those who choose to leave their profession. Finally, other choices considered include consulting and research. The training of doctors fortunately leaves them with options not involved directly with the flaws of medical care, but this is bad for us as citizens, overall. The etiology of their departure from their designed profession is largely due to the negative state perceived by themselves as well as others of their profession as medical doctors.
    Again, and for perhaps Primary Care Physicians in particular, the medical profession clearly needed by others to some degree appears to be absent as a desired path of today’s careerist. The authentic reasons for what many believe to be a negative perception of possibly the entire health care system may never be known, yet many would agree that most U.S. citizens are understandably concerned with the state of this system of great importance to society. Yet need to be active more in assuring this necessity is more aseptic.
    “In nothing do men more nearly approach the Gods then in giving health to men.” — Cicero
    Dan Abshear (ex-military medic and physician assistant for nearly 20 years)
    Author’s note: What has been written has been based upon information and belief of a layperson, yet also the assessments of a patient.

  8. dj on December 12th, 2008 4:25 am

    Remember the concept of “Gatekeeper”????

    New Spin=”Medical Home”

  9. Quiact on December 21st, 2008 3:39 pm

    Our Paraplegic Health Care System That Now Exists In The U.S.

    The following are facts that are believed to exist regarding the present U.S. Health Care System. This may be why about 80 percent of U.S. citizens understandably want our health care system overhauled:
    The U.S. is ranked number 42 related to life expectancy and infant mortality, which is rather low.
    However, the U.S. is ranked number one in the world for spending the most for health care- as well as being number one for those with chronic diseases. About 125 million people have such diseases. This is about 70 percent of the Medicare budget that is spent treating these terrible illnesses. Health Care cost presently is over 2 trillion dollars of our gross domestic product. One third of that amount is nothing more than administrative toxic waste that does not involve the restoration of the health of others. This illustrates how absurd the U.S. Health Care System is presently. Nearly 7000 dollars is spent on every citizen for health care every year, and that, too, is more than anyone else in the world.
    We have around 50 million citizens without any health insurance, which may cause about 20 thousand deaths per year. This includes millions of children without health care, which is added to the planned or implemented cuts in the government SCHIP program for children, which alone covers about 7 million kids.
    Our children
    Nearly half of the states in the U.S. are planning on or have made cuts to Medicaid, which covers about 60 million people, and those on Medicaid are in need of this coverage is largely due to unemployment. With these Medicaid cuts, over a million people will lose their health care coverage and benefits to a damaging degree.
    About 70 percent of citizens have some form of health insurance, and the premiums for their insurance have increased nearly 90 percent in the past 8 years. About 45 percent of health care is provided by our government- which is predicted to experience a severe financial crisis in the near future with some government health care programs, it has been reported. Most doctors want a single payer health care system, which would save about 400 billion dollars a year- about 20 percent less than what we are paying now. The American College of Physicians, second in size only to the American Medical Association, supports a single payer health care system. The AMA, historically opposed to a single payer health care system, has close to half of its members in favor of this system. Less than a third of all physicians are members of the AMA, according to others.
    Our health care we offer citizens is the present system is sort of a hybrid of a national and private health care system that has obviously mutated to a degree that is incapable of being fully functional due to perhaps copious amounts and levels of individual and legal entities.
    Half of all patients do not receive proper treatment to restore their health, it has been stated. Medical errors desperately need to be reduced as well, it has been reported, which should be addressed as well.
    It is estimated that the U.S. needs presently tens of thousands more primary care physicians to fully satisfy the necessities of those members of the public health. This specialty makes nearly 100 thousand less in income compared with other physician specialties, yet they are and have been the backbone of the U.S. health care system. PCPs manage the chronically ill patients, who would benefit the most from the much needed coordination and continuity of care that PCPs historically have strived to provide for them. Nearly have of the population has at least one chronic illness- with many of those having more than one of these types of illnesses. A good portion of these very ill patients have numerous illnesses that are chronic, and this is responsible for well over 50 percent of the entire Medicare budget. .
    The shortage of primary care physicians is due to numerous variables, such as administrative hassles that are quite vexing for these doctors, along with ever increasing patient loads complicated by the progressively increasing cost to provide care for their patients. Many PCPs are retiring early, and most medical school graduates do not strive to become this specialty for obvious reasons. In fact, the number entering family practice residencies has decreased by half over the past decade or so. PCPs also have extensive student loans from their training to complicate their rather excessive workloads as caregivers.
    Yet if primary care physicians were increased in number with the populations they serve and are dedicated to their welfare. Studies have shown that mortality rates would decrease due to increased patient outcomes if this increase were to occur. This specialty would also optimize preventative care more for their patients. Studies have also shown that, if enough PCPs are practicing in a given geographical area, hospital admissions are decreased, as well as visits to emergency rooms. This is due to the ideal continuity in health care these PCPs provide if numbered correctly to serve more, the quality improves, as well as the outcomes for their patients. Most importantly, the quality of life for their patients is much improved if there are enough PCPs to handle the overwhelming load of responsibility they presently have due to this shortage of their specialty that is suppose to increase in the years to come. The American College of Physicians believes that a patient centered national health care workforce policy is needed to address these issues that would ideally restructure the payment policies that exist presently with primary care physicians.
    Further vexing is that it is quite apparent that we have some greedy health care corporations that take advantage of our health care system. Over a billion dollars was recovered for Medicare and Medicaid fraud last year through settlements paid to the department of Justice because some organizations who deliberately ripped off taxpayers. These are the taxpayers in the U.S. who have a fragmented health care system with substantial components and different levels of government- composed of several legal entities and individuals, which has resulted in medical anarchy, so it seems.
    Health 2.0, a new healthcare social networking innovation, is informing patients about their symptoms and potential if not possessing various disease states- largely based on the testimonies of other people on various websites. This may be an example of how so many others rely now on health concerns from those who likely are not medical specialists, instead of becoming a participant, if not victim, of the U.S. Health Care System.
    Thanks to various corporations infecting our Health Care System in the United States, the following variables sum up this system as it exists today, which is why the United States National Health Insurance Act (H.R. 676) is the best solution to meet our health care needs as citizens, it appears. We would finally have, as with most other countries, a Universal Health Care system that will allow free choice of doctors and hospitals, potentially. It should be and likely will be funded by a combination of payroll taxes and general tax revenue:
    Access- citizens do not have the right or ability to make use of this system as we should.
    Efficiency- this system strives on creating much waste and expense as it possibly can.
    Quality- the standard of excellence we deserve as citizens with our health care is missing in action.
    Sustainability- We as citizens cannot continue to keep our health care system in as it is designed at this time- as it exists today.
    http://www.mckinsey.com/mgi/publications/US_healthcare/index.asp
    Dan Abshear

  10. Bob Swerlick on July 13th, 2009 5:48 pm

    Please see link below http://online.wsj.com/article/SB118101135977724637.html

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