One positive facet of Obamacare is the rebuilding of our primary care system. Unfortunately, congressional forces are aligning that will obstruct replacing this back bone of our health care. Even more surprising, the proposed congressional actions are bipartisan in nature and bipartisan work tends to pass into law. How is this happening?
Much of the medical education in our health care system is paid for with Medicare dollars. Hospitals that serve as training grounds are provided extra payments through Medicare to make up for the cost of training. Studies show the amount that Medicare pays exceed the actual costs of training, so it is natural that Congress wants to decrease these payments. Of course cuts will be “across the board” and every organization who receives funds will incur some of the pain. Unfortunately, the story of funding for training primary care doctors is sordid. Bear with me here…
In the old, old days, doctors went to medical school, did a one year internship and hung up their shingle. In 1933, the American Board of Medical Specialtiesstarted certifying each of the medical specialties. So after doctors became primary care doctors, they proceeded to a specialty – everyone had at least a base of primary care experience. This changed over time, and specialists entered their specialty directly.
The 1950’s and 1960’s almost saw the demise of family medicine. Specialists saw no need for primary care doctors and opposed creating a “specialty” dedicated to family medicine. They dominated leadership in medical societies and decision making bodies on pay structure. They worked through theAmerican Medical Association’s Relative Value Scale Update Committee(RUC) to guarantee that specialists would be paid more than primary care doctors for exactly the same work. For example, a primary care doctor who sees a patient for removing a foreign body from the ear will be paid less than a otolaryngologist who sees the same patient for the same problem and provides the same treatment. (CORRECTION: I made an error in my understanding how the pay discrepancies came into being. Primary and specialty physicians are paid the same for the same procedural code. However, the actual cause of the pay discrepancy is that specialists (through RUC) weight procedures they regularly perform as more complicated and deserving of higher pay. The Wall Street Journal reviewed how RUC shorts primary care and greatly increases the cost of health care nicely in this article. I extend my apologies for the mistake.)
What was the result? People started seeing specialists for the most mundane problems. Although we are all special, most of our health problems are mundane and do not require specialty care. For those who aren’t so ill, isn’t it great you can ask your family doctor about the wart on your finger while you are seeing her for your ankle sprain? The orthopedist would send you to the dermatologist for that one.
For a complicated patient with multiple medical problems, too many “cooks in the pie” creates more problems. A good family physician or general internist will manage the majority of the conditions, coordinate specialty care, and make certain a patient’s values are respected while their needs are being met.
On a societal level, we have decades of studies proving primary care is the most efficient way to take care of a population and keep them healthy. Other countries never abandoned their primary care backbone, and subsequentlyhave healthier populations at half the cost of what we pay in the United States.
Fortunately, a number of physicians recognized the value of family medicine and continued to fight for recognition as a specialty. In 1969, family medicine officially became the 20th specialty under the American Board of Medical Specialties. Family doctors train for three years after medical school, complete a load of continuing education, and pass a thorough exam every ten years.
The struggle for recognizing the value of family medicine did not end there. The pay disparities between primary care and specialty care do not occur just at the level of the physician. Hospitals benefit from specialty care too. Doctors who “do more” generate a lot of revenue for everyone else, so hospitals love their specialists. I received an email recently from a person who had a skin cyst removed. The physician wanted to perform the surgery in the outpatient surgery center instead of performing an office procedure, which is the most common place to remove a skin cyst. The money savvy patient asked how much it would cost and was told about $500 by the doctor’s office. When all was said and done, the bills from the other entities involved added up to about $5,000. This is a travesty.
To circle back around to how Congress plans to compound the problems with rebuilding our primary care system…
The more revenue a teaching hospital can bill through Medicare, the greater the amount of money they receive for medical education. A hospital that has significant specialty care creates more Medicare charges and gets higher pay from Medicare to train physicians. And the problem? The teaching hospital is not required to report how that money is allocated. Each hospital gets so many “slots” for residents, and they can use the slots and the money however they feel is necessary. There is no accountability and little incentive to promote primary care. A perfect example of unintended outcomes occurred in my old stomping ground, the University of Florida. In 2005, Gator Nation discontinued the Family Medicine residency program in Jacksonville and used the open slots for surgical specialties such as ophthalmology.
The Medicare Payment Advisory Commission released a report in 2010 that urged Congress to correct funding issues in physician training. They encouraged more accountability in use of funds and urged a move toward funding based on needs of the health care work force. Did anything come of this? Of course not. Congress does not want to get into the messy battle of primary versus specialty care.
Where are we now? Congress is at the verge of passing across the board cuts to graduate medical education funding. Many of those training programs involve only primary care training, and they will get cuts just like everyone else. And for the “broad based” institutions with many specialists and few primary care slots, who gets to decide how that money is spent? We remain stuck. It is still the institutions that train the doctors, and for now despite the implementation of Obamacare, specialists win the money war.
How do we fix this disparity?
- Urge Congress to make targeted cuts in funding and support spending for primary care training.
- Institute the Medicare Payment Advisory Commission recommendations for greater accountability of funds used for graduate medical education training.
- Focus future funding based on health care work force needs.
- Consider the recommendations by the Association of Academic Health Centers for a one time increase of 3,000 entry level positions in needed fields such as family medicine and general surgery.
Let me make one thing clear – specialty care is needed and highly valuable in the right situation. A good family doctor understands the critical and calls in a specialist immediately. They also recognize the common problems, and treat appropriately. Finally, they recognize the normal, and reassure the patient. If something isn’t critical, common, or normal, the specialist should be consulted early to help the family doctor figure out the best course of action. We all need to work together to take care of the health of this nation and Congress needs to support that effort.
I’m optimistic the problem overall for Congress is just a lack of understanding. Maybe by providing a little education, we can get Congress to choose the right path for funding health care education in this country. Please give them a call.
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