Universal coverage and primary care

Elissa Mummolo summarizes Massachusetts’ problem of adopting universal coverage before addressing physician access.

Waiving tuition for medical students who choose primary care is a good start.

However, there is a lag time of about 10 to 20 years before these changes take effect. Every medical school has to offer similar incentives, and it will take years for the attitudes of medical students to change.

Meanwhile, what do we do now? Baby Boomers are rapidly approaching Medicare age. The answer is to provide decisive financial incentives for new medical graduates to choose primary care, and to prevent the current crop of doctors from bailing to more lucrative endeavors.

Radically skewing the payment system towards cognitive services is the only solution that will provide short-term changes. By radical, I mean tripling or quadrupling the RVUs assigned for office visits at the expense of procedures.

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  • Anonymous

    who is going to make up the revenue lost from waived tuition? the other students?

    raising the cognitive portion is fine if you don’t want procedures done on your patients, which will result from such a drastic change. i fail to understand the attraction of constantly trying to divide up the medical specialties with these comments. ymmv

  • The Happy Hospitalist

    I absolutely agree. The procedural payment model is so out of whack it’s destroying the fabric of comprehensive care in this country laughable. I gave an example the other day on my blog about central lines. My central lines pay me the equivalent of almost $400 an hour. While my hospital follow up visits pay me about $120 an hour. Same training. Same doc. Unbelievable skewed payment model. It’s why hospitalist medicine must be subsidized by hospitals. Because Medicare wont.
    The Goofy Line And Its Economics Explained

  • The Happy Hospitalist

    anon. The medical specialties have already been divided. Economically speaking. That’s the result of SGR and failed Medicare policies. Any doctor who does cognitive care would benefit dramatically with an increase in payment for cognition. Patients would benefit as well by avoiding unnecessary invasive and non invasive evaluations. I see unnecessary procedures every day. Hell, I even saw a patient get an angiogram and attempted stenting of the dorsalis pedis artery for a small ulcer on the big toe. $15,000 later and I’m happy to tell you the big piggy survived. Which I’m sure would have happened had this expensive undertaking never been done. But with a few key words placed in the chart and this ridiculous procedure is considered “medically necessary” and paid for 100% by the Medicare National Bank. I am shocked everyday by the unnecessary things that get done to patients because we can. And I can assure you a big part of that is driven by money. Money from the incredibly skewed procedural payment model in this country. Almost every procedural specialty I work with has extenders that do their daily cognitive rounds while they spend all day in the procedure lab or the OR. That is not by chance. I can assure you of that. As I”m sure you are well aware. Seeing patients does not pay. That’s why hospitals subsidize hospitalists to the tune of $100,000 per year per hospitalist. That’s just sad. That our services save so much money (the $260/patient figure reported last year is laughable) for hospitals that they are willing to dish out big bucks to have a well run hospitalist program.

    anon, the solution in the confines of the current fixed pot known as Medicare Part B/RVU/RUC/SGR must involve a redistribution of resources(money). If our goal as a nation is to produce more comprehensive care doctors, you must pay them more. A lot more. Not 10′s of thousands of dollars . Add a zero to that at a minimum. Short of discarding the whole payment system,which got us in this mess, there is no viable alternative.

    The medical home model, unless it raises comprehensive care docs salaries/take home pay 100,000 and more, will do nothing to encourage more medical students to enter this field. The back bone of any medical system in the industrialized world is comprehensive care. And ours is dead now. Not 10 years from now Now.

    A drastic change is necessary to shift the out of control runaway spending on unnecessary procedures and interventions (that I see all the time) back to disciplined cognitive based evaluations. But thinking doesn’t pay, and that’s why it doesn’t happen. Volume and procedures will trump thinking any day of the week. You know that.

    Anon. You seem to want a solution without a change in the current payment model. How do you proceed under the premise that there is no additional money to throw at the system.? Unless of course you believe that the money will simply appear. Or unless you believe comprehensive care docs shouldn’t be paid more.

    I suppose one solution is to have all comprehensive care docs go into a cash only model and exit Medicare Part B. Those patients who can’t afford it can go to a new system of federally funded comprehensive care clinics with federally salaried comprehensive care docs. Your VA style care. In my city, the current wait for an appointment at the federally subsidized comprehensive care clinic is 3 months. They are bursting at the seams with need from the poor and uninsured. AND the government denied their request for expansion. How’s that for government run health care. Denying expansion of resources for a need based clinic bursting at the seams.

    The only solution is to dramatically increase funding of comprehensive care. And that means paying comprehensive care doctors more. Much more. And in the confines of the current system, that means dramatically increasing the RVU value of cognitive care codes. And in the confines of the current system, that means a redistribution of the fixed pot of money. Unless you dramatically increase the fixed pot, there is no alternative.

    And you know it.

  • Deron Schriver

    Happy – I agree with you that the RVUs need redistributed to promote what we need to happen: better coordinated care, more face time with patients, and more patient education and promotion of healthy lifestyles.

    However, I will challenge you on the compensation issue. I’m not sure we need to increase the comp of PCPs and hospitalists as much as we need to decrease specialist compensation. Overall, physicians in this country make far more than in any other country. The RVU redistribution would enhance your income enough, and I’m not sure it needs to go beyond that.

    We could make better use of NPs and PAs for coordination and education activities at the primary care level. Physicians should be doing only the work that requires their education and licensure.

  • Anonymous

    Dervon,

    Care to back that up? UK primary care physicians (government employed) can make 2x as much or more than their US counterparts.

  • Anonymous

    I do agree that primary care needs a pay boost, but you are contend that they need a 100,000 dramatic pay boost? So the average primary care doc would make 280,000, while the average cardiologist has a salary of 320,000 if everything were to remain as it is currently (which it would not be able to since PCP outnumber high paid specialists)? Good luck getting anyone to spend the extra three plus years to do a cardiology fellowship or any other fellowship for that matter.

  • Deron Schriver

    Anonymous at 2:14 – It is WIDELY known that U.S. physicians are the highest paid in the world. In fact, I find it bizarre that you would even dispute that fact. You can find proof of that all over the place. Here’s one of many:

    http://www.worldsalaries.org/generalphysician.shtml

    I would love for you to back up the 2X figure because it’s garbage or possibly an anomaly at best. I also think it’s cowardly to post something anonymously.

  • Kevin

    Deron,
    Comparing physician salaries between the US and abroad is irrelevant:

    http://www.kevinmd.com/blog/2008/09/if-you-dont-care-to-have-pity-for.html

    Medical school is subsidized abroad, and malpractice costs are a fraction of what American doctors pay.

    Only if you make US medical school free, and substantially decrease costs of malpractice, can you compare salaries with other countries.

    Thanks,
    Kevin

  • Deron Schriver

    Kevin – Your points about malpractice premiums and med school costs are good ones, but the compensation gap is far too great to call it irrelevant.

  • Anonymous

    Additionally Deron, our European counterparts rarely put in the number of hours that we do. But hey don’t believe, I just happened to have worked on both sides of the pond. I am sure someone who has worked in healthcare finance/accounting/administration knows more about the subject than I do (please give me compazine before I puke)
    PS: how come I have never seen any of your ilk around at 02:00 when I am there emergently? Maybe YOU need a pay cut.

  • Deron Schriver

    anonymous (I hope you don’t mind my calling you anonymous) – I hope you’re a little more professional in your practice than you are as an anonymous poster on the www. Part of the reason you get paid more than double what I do (if you make an avg PCP salary) is the fact that you have to be available 24/7. That’s part of your chosen profession.

    Don’t get me wrong, I have tremendous appreciation for what physicians do. I work with them on a daily basis and my number one job responsbility is making sure that my physicians make as much money as possible. I am 100% on board with the fact that there needs to be a compensation realignment between PCPs and specialists. With that being said, I don’t see the average physician deserving a big raise because you are not significantly underpaid in comparison with other professions in this country.

  • Anonymous

    Physicians overall may be highest pain in the USA, compared to the rest of the world.

    Dowsn’t apply to primary care phyaicians.

    NHS GP’s can make the equivalent of US$250,000 How do I know? I ask them.

    They’re private strictly speaking, not “government employees”. Of course, when you’re talking about government payment schemes, this might be a fine distinction.

    Procedural specialties, yes, they are definitely paid a lot more here.

    And actually, it makes sense. A government-run healthcare scheme is politically sensitive. Give the people free primary care, most will never need specialty care, and things look rosy. If one patient suffers from a long waiting time for heart surgery or cancer care, compare it to a thousand who remember their free PAP smear or free minor medical event. Turn that into votes.

    So yes, primary care usually does well in that system.

  • Anonymous

    Deron-

    There are good reasons some of us post anonymously. That said, I think the most important flaw with international comparisons vis-a-vis the U.S. primary care practice is that they are largely irrelevant to the menu of choices actually faced by U.S. medical graduates.

    Think about it. When a U.S. student graduates from medical school, his or her choices are not “should I practice in the U.S. or in some other country?” The choices are “should I make $150K a year working like a dog after a 3-year residency, or should I do, say, radiology and make $500K a year while enjoying a nice, predictable lifestyle with relatively low hours?”

    Of course, now I suppose there’s the option to leave the U.S. and practice primary care in the UK for big $$. I wonder if IMGs have shifted from taking rural PCP jobs in the US to taking similar jobs in the UK.

    I sympathize with the general sentiment the U.S. doctors are well-paid. But some specialties are so ridiculously well-paid (GI, cardiology, dermatology, anesthesia, radiology, pathology, etc) that the _discrepancy_ in pay chokes off the pipeline of new PCPs. So there are 2 possible solutions: increase PCP pay, or decrease procedurist/imager pay while holding PCP pay constant.

    If you think international models of physician compensation are better, then you would do the second option and maybe have free medical school. This might be politically tough…the U.S. electorate has repeatedly shown a real dislike for learning from other countries.

  • Anonymous

    If you look at opportunity cost of training, primary care does the worst compared to business or law.

    The study was run back, 1994 or 1995 in JAMA or NEJM, it’s been a while. Make the assumption that someone able to get into medical school could get into the top half of law of MBA programs.

    If one accepts that premise, calculate average pay, length of training, the best return is a MBA degree. Secod is a tie between law and specialty medicine. Primary care is dead last.

    A doc told me that years ago when I was a high school kid thinking about medicine. He said if you just want money, take your effort and sacrifice as you would in medical training. Put it into just about any endeavor you like. Build houses. Become a plumber. Instead of spending the money, put it into a business as the doctor would be paying tuition and working long hours for low wages in postgraduate training. You will be better off financially in the end.

    I say that’s true……if you really do the sort of sacrifice in youth that a doctor has to do.

  • Deron Schriver

    If our system gets the reform it needs, life for PCPs will get better. The RVUs need to be realigned, the complexity needs to be removed from the system, the extenders need to be better employed to take some pressure off physicians, etc.

    Change is coming. I just hope the single payer folks don’t beat the real reformers to the punch. Don’t be surprised if I come back to all of you asking for your input in a reform effort I’ve just joined.