Congratulations to Barack Obama on his historic Presidential victory. He dominated New Hampshire, carrying my home state by over 10 points.
I voted with the nominees’ health care platforms weighing heavily. Both did not offer plans that I felt would work, as I wrote previously. While reading their competing pieces in the NEJM however, Obama made the more compelling case:
There is little incentive for young physicians to enter into primary care. And U.S. physicians practice with constant concern about malpractice lawsuits . . .Doctors should be paid fairly by private insurers and by Medicare. Payment reform should improve patient outcomes and should lower overall costs by removing incentives for unnecessary care and rewarding the right care, provided at the right time, for the right reasons. Unlike my opponent, I voted against the recent reduction in physician payments. We can’t start health reform by penalizing doctors . . .
I will invest in programs, including loan repayment, training grants, and improved provider reimbursement, to give young doctors incentives to enter primary care.
John McCain on the other hand, did not include any support for primary care. In fact, the words “primary care” were nowhere to be found in his article.
Despite the fact that Obama’s supposed tort reform stance is questionable, like McCain, he acknowledges that malpractice premiums are crippling to physicians and is willing to listen to approaches to curb lawsuits:
I will address medical malpractice with the central goal of preventing medical errors in the first place. Through substantial investment in information and decision-support technology and other patient-safety initiatives, we will reduce the types of medical errors and oversights that lead to lawsuits. And I am open to additional measures to curb malpractice suits and reduce the cost of malpractice insurance. We must make the practice of medicine rewarding again.
In the end, Obama’s NEJM piece was influential, and true to my word, McCain’s absence from July’s Medicare vote to raise physician payments was indeed a factor.
Barack Obama received my vote on November 4th. I do not agree with everything on the Democratic platform, but it was clear he understood the plight of primary care physicians better than John McCain.
Now that he’s won, let’s see some of his initiatives put to action. He must increase access to generalist physicians before expanding coverage. His plan mirrors that of Massachusetts’ reforms, minus the forced coverage, so he must be aware that without generalist physician access, the newly insured are simply going to increase the burden on emergency departments. His proposal of providing financial incentives to medical students will help long-term, while improving payment to cognitive services will prevent the current generalists from leaving primary care.
With that in mind, here are two specific solutions that will have the most immediate impact:
i) Increase Medicare’s reimbursement of the E&M codes 99211-99215 by 20 percent or more. These are the cognitive codes primary care doctors use most, and they are reimbursed at a rate substantially less than comparable procedure codes. Consider the fact that the 2 minutes it takes to freeze off a wart pays more than a 25 minute office visit. Increasing Medicare’s fees for these codes will make a bold statement that private insurers will follow. The subsequent increase in primary care revenue will prevent doctors from leaving the field or going to cash-only practices.
ii) Forgive medical student debt and subsidize tuition for every medical student who chooses primary care as a career. Only two percent of Internal Medicine residents choose primary care. Money is not the only reason, but it’s often influential. If tuition were fully subsidized and medical debt burden relieved, there would be less pressure for prospective doctors to gravitate to lucrative specialties.
The uninsured are a significant problem, and covering them is embraced by every Democratic candidate. Enacting universal health insurance is an expensive proposition, and if instituted poorly, will further cripple the system to a degree far worse than the current economic crisis.
I’m putting my faith that Obama will provide realistic solutions and ensure that our primary care system can handle the influx of newly insured patients before guaranteeing coverage for all.
Update:
Here’s how fellow internists Robert Centor, Rob Lamberts, and Matthew Mintz would advise President-elect Obama.
topics: obama, primary care
Related posts:
- The Obama health care summit, and did the President offer any clues to the upcoming health reform effort?
- 10 President Obama posts you may have missed
- Medical malpractice reform by President Obama and the White House
- Is Obama serious about medical malpractice reform?
- Is President Obama trying to do too much with health reform?
- Did Obama provide any health care clues in his inaugural address?
- Expect more primary care work under an Obama health plan
{ 15 comments }
I voted for McCain. And I voted for McCain because as a Peditrician native to North Carolina, I did a stint in those state & federal loan-repayment-for-public-service programs you talk about . . . and was treated horrifically by the mill-town "non-profit" hospital that ultimately broke the law in order to cover up bad medicine and keep "the business" for itself.
The NC state capitol is ruled by the party of Obama – the one that talks about "change". Yet I have yet to get any help from the state or federal governments I served in redressing the wrongs that were done to me.
It's why I'm in the blogosphere.
So in terms of "sacrifice", I've already given at the office.
Primary care is in free fall because those of us who practice it are considered "a dime a dozen" by the (largely overpaid/skimming-their incomes-off-the-top) health care executives & administrators that make the big decisions.
Michelle Obama is a former hospital administrator. And I have to wonder if she would approve of what two of her kind did to me.
I couldn’t find the “two-percent” article, so here you go:
http://jama.ama-assn.org/cgi/content/abstract/300/10/1154
Bottom line to keep in mind when reviewing the President-elects prior pledges: There is only pledge that he has made for which the moment of action has come and gone showing us what his word means to him–his pledge to accept public financing of his campaign and accept the limits that go with that.
When someone breaks the first promise they make, I don’t see any reason to waste my time listening to what they say after that. I just keep my eyes on their hands.
Dr. Kevin – I would not recommend that we dish out that much extra for the sick visits (99211-99215) right out of the box. They recently got a good boost, and I could see maybe another 5-7% right now. I want to see increased reimbursement for the preventive codes (99394-99397), because the premium should be on preventing illness more so than treating it.
Dr. Johnson – With all due respect, slinging blame at administrators is not doing anyone any favors. Using your personal situation to characterize an entire profession is actually kind of destructive, particularly at a time when we need to work together to develop solutions.
Two years until the application process. Lets see what this bad boy can do!
You should be ashamed of yourself Kevin. All you have to do is surf the internet a little to see what democrats actually think about us rich, overpaid doctors (this includes ALL doctors). There is no need to increase payment to primary care physicians when there is already a flood of nurse practioners, nurse doctors, and pa s coming into practice each day.
Mark my words. You may be rewarded in the short term marginally, but in the long term you will be replaced. 5 nurse practioners with one physician overseeing them. That is the practice model you have voted for.
PS: michelle obama has been a health care ceo already. you don’t hear about many bold steps she took to help out physicians do you?
I just regret that I am in the only profession in the country that repeatedly shoots themself in the foot. I don’t know what more to say, except when the law of unintended consequences comes to roost I want you to write a big opinion piece about how you were warned over and over. This will not be Obama’s fault, this will be on you. As a previous poster mentioned, Obama has already broken his word on campaign finance reform that he made in national debates. What will stop him from not fulfilling these promises (most of which you seem to infer that maybe he will due out of the goodness of his heart) that are written in journals that no one reads except a small percentage of doctors.
Deron, respectfully, my “personal situation” is ten years old and began on the Democrat’s watch (Bill Clinton/Jim Hunt).
I’ve worked nearly 40 assignments since what was done to me in my own hometown. Believe me when I tell you that the problems I speak of are UNIVERSAL. I have watched different people/groups/institutions make the same sad/sorry mistakes over and over again – most of them devaluing the doctor – some of them endangering the patient.
In that same time period, I’ve heard countless speeches by well-meaning types like Barack Obama on “change” and “ethics” and “reform” . . . and I simply do not see it happening . . . especially in North Carolina.
Talk is cheap.
Here, Kevin suggests that loan-repayment-for-primary-care (or public service) is some kind of magical answer . . . or a new idea . . . and it is NOT on either count. These programs traditionally treat the doctor as if he/she is an indentured servant. They are also a revolving door.
The campaign is over and it’s time to leave the “we can’t be negative” act at the Oval Office door. Obama is not going to get anywhere if the only people he listens to are “yes” men and women.
It’s time to get real.
In terms of “developing solutions” it also seems to me that it would be very “productive” for some of the young guns of medicine (many of whom, like Kevin, probably voted for Obama) to listen some of us who have been burned (in my case, very badly) . . . and learn from those experiences. Moreover, in order to work together, I believe that the businessmen now in the equation of medicine MUST learn how to respect the doctors that they have for so long treated like pawns on their personal chessboards to profit.
Unless this happens, and happens soon, Anon 8:02 is right on the MONEY about the practice model Kevin voted for.
Deron,
Medicare doesn’t cover routine physicals, so the 99394-99397 codes are not applicable to any type of government action.
Unless they start covering physicals of course.
Kevin
Sorry to burst your bubble, Kevin, but no way is CMS upping reimbursements 20% for anything. If you think this will happen, I humbly suggest you give up smoking rope. Moreover, IT will not end medical errors and will undoubtedly result in yet more unfunded mandates for American docs. We are so screwed.
Disagree with Doc99…the fundamental misconception you have is that upping 99211-15 will increase the costs to taxpayers. With the SGR, this is false. Increased funds for cognitive services will be paid for by decreased payments for procedures and imaging…a much-overdue payment reduction which is, in my opinion, even more important to the future of primary care.
Remember, procedurists and imagers have a great political motive for keeping cognates relatively poor…it’s the cognates who can’t accept Medicare beneficiaries if the annual SGR override doesn’t pass. Without this threat, there’s nothing to stop SGR cuts from actually kicking in. No way in hell a gastroenterologist is going to stop colonoscopizing 70-year-olds, even with a 20% pay cut…the money is still too good.
As a brand new Pediatrician, starting out this past July, I have to say my gut tells me to watch out. I think Anonymous at 8:02pm is right on the money: why do we as a profession seem to enjoy being martyrs to a cause? Why do we have to accept that ‘we’re not in it for the money?’ Why can’t we fight and vote appropriately and demand that as elite, well educated, hard working professionals we deserve to be paid well? And I agree with Dr. Johnson: loan repayment is not an incentive. A bright future for the business side of primary care IS. It is an incentive for me. It is an incentive for the young people at the top of their college classes right now considering the question, ‘do I want to go into medicine?’
I am particularly worried, as a pediatrician, that there will soon be a government run coverage system that will undercut the private insurers who are, right now, what keeps the incomes of my collegues reasonable. If reimbursement shifts toward the medicaid model, there will be a lot of pediatricians pulling their hair out worrying over the payment on their stinking toyota corollas. Not me, I’ll just go back and subspecialize because I still can. Or maybe I’ll just go to law school. Or maybe, just maybe, we as a profession will draw a line in the sand and refused to be devalued any more then we already have been. The politicians, the rest of society, they wouldn’t mind one bit if it was all just free. I wouldn’t mind if law advice was free but it isn’t. Obama is a democratically elected president and by definition he is interested in pleasing the largest number of people. In case anyone forgot, physicians are an elite minority. Nobody out there is really interested in our well being. I think its time we take the valuable assets we offer and demand decent wages for them like every other businessperson and professional in America insteading of crossing our fingers and hoping for the best, as we lay our heads down after another 40 patient day.
Sorry Anon … but 20% increase?! I’m seriously laughing at that one. And which imaging procedures will be cut 20% to make up for this? Covering Mammograms only every three or four years?
Doc99…evidently you don’t know how the SGR works. I recommend a little google time.
The short answer to your question is this: All of them.
Obama’s victory was very momentous yet very challenging. He has to inherit a country at its great depression. Healthcare is one of the challenges Obama shall be facing come January 20. We should do every way possible to uplift the healthcare services in this country.
Driving down the costs of healthcare is paramount to increasing healthcare accessibility and providing quality healthcare to every American. As long as the healthcare industry remains “for profit” this will not take place. We have the most expensive healthcare system in the world and we pay more for prescription medications than any country in the world. The healthcare industry survives by showing a profit to its investors and in order to do so they must deny care or increase the number of unneccessary procedure. I believe we are on the verge of a collapse of the healthcare system similar to what we have just seen with the financial system. For more discussions on similar topics, please visit my blog at http://www.takingcontrolofyourhealthcare.com.
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