Comments on: Are specialists preventing the government from spending more on primary care?

By: Tom

Tom — Sat, 31 Oct 2009 14:35:15 +0000

While it was nice of you to take the time to demonstrate that via the articles you cited, it was unnecessary, we all believe it. However, no-one wants to be the sacrificial goat on the altar of the public good. Can you blame them for that? I repeat, the best way for a PCP to be reimbursed is not by the government or insurers (who can and do arbirtarily change reimbursement), but by their patients.

By: David Emil Joseph Bazzo, MD

David Emil Joseph Bazzo, MD — Fri, 30 Oct 2009 23:16:46 +0000

I hope that we as physicians we can come together and agree on evidence-based reasons to improve our patients’ access to primary care. That means finding ways to recruit and retain more medical students into family medicine and other primary care specialties. Leaving aside the issue of physician pay, for just a moment, let’s look at the evidence for solving the shortage. With our nation facing an epidemic of largely preventable chronic diseases – such as Type 2 diabetes and heart disease – both prevention and disease management become ever more critical for improving patients’ health and reducing health care costs. According to the literature:

• In communities where primary care physicians provide the majority of care, researchers found that patients are healthier and costs are lower.(1) Researchers from Johns Hopkins School of Public Health analyzed data from 3,000 counties and found that a higher ratio of primary care physicians to specialists in a population results in lower mortality rates and lower health care costs.(2)

• Research shows that adding just one primary care physician per 10,000 people contributes to a three to 10 percent decrease in deaths.(3) Studies also indicate that patients with access to primary care doctors suffer from fewer and less severe chronic diseases such as diabetes and heart disease.(4),(5)

• By providing primary care medical homes and emphasizing enhanced chronic care management for Medicaid beneficiaries, Community Care of North Carolina saved taxpayers between $231 million and $255 million in fiscal years 2005 and 2006 alone while improving care for more than 725,000 patients.(6)

• Since Geisinger Health System in Pennsylvania restructured care and began using the patient centered medical home model for 2.5 million patients, preliminary data reveal a 20 percent reduction in hospital admissions and a seven percent savings in total medical costs.(7)

Although our debates about how to solve the primary care physician shortage are difficult, the wellbeing of our patients demands that we find the answers. The California Academy of Family Physicians (www.familydocs.org) strongly supports the passage of meaningful health care reform legislation this year as a start.

David Emil Joseph Bazzo, MD
San Diego, CA

Citations:

(1) Starfield B. et al. “The effects of specialist supply on populations’ health: Assessing the evidence.” Health Affairs 24 (2005): w97-w107. Published online March 15, 2005: http://content.healthaffairs.org/cgi/content/abstract/hlthaff.w5.97

(2) Ibid.

(3) Barbara Starfield (Johns Hopkins University) research summary at:
http://pcpcc.net/content/evidence-quality

(4) Agency for Healthcare Research and Quality. National healthcare quality report 2007.

(5) Starfield, B. et al. “The effects of specialist supply on populations’ health: Assessing the evidence.” Health Affairs 24(2005):w97-w107. Published online March 15, 2005: http://content.healthaffairs.org/cgi/content/abstract/hlthaff.w.5.97

(6) Steiner, B.D. et al. “Community Care of North Carolina: Improving care through community health networks.” Annals of Family Medicine 6.4 (2008): 361-367.

(7) Paulus, R.A. et al. “Continuous innovation in health care: Implications of the Geisinger experience.” Health Affairs 27.5 (2008): 1235-1245.

By: Neurodoc

Neurodoc — Thu, 29 Oct 2009 19:21:30 +0000

Dr. Laffel is the precise reason we are all going to lose in the end. The specialist vs. primary care compensation debate is, as described by another poster, comparing apples to oranges. As a neurosurgeon who went through 7 years of residency and a post residency fellowship to hone subspecialty skills all the while making less than 40,000 K a year, starting a family and managing huge school debt, I find his comments ignorant at best. My friends in Medical scool who went primary care finished their 3 year residency and began making the “paltry” primary care salaries of 150K or more. Mean while now that we are both practicing, i’m the one in the ER at 2AM treating head bleeds and other emergencies while most of their practices dont even goto the hosptial to see their patients anymore instead leaving that job to salaried Hospitalists.

Oh, lets not forget my 70K per year malpractice premiums which are conservatively about 10 times what you pay.

Ignorance like that displayed in the initial post is exactly what the Govt is counting on to take all of us down and destroy health care access and quality in this country at the expense of cheap politics.

By: Evinx

Evinx — Thu, 29 Oct 2009 19:00:35 +0000

Gee, the govt installs price controls via Medicare, Medicaid, CPT codes, etc heavily affecting PCPs. The PCPs try to increase efficiency (so as to not reduce revenue) by overbooking, spending 6 minutes/patient, etc. No place to go. The market place gets the message and fewer become PCPs.

The solution is simple. Allow markets to work, ie, cut the govt umbilical cord. Re-read Tom’s post above. When enough say no more Medicaid, no more Medicare, then this nonsense will stop.

No one ultimately can “win” when you negotiate with politicians – their objectives will never align with yours. Have the lessons of the past 45 years taught us nothing??

By: buckeye surgeon

buckeye surgeon — Thu, 29 Oct 2009 18:52:07 +0000

Yeah, it’s just a “shocker” that specialists would be opposed to a zero sum plan to shift reimbursements from them to primary care docs. Such nefarious schemers they are, single handedly undermining our noble politicians’ plan to make primary care more appealing!

As others have said, this sort of take is counterproductive to the nth degree.

By: ninguem

ninguem — Thu, 29 Oct 2009 17:42:21 +0000

Regardless how onefeels about the “fairness” of specialty pay versus generalist pay, I bet there’s one thing where we can all agree.

Any pressure on government and insurers to even out specialist pay vs. generalist pay will definitely result in the pay evening out.

The specialists will get their pay cut, and the generalists will stay the same. There, now it’s even.

Any generalists out there, would you feel better?

Would you really?

By: Doc99

Doc99 — Thu, 29 Oct 2009 14:06:25 +0000

This type of post truly is counterproductive. “We must all hang together; for assuredly, we will all hang separately.” B Franklin.

By: Jay W. Lee

Jay W. Lee — Thu, 29 Oct 2009 04:00:07 +0000

As a primary care physician, I am concerned about the projected shortage of U.S. physicians almost as equally as I am concerned about the poor distribution of the present U.S. physician workforce. Look at MA; even if you expand insurance and give people a card that is supposed to give them access, that access is a phantom if there are not enough physicians, primary care and specialists, to see these folks (and as we are seeing with Medicare and Medicaid, many docs are opting out across specialties). Regards the present maldistribution of U.S. physicians, it distills down to payment. Now, I’m not here to write that specialists should get paid less in order to pay primary care physicians more…but I would, if push came to shove. Follow me here: after nearly 8 years of schooling and 3-6 years of post-graduate work ahead of them, medical student has accrued lots of debt and decides to enter higher paying specialty, usually procedurally-based (RUC effect); makes microeconomic sense, right? Here are a few proposed solutions that would not necessarily change payment for specialists (could you support these? see, not everything needs to be zero-sum): loan forgiveness for medical students choosing and staying primary care, expanding national health service corps, addl PMPM payments for primary care docs to compensate for care coordination. These would serve as incentives for medical students to enter primary care and for those of us in it to stay. Personally, I would like to see the U.S. physician workforce reach 50:50, i.e. even supply of primary care and specialist docs, with fair payments for everyone. We can get there…but not with the mentality of “not if I get shorted even one cent”. The reforms need to be uniquely American solutions to uniquely American issues. Are we Ameri-cans? Or Ameri-can’ts?

By: Carla Kakutani MD

Carla Kakutani MD — Thu, 29 Oct 2009 03:57:45 +0000

It certainly is not helpful for doctors to try to out whine each other about how much they work and how little they make. But the reality is that the system is stacked in favor of procedures, and that system is carefully preserved by the AMA’s subspecialist-controlled RUC. The end result of this decades long “thumb on the scale” is a glut of subspecialists, an empty primary care pipeline, expensive and fragmented care in urban areas and dwindling access in rural areas.
How is this good for anyone? Do a little thought experiment and imagine what life will be like when a subspecialist can no longer say to patients: “I don’t (do disability forms, give vaccines, discuss mental health issues, refill those prescriptions, know what that rash is, etc, etc), please talk to your PCP about that” because there won’t be any place to send people back to. Enjoy!

By: Nuclear Fire

Nuclear Fire — Thu, 29 Oct 2009 02:51:46 +0000

Some specialists may get paid a lot more but not all. Rheum certainly doesn’t. Specialists also have trained a lot longer and provide a higher level of care. Of course they get paid more. Specialists are not the problem.

While I’m ranting, I’m sick of hearing the politicians blaming specialists for costing the system so much money. I see tens of thousands of dollars wasted daily on MRIs ordered by primary care docs who should have easily been able to manage simple musculoskelatal probelms without any scans but from lack of ?time/knowledge/basic exam skills they have no clue what is going on so rather than get the patient to an adequate physician, they first get the scan and when it doesn’t show anything or anything specific consult rheum or ortho. Order the consult first and at least save some money if you don’t have a clue about anything beyond controlling blood pressure. A consult is a lot cheaper than a useless MRI that you don’t know how to interpret in the first place.