How Medicare undermines primary care

When I was a family medicine intern, I met a diabetic patient in the hospital who had stopped seeing his regular doctor after he lost his job and his health insurance.  His untreated diabetes made his feet go numb.  He stepped on a nail and didn’t realize it until he noticed a smell that cost him his foot.

He spent thousands of dollars on the surgery and subsequent hospital stay—far more than it would have cost him to visit his primary care doctor and get the medications he needed to stay well.

Not all medical care is created equal. Keeping patients healthy by preventing disease (the definition of primary prevention) or catching disease early to prevent complications (the definition of secondary prevention) saves the crippling costs of the tertiary care that America excels at, which we reward preferentially with our current reimbursement schemes, and which is breaking our economy.

In the 2004 Health Affairs article “Medicare Spending, the physician workforce, and beneficiaries’ quality of care,” Katherine Baicker and Amitabh Chandra show that the states that have the most primary care doctors in relation to other specialties usually have better quality care–with lower costs.  As long as all patients can get the right care at the right time at the right place, including access to specialist care and the procedures they need when they need them, emphasizing primary care prevention and wellness creates a healthier population for less money.

Part of health care reform will be paying more for the primary care that keeps patients well.

Unfortunately, the current method by which Medicare reimbursements are decided undermines primary care.  (As the largest insurance program in the nation, it drives the payments of private insurance too).

Since 1992, payments have been decided by assigning a relative value to the work that a physician does—based on physician effort, years of training required, and cost of equipment—then multiplying this by a set amount based on geography to determine how much physicians will be paid.

The “resource based relative value units” are determined by a committee sponsored by the American Medical Association, the Relative Value Scale Update Committee, or RUC.  This committee decides the relative value of different types of medical services. The RUC is comprised of a representative from each of 23 specialty societies, along with six other representatives.  The primary care specialists who comprise more than fifty percent of health care providers–family physicians, pediatricians, general internists –get only three votes out of twenty nine in deciding “resource based relative value units.” The American Medical Association has two representatives, including the Chair of the closed-door discussions.  (The AMA makes $70 million each year from licensing the fee schedules, and is the fourth single largest Congressional campaign donor.)  Not surprisingly, Medicare payments, decided primarily by specialists, favor increased reimbursements for procedures and increased use of new technologies.

Let’s compare.  What is the relative value of stenting a heart? (24) Of taking an hour to conduct a complicated discussion on end-of-life decisions?  (2.5)

Incentives drive care, which drives results.  Right now, reimbursement schemes pay specialists a lot to do procedures in a fee-for-service basis, and literally don’t pay primary care doctors to take the time to talk to patients to make sure they’re receiving the best care possible that they need. Disease prevention, screening, treatment, management and care coordination have gotten short shrift.  I get paid more for a two-minute wart removal than for the complex coordination of the care of elderly patients as they leave the hospital with multiple medical problems.

If an Independent Payment Advisory Board has the power to determine reimbursements for Medicare–which covers a quarter of insured patients, and would drive reimbursements for all insurance companies–and if the Independent Payment Advisory Board uses that power to pay primary care physicians more for the work we do counseling, coordinating care and otherwise keeping patients healthy—then without costing more money, our health care system would create a healthier America.

Kohar Jones is a family physician who blogs at Progress Notes.

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