How Medicare can fix the shortage of primary care physicians

Primary care physicians (PCPs) have been marginalized by Medicare for decades with low reimbursement rates for routine office visits which has led to the 15-20 minute office visit with 10-12 minutes of actual “face time” and a panel of patients that well exceeds 2000.

Is there a good solution to the Medicare cost and quality issues? Setting aside either the Democrats’ approach to basically enact price controls by ratcheting down reimbursements or the Republican’s plan to re-structure Medicare to a defined contribution plan, albeit not for ten years, are there approaches that could be instituted now that would have an immediate impact on improving quality of care and thereby reducing costs?

A 10-12 minute interaction means no time for the PCP to truly listen, no time to prevent, no time to coordinate and no time to just think. This has in turn meant that whenever a patient has a slightly more complex issue, one that is not easily recognized in a short time frame, then the PCP is quick to refer to a specialist. It is this very act that dramatically drives up expenditures with added tests, imaging and procedures along with the specialist’s fees. Medicare has been exceptionally short sighted in this regard and as a result is the prime culprit in the rapidly rising costs of care.

Further, this lack of time being reimbursed means that two critical quality care needs area left largely unattended. The first is offering extensive preventive care and the second is coordinating the care of the patient with chronic illness. Recall that 85% of Medicare enrollees have at least one chronic illness and 50% have three or more. These are mostly the result of years of adverse behavior patterns but it is never too late to begin preventive care so time spent here is valuable for better health quality and ultimately reduced costs.

And those with a chronic illness need to have their team of caregivers coordinated — every team needs a quarterback and the PCP is the obvious choice. But Medicare does not reimburse for this critical function which when done correctly means less reliance on specialists, tests, procedures and prescriptions. The result of this low reimbursement for routine visits and lack of reimbursement for either extensive preventive care or chronic care coordination over the years is a PCP shortage, many current PCPs no longer accepting Medicare, and the remaining PCPs trying to see 24 to 25 patients or more per day, each for 15 minutes despite the patient’s complex problem list. And this means less than stellar patient care in many instances.

The result is a real problem facing Medicare right now — the rapid loss of primary care physicians (PCPs) who will no longer accept Medicare. In 2009 there were 3700 physicians that opted out of Medicare; the number rose to 9500 in 2012 according to CMS in a Wall Street Journal article; this on top of the shortage of PCPs across the country, with no end in sight.

The ACA does include an extra 10% increase to primary care providers but this will probably be too little, too late. And if the mandated 27% across the board physician cut in reimbursement is ever implemented by Congress (it probably never will be but Congress refuses to clarify itself) then it is reasonable to expect that there will be a mass exodus from accepting Medicare reimbursements by all physicians, not just PCPs.

What is the fix? As long as fee for service predominates in the payment system, Medicare needs to increase its reimbursement of PCPs in a manner that ensures that they will offer the patient more time per visit. Time to listen, to prevent, to coordinate and to think. And in a capitated system, Medicare (or its agent) needs to pay enough per patient per month/year to insure that each PCP does not have more than a maximum of 1000 patients (even fewer if the practice is largely geriatric) so that there can be adequate time per patient encounter.

Stephen C. Schimpff is former CEO, University of Maryland Medical Center, chair, advisory committee, Sanovas, Inc., and the author of The Future of Medicine – Megatrends in Healthcare and The Future of Health Care Delivery- Why It Must Change and How It Will Affect You.

Comments are moderated before they are published. Please read the comment policy.

  • buzzkillerjsmith

    Dr. S’s diagnosis is quite correct, but I fear his treatment will be quite a while in coming, if it comes at all.

    America needs an epiphany, a realization that it’s not living right in terms of structuring its medical system. Then it needs to take effective action to right things. And of course such action must result in some people liking the system worse than they like it now.

    Easier to just keep complaining and to take punitive measures to try to force docs into line, at least until the whole system unwinds.

    • Bob

      What we need is to get rid of $1 trillion a year in waste, fraud and abuse that all the politicians know about, or let the government cut so far and raise taxes so much that the system fails completely that the President of the American Cancer Association figures is around 10 years from now when health care is 26% of the GDP and it collapses.
      I think it will be sooner accounting for how many “new and poor or old citizens we find with the ACA!

  • NewMexicoRam

    It won’t happen.
    Primary care has lost most political power over the last 20 years.
    It will continue to be long days, shorter visits, and disgruntled patients and doctors.

  • Deceased MD

    It is all going to hell in a handbasket. When is everyone else in the world going to see what we’re talking about?

    • buzzkillerjsmith

      People will see what we’re talking about when a politician’s kid or wife dies because if a lack of timely medical care. Or maybe if it is a star or a famous athlete. The rest of us hoi polloi barely register in this county.

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        Not going to happen… What’s the medical equivalent of private schools, private jets and $50,000 per plate fund raising events?

      • Deceased MD

        I hate to say it Buzz but I am not sure if they will ever put the pieces together. In the example you give, if someone well known dies, heads will roll and there will be more regulations. It is so convoluted to understand how corrupt things have become and how all the pieces fit together.

        • Suzi Q 38

          Don’t people who are well connected or have VIP status get better care than the rest of us, anyway?

          • Deceased MD

            Good point.

          • ninguem

            Do the VIP’s get “better” care?

            It’s a big “it depends”.

            Michael Jackson comes to mind.

          • EmilyAnon

            But that was his undoing in choosing a compliant Dr. Feelgood.

          • ninguem

            Exactly my point. The VIP’s can get good care, but they can also get the very WORST care.

            It’s a big “it depends”.

        • buzzkillerjsmith

          You’re probably right. I guess I was just feeling too hopeful.

          • Deceased MD

            You know I think we all have a flicker of hope so don’t let me interfere. It’s hard to know that things could be so much better but feel helpless to change it. Your idea of a union sounds like a start but my concern is that we are not turned into a carpenters union as it is a profession.

  • Deceased MD

    It’s truly hard to believe this is happening. When I was in medical school, the last thing I could imagine happening was Primary Care falling apart. It is haunting that around the time of finishing medical school, a little known economics professor at Harvard came up with a bright idea;the RUC.

    Who would ever think that this novel approach would get in the wrong hands and be used in a way that the economics professor never dreamed of? And who would have ever dreamed that the power behind this undermining of PC is the AMA?

    I don’t know about the rest of you, but I always thought the AMA was rather weak and unhelpful when I graduated. I never felt they were supporting physicians. Only to wake up and realize they are very responsible for engineering medicine in this very destructive 2 tiered system. The “specialists” vs. PC. We know the rest of this perverse story. On a side note, I always thought it was odd that they dropped offering health insurance to its own members.

    • NewMexicoRam

      It may have been different if primary care docs would have had dues half the amount that the specialists paid.
      But then, the idea wasn’t to keep primary care a part of the membership anyway.

      • Deceased MD

        These guys don’t play fair as you say. They don’t make their money on dues anyway, They have bigger fish to fry with industry. Physician’s dues wouldn’t cover all those lobbyists trips to Washington.I think they are about as patriotic to medicine as cyanide and apple pie.

    • buzzkillerjsmith

      I didn’t imagine it. Unintended consequences make life interesting though often in a way that’s not that great.

    • Suzi Q 38

      When were you in medical school?
      I agree. When I was visiting physician’s offices, there were so many GP’s, FP’s and IM’s.

      For reasons discussed they are no longer plentiful.

      I have to be really nice to mine, now.

      I don’t want to be the one that “pushes” him over the edge and helps make his decision to retire.

      • Deceased MD

        LOL! I don’t think you are going to make the guy retire. I graduated med schl around 1990. Things were already starting to go south by then but who would ever dream up this stuff some 20 odd years later?

  • futuredoc

    Thanks for the comments. As long as PCPs don’t have the time they need to listen, prevent, treat and just think becasue of the dysfunctional healthcare delivery and payment system that places them in a nonsustainable business model – then they will be frustrated, patients will be dissatisficed and the qulaity of care will be less than optimal.
    Stephen Schimpff MD

    • Suzi Q 38

      I agree.
      At least now I expect the changes. Before, I didn’t see it coming at all.
      Now, I make sure to follow-up on whatever results or care that I need.
      My doctor is so busy, that chances are, he forgot to order whatever test he said that he wanted to order.

      In years past I didn’t have to do that. Also, the doctor had more time to discuss my care with me.

    • Bob

      I don’t think most patients even think about their physicians having taken time finding ones who they trust and believe care for them not just treat them. I know I carefully select mine and will until I am no longer allowed to by the government. Then I’ll move somewhere else or visit a lot.

  • ninguem

    Sigh……

    Anyone who has actually worked in teaching hospitals knows the term “VIP syndrome” where someone well-connected gets “special treatment” with disastrous results.

    The “top doctor” can…..and often is…..someone who looks good on paper, and was very good at a particular aspect of medicine and surgery…..years ago. The “top doctor” has a reputation, but what you may well want is the senior fellow who did the operation…..or whatever…….half a dozen times last week.

    • Suzi Q 38

      Thanks for the information.
      What you say makes sense.

      I will definitely keep that in mind.

  • ninguem

    Here’s an example of the “VIP syndrome” in hospitals:

    http://www.youtube.com/watch?v=oftjwYmlfoA

    • Suzi Q 38

      I like your humor.

  • http://www.waynecaswell.com Wayne Caswell

    One thing that gives me hope is telehealth and the proposed Telehealth Enactment Act (http://www.mhealthtalk.com/2013/10/telehealth-enhancement-act/), which would allow practitioners to support Medicare patients across state lines.

    The PCP or specialist may be miles away, but patients can still see and talk with them remotely; and with a few medical sensors (blood pressure cuff, digital stethoscope, medical imaging attachment), they can have remote exams too. If they don’t have the skills or tools, a nurse or aid can come to their home or workplace to connect the care team in a video conference with the remote expert(s).

    As this trend continues, regulators must adapt and figure out how to handle licensing and oversight across state lines (or international borders). Traditional States Rights will be challenged as our world becomes increasingly mobile and connected and where we change jobs and careers every few years and move about to exploit new opportunities but still want to keep our PCP.