Balancing the physician work force: It takes more than money

Here we go again. There is yet another round of evidence of how the physician workforce hole we’ve dug for ourselves keeps getting deeper, but there has been still no substantive payment reform on the government side (Medicare/Medicaid) or the private payer side.

One recent study appeared in Academic Medicine. Clese Erikson and colleagues surveyed a random sample of 4th-year medical students in 2010. Only 13% of the students stated they were very likely to become primary care physicians. The way the researchers framed the question was important. Spin doctoring by the medical schools over the years has led politicians to believe that about half of medical students choose primary care fields. The schools include internal medicine residents, of whom over 90% do not provide ambulatory primary care; and pediatric residents, of whom over half do not provide ambulatory primary care when they finish their training. I’ve even seen some medical school primary care reports in the past that included general surgeons and ER docs. Compare this 13% number to the fact that other developed countries have nearly 50% in primary care (the U.S. is at about 30% now).

Another study measured how much Medicare pays for cognitive services (thinking, like primary care) vs. procedural services. It measured the payment per hour of actual work for two common procedures — colonoscopy and cataract extraction — and compared them to a common primary care outpatient code. Previous studies have found a difference of up to 12 times with this comparison. These authors made an extra effort to identify all of the time required to do the procedures, such as obtaining consent and explaining the findings of the procedure to patients and family members. The authors concluded that these two procedures still paid between 368% and 486% more than primary care at Medicare rates. It is safe to assume that this ratio is even worse in the private sector.

No, money is not the complete solution to balance the U.S. physician workforce. However (and I’m not making this up), when I worked with administrators at CMS (Center for Medicare and Medicaid Services) during my innovation advisor year, a high-placed official actually and seriously asked me, “Do you think if primary care physicians were paid more that more medical students would choose primary care?”  It took all of my limited self-control to not laugh, scream, or cry.

Other pieces of the solution to get more medical students into family medicine are concepts such as respect, encouragement in medical schools, and a new NIH family medicine research institute. (There is no NIH institute or large foundation funding for primary care research, but there is for nursing, social work, alternative medicine, aging, etc.). Proper payment will go a long way to addressing these issues as well. Even if the medical school culture could be changed first (which it won’t, by the way), students aren’t stupid. They can peer into the future, which is why programs such as primary care loan repayment schemes make a small difference in moving the medical student choice dial.

The fundamental reason there is such a huge income disparity between primary care and the -ologists is the CMS fee schedule and documentation, coding, and billing rules. Over 90% of private insurers use ratios of the schedule, so the impact of CMS goes well beyond Medicare and Medicaid.

There was a 10% tweak in the Obamacare law to raise primary care pay. It only lasts for two years and was implemented very slowly. Compare this number with the ratios I just mentioned and the fact that some -ologists easily make three times more than primary care physicians on average. Only the most committed students would choose primary care, and its not enough for the needs of the country.

One gets what one pays for. In the U.S., we value -ologist high-tech procedures and open access to ERs, so we are left to enjoy worse health at a higher cost than the rest of the developed world.

Richard Young is a physician who blogs at American Health Scare.

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  • southerndoc1

    The title is a complete misrepresentation of the point of the article.

  • Thomas D Guastavino

    Is it possible for you to make your point without demeaning the “ologists”?

    • PCPMD

      What did you find demeaning about how proceduralists were depicted in this article?

      • Thomas D Guastavino

        “We value -OLOGIST HIGH TECH PROCEDURES and open access to ERs, so we are left to enjoy WORSE HEALTH at a HIGHER COST than the rest of the developed world”

        • PCPMD

          Umm…isn’t this basically the truth? Every major study on the topic has shown that an over-reliance on procedural and specialty care results in higher costs and poorer outcomes. Additionally, it starves the healthcare system of resources (both in dollars and man-power) to support an adequate primary care foundation, which studies show results in better outcomes at lower costs.

          So what about this do you find demeaning?

          • Thomas D Guastavino

            Would you please define “over-reliance” for me?

          • guest

            When articles like this appear in the New York Times, “over-reliance” is probably a problem. I personally would think that the specialists would want to do something about it, rather than attempt to deny that a problem exists.

            http://www.nytimes.com/2014/01/19/health/patients-costs-skyrocket-specialists-incomes-soar.html?src=me

          • Thomas D Guastavino

            Was exactly is it that you expect specialists to do about this “problem”

          • guest

            I think specialists should do a better job of advocating for their colleagues in primary care. The mentality of “we have our CPT reimbursement schedules the way we like them, what do we care how the PCPs are doing,” is going to end up backfiring big time on everyone in the medical profession.

          • guest

            I am personally not a PCP, but in looking at the system both from the standpoint of a patient as well as a physician, I see how it is not working out well for patients. If my PCP got more money to spend more time with me and think about my care, I might get referred to fewer specialists, and my care would be better coordinated and most likely higher quality. No one is “insisting” that higher reimbursement for PCPs come out of specialists’ pockets. That’s your own construct. But it’s really not arguable that there are no specialists out there actively advocating for more equitable pay for PCPs.

          • Thomas D Guastavino

            So…. you believe that as a patient you would be better off if your PCP were paid more so they would hold on to you longer and “think” about your care rather then refer to a specialist ??

          • guest

            Why yes, as a physician and a patient I do happen to believe that. I believe that there’s a fair amount of evidence to support that view, too.

            And may I ask why you put “think” in quotation marks? You do realize that that’s what we are supposed to be paid to do, right? Even those of us who do procedures? There is an expectation that some “thinking:” be involved in providing medical care.

          • Thomas D Guastavino

            You are implying that they are not “thinking” now because they are not paid enough. What about a direct pay PCP? As a patient you would get the PCPs time and they would get the pay. As a specialist I have to say that I am a little jealous because there is very little opportunity for us to set up a direct pay model.
            Anyway, I digress. The point I am trying to make is that PCPs and specialists should be on the same side. Our problems are not with each other but with the government, insurers, and the trial bar that are happy to see us to fight over a shrinking pie.

          • southerndoc1

            “The point I am trying to make is that PCPs and specialists should be on the same side.”

            Um, where were the specialists during the past thirty years when the PCPs didn’t get even get a slice of the pie, but the left-over crumbs? And now it is a zero-sum game, unfortunately. Don’t count on me to sing Kumbaya

          • Thomas D Guastavino

            OK, I give up. Good luck guys, I think we are all going to need it.

          • guest

            I agree with you on that last point, but what I see is that specialists have put themselves on the opposite side from PCPs by going along (however passively) with a corrupt RUC and inequitable compensation structures. It is up to the specialists to put themselves on the side where the PCPs are, by advocating for them.

            The fact that specialists have failed to do this, has resulted in PCPs feeling that they have no choice but to start speaking out, since their attempts to rely on professional solidarity have left them very much at a disadvantage.

            Again, I am not a PCP, but this is what I see going on in the present system. Rather than the specialists at this point try to continue to cite professional solidarity as a reason for the PCPs to continue to put up and shut up, if our profession is going to survive, the specialists need to stand up for what is right for their PCP colleagues.

          • Bob

            I think you are paid to little too, but you are the one who signs on to contracts knowing this, right.
            Are you taking new entitlement patients? Are you waiting for exchanges to tell you if you can take new patients? If so you worked your way into a bind but there are many ways out of it;, just think of your 4 options: Work for a hospital, government, yourself or change what your doing like maybe becoming the specialist you always wanted to be and take less patients at higher rates!

          • guest

            Actually I myself happen to be a specialist who is employed by a government hospital, so I am not speaking out of any personal feelings about my own professional situation.

            I am speaking out more out of concern about the fact that at the rate things are going for PCPs, there won’t be any good ones left to take care of me and my family when we need one.

          • Bob

            PCP’s do one thing and one thing only: they review the health of their patients and write 3 things: Rx’s, tests and referrals, from which the patient improves great, and if not the problem is isolated and referred to a specialists in the located problem area, who has more experience and knowledge.
            The number of physicians of all sorts, did not increases on New Years Day, while indications are that 20 to 40 million more citizens will be added to Medicaid rolls and for the next year 4 million citizens will become 65 years old increasing Medicare rolls, including a certain percentage of physicians, nurses and other providers, and many more who will retire at 62 on social Security finding working for and under government dictates doesn’t work anymore.
            Money is the least important factor, and if it is that important perhaps someone should go after $1.2 trillion in waste that has been reported, in our $3 trillion healthcare costs!

          • Doug

            “PCP’s do one thing and one thing only.”

            I’m already thinking “Careful…”

            “…they review the health of their patients and write 3 things…”

            Okay, well that’s a sum of four things. First statement already wrong. But please continue.

            “Rxs, tests, and referrals…”

            Can’t. I cannot abide that. Primary Care Providers do administer prescriptions, tests and referrals. They also TREAT themselves with physical maneuvers – but I assume you’re leaving DOs out of this? – and do plenty of procedures themselves. They act as counselors, healthcare navigators, patient advocates, preventative medicine experts, public and population health interpreters. They are far more than I’d care to drag this paragraph on to list. Specialists are important. Nobody thinks they’re not. But I can’t just watch primary care get dumped on as “doing one thing.”

          • Bob

            So sorry Doug, but all the ones I ever saw always did just one thing reviewed my health.
            In doing this they did do what you refer to as Physical maneuvers if you call taking my BP pulse and vital signs, which they stopped doing decades ago as nurses do that now. And they tap on my chest and listen to my heart with a statoscope, and do various other things that they note in my records next to what they noted the last visit, which didn’t change much over 70 years and hasn’t done much for me. If by administering prescriptions you mean giving shots, you’d be right; but never has any of them done a culture before that which, as you know, determines if the problem is curable by an antibiotic and what the drug of choice is, and in doing this has made most of the antibiotics ineffective. Never got any drug prescribed unless you call samples prescriptions, but I know some docs do dispense if they follow pharmacy rules.
            I, in no way mean to demean what PCPs do, nor detract from the process, but it’s clear that they don’t stay long as PCPs in general as they too want to make more, except for chiropractors and DO’s which I know are PCP’s too, but I don’t think they can specialize without a MD license.
            Most people don’t know what a DO is and how they differ from MD’s, NP’s and PA’s, and I’m thinking your a DO from what you write, so tell us how you all are different?

          • Doug

            Physical maneuvers doesn’t mean just taking your vitals. I was thinking more along the lines of OMT when I wrote that – that’s osteopathic manipulative therapy – but DO and MD PCPs alike reduce dislocations and set manageable fractures, they do skin biopsies, cryotherapy, I&Ds, colposcopy, IUD insertion and removal, implanon management, some even get into colonoscopy and EGD. Again, I’m leaving a lot out. By administering prescriptions I don’t mean giving shots, which they do. They take cultures – yes, sometimes for definitive identification of the presence of a bacteria and to obtain sensitivity data on said bacteria. But some antibiotic therapy is empiric – recommended by guidelines given a clinician’s judgment, while cultures grow (they’re not instant, not even in a hospital). And PCPs prescribe drugs frequently, and yes samples are occasionally included in that. But PCPs aren’t alone in sample provision.

            But as to your knowledge of DOs, coupled with the rest it makes me want to ask with all seriousness and respect if you’re writing from outside the United States? MD and DO primary care docs don’t transition out to make more. They stay. And a recent Medscape survey shows that Family Medicine docs have the 2nd highest work satisfaction right behind dermatologists.

            As for the DO difference, I could write forever. So to be brief now I refer you to the information the AOA has (http://www.osteopathic.org/osteopathic-health/about-dos/about-osteopathic-medicine/Pages/default.aspx) but also to this clever little buzzfeed that isn’t completely how I’d like it but a good quick read (http://www.buzzfeed.com/ninjacowboy/osteopathic-medicine-does-exist-irad). DOs learn the body of medicine like MDs, but we get extra training on top for manipulative therapy and house all of this in a philosophy to treat the patient – the whole patient. They are doctors of medicine – not nurses, not physician assistants. OMT is not chiropractic, although a portion of things they do is similar. They can go to any residency, become any specialty, and don’t need a special license to specialize – particularly, that of getting an MD on top of the DO. I can provide more, but I’ll hold off for now.

            What I would encourage of you, Bob, is to explore a world where primary care does what it can for you. I can only speak to it in the US as I train to become a Family Medicine doc, and yes I am a DO, but we do so much. And it’s a varied field – it allows each to practice to their ability and interests. But you should experience the richness of what a caring and true PCP can do. And I also hope you can see a DO as well – not to elevate DO above MD or vice versa, but to experience OMT and to see for yourself which school’s way of doing things better suits your preferences as a patient.

          • Bob

            You’d be wrong in believing I was never treated by a OD, the VA has lots of them, but I never had any do what you describe. Vets don’t care as long as they are seen and treated, but MD’s run the show.

            I have been treated and seen others treated by many different caregivers and don’t find much difference until you locate the problem and then only a specialist can “drill down” and treat the problem in a focused manner, which has me and others having known medical conditions paying more going directly to the specialists we have found needed hardly ever needing PCP’s and now being switched to PA’s and NP’s in the specialists offices with ACA.

            I having been in healthcare for many years and have known the “friction’ that exists between MD’s and OD’s mainly as it surrounds hospital admitting privileges and while with RI Hospital knew a OD hospital was just down the street. Until you drew my attention to it, I didn’t know OD’s make up 7% of the docs in the U.S. where I have always lived and upon looking find 60 countries have OD too.

            There must be a reason that you are becoming a MD, as it seems ODs can indeed specialize. I think you’re wise however since from what I read since your post, I can’t see how any OD can provide care to any patient within 15 minutes, which also would cut out Chiropractors, who similarly use manipulations in their practices, and I’m thinking CMS has overlooked, essentially cutting off 7% of caregivers.
            Thanks for bring this to my attention Doug.,
            Best to you in your practice.

        • rpachigo

          sounds like he’s jealous. You can sense his seething between the lines. Very unhealthy especially for your BP like the earlier article referenced.

  • buzzkillersmith

    Mostly a pretty good post but the author brings out the old story about respect, encouragement, and NIH research thing. These are of minimal importance.

    It’s the work/money tradeoff. Full stop. If med students don’t get that worked out to their satisfaction, the cause is hopeless.

    I actually do think it is hopeless and that physicians will hand-off primary care to nurses and PAs almost completely, if enough of them can be found to take it.

  • adh1729

    Act I: pay primary care docs poorly
    Act II: now there is a shortage of primary care docs
    Act III: make up the shortage with mid-levels
    Conclusion: $$ saved, and the primary doc is abolished. The government wins.
    See how wonderful Medicare was? Only the far-right radical prophets knew in 1962 that the government was merely taking over the medical profession, and had no genuine love for the elderly. (Remember how Reagan had to face his previous opposition to Medicare, in the 1980 and 1984 elections?)

    • guest

      Except…money is not saved, because once the mid-levels are securely established, they begin to advocate for pay parity with physicians. So in the end, no savings are accomplished, the only change is that care has been watered down.

      • Guest

        And to further the fallacy of the original statement, the mid-level providers – more hastily trained and less equipped AND less incentivized to focus on metrics of value (quality / cost) – order more unnecessary testing leading to less $$ saved in the long run. It’s nothing against PAs, NPs, etcetera in terms of their intellect – it’s a sheer lack of training quantity. It’s patient hours, and educational oversight. Schools are businesses, they see a demand for these professionals because of where healthcare is going, and the school that promises students the shortest time to the finish line wins the tuition dollars. So train ‘em quick, and check the necessary boxes. You can’t fake the “10,000 hour rule.”

        It’s a story as old as time – pay me now or pay me later, but the lunch ain’t free and it never will be.

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