A new buzz around primary care

I recently described the loathsome “relative value unit” (RVU) and its role in the decline in prestige and pay in primary care.  The RVU is maintained and updated by a small panel of 31 physicians called the Specialty Society Relative Value Scale Update Committee (RUC).  Twenty-seven of the 31 physicians are specialists, which is not at all representative of the physician workforce, given that primary care doctors comprise over one third of it.

Yet this small group wields enormous power by updating the relative value of each physician’s work. Their opinions inform Medicare’s payment schedules, which subsequently influence those of nearly all private insurers. Since specialists largely fill the panel, it is not surprising that, on average, procedures that specialists perform have higher relative value than the work primary care physicians do.  It is equally unsurprising that, over the same 25-year period that this RVU system has been in place, we have also seen a marked decline in the number of physicians choosing to do primary care.

Many reformers have questioned the rationality of the current system. Princeton University economist Uwe Reinhardt wrote, “Surely there is something absurd, when a nation pays a primary care physician poorly relative to other specialists and then wrings its hands over a shortage of primary care physicians.”  However, those who attempt to reform the RUC have consistently been met with the resistance of strongly entrenched interests. After all, there is $60 billion in Medicare money on the line and billions more in private insurance payments at stake. It does not seem that it will be easy to change the composition of the RUC anytime soon.

Fortunately for patients and primary care doctors, we do not have to wait for the RUC to change in order to change the way that physicians are paid. One of the less talked about elements of the Affordable Care Act is how it will likely lead to massive changes in the ways insurance companies and hospitals make money.   Dr. Ezekiel Emmanuel, one of the chief architects of Obamacare, recently penned an article called “Insurance Companies as We Know Them Are About to Die (And here’s what’s going to replace them).” In it he writes that in the future hospitals will no longer receive money from insurance companies for procedures their physicians perform. Instead, hospitals will form accountable care organizations (ACOs), and act as both insurance company and hospital: much like Kaiser Permanente does today. Patients will sign up for an ACO on the health care exchange, and they will only see doctors and go to hospitals in the ACO network.  While this may have a similar ring to the unpopular HMOs of the 1990s, there are many differences, most notably that the quality of care patients receive can be measured through now-ubiquitous electronic medical records.

Once this happens, hospitals no longer have the financial incentive to simply perform more procedures in order to make money.  Instead, since the payer and hospital are part of the same organization, profit is driven by performing only those procedures that are required to keep the patient healthy. Obviously, keeping patients healthy and preventing illness has always been the main purview of primary care physicians. Therefore, in ACOs, the relative value of a primary care physician will be quite high.  Patients who are kept healthy with high-quality primary care, and who require fewer ED visits, procedures, and hospitalizations will form the main revenue base for ACOs.  And because most physicians in the ACO are salaried, the RUC panel, whose recommendations are based on the old fee-for-service payment system, may not have much impact on how much ACOs decide to pay their doctors.

The future is not far off.  Hospitals are already forming ACOs and buying up primary care practices. Insurance companies are already buying ACOs.  More physicians are working for salaries and primary care salaries are on the rise.

What does all of this have to do with medical students and their increasing interest in primary care?  If you ask most medical students about the details of ICD-10 codes, RVUs, or DRGs and how these changing codes will affect their future salaries, they will look at you as if you are speaking a foreign language.  However, if you ask medical students how the Affordable Care Act will change medicine, you will hear many informed opinions. Many medical students see that there is a surging demand for primary care physicians. They see new scholarships and loan forgiveness programs for primary care doctors. They see that while primary care physician pay is not soaring, it is starting to rise steadily. And they see that while health care is in a state of great flux, the changes that are happening are elevating the status of primary care doctors in order to keep patients healthy and prevent illness.

Perhaps it is too glib to say that medical students are simply starting to look at primary care because of money and prestige. Of course, there are a multitude of factors that an individual medical student considers when she picks her specialty — a great mentor, a significant life experience, a relative with a particular disease, a special academic interest. However, when looking over a panel of medical students, there is no doubt that there is a new buzz around primary care. Payment systems are changing to the benefit of primary care; our breadth of practice is broadening; and there are burgeoning opportunities for primary care doctors to become leaders in medicine.  These are all great reasons for medical students to think that primary care is cool — again.

Anoop Raman is a family medicine resident who blogs at Primary Care Progress.

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  • Patient Kit

    It is fascinating how differently med students and seasoned practicing primary care docs see the future of primary care in this country. Even on the prestige issue alone, one group sees it on the rise while the other group predicts it’s complete demise.

    • buzzkillerjsmith

      Medical students don’t know jack about medical practice. You heard it here first.

      • Patient Kit

        I knew you’d show up once you saw your name in the title, although I still think your real name is Dr House. ;-) I try to remember that med students are the same age as kids who voluntarily sign up in the military to go off to war without really understanding what the war they are putting their lives on the line for is about.

        • buzzkillerjsmith

          Of course I’d show up after seeing my name here. What sort of megalomaniac would I be if I didn’t?

          That’s right. Med students are young. But they are very smart and they learn quickly.

          • Patient Kit

            There’s book smart and street smart. And it’s possible to be very smart and clueless at the same time. But seriously, I do know that you have to be very smart to get into med school. I’m in awe of what it takes to be a doc. And some speak five languages on top of everything else. Awe.

          • buzzkillerjsmith

            Don’t be awed. We put our pants on one leg at a time, just like everyone else. But when our pants are on, we’re doin’ weird stuff to people!

          • Patient Kit

            Sorry. Even though I absolutely know that docs are human and real and flawed and vulnerable like the rest of us, I remain awed by some docs. Not all docs, of course. But when a doc has the whole package: intelligence, knowledge, skill, talent, compassion, empathy, humility, great communication skills, I am awed –because they are awesome. I especially like docs who have interesting interests outside of medicine. But I do realize that many docs aren’t awesome. ;-)

  • Dr. Drake Ramoray

    Primary care may very well be valued but the primary care Doctor will be replaced by a PA/NP

    • guest

      But of course, they have MBAs and have never really practiced medicine, probably didn’t pay too much attention in med school and residency since they knew they wouldn’t practice, so exactly how are they qualified to “manage” mid-levels? Oh right, they have MBAs….

  • buzzkillerjsmith

    I went back to the Bay Area to visit last week and had a long conversation with a doc I used to work with at Kaiser. He hates it but has been in too long to quit and is too young to retire. He stated repeatedly that going into family medicine was the biggest mistake of his life.

    He said that Kaiser is run by and for the subspecialists and that PCPs (and hospitalists) are treated like dirt. No one listens, no one cares, the system is run by admin types who might have MDs but who are now suits. Dictums come from on high–zero autonomy. Cogs in the machine.

    And Dr. R. thinks this will appeal to young primary care docs. Maybe it will, but not for long.

    • guest

      It will probably appeal to the type of med school graduate who wasn’t really that interested in practicing medicine in the first place.

      • Patient Kit

        I’m amazed that people who were never really interested in practicing medicine actually go through med school! That seems kinda insane to me. Do they go through residency too or just med school?

        • guest

          I saw my fair share of med students shoved into med school by parents with high expectations. Those types go through everything and end up to be fairly depressed, though financially successful, physicians.

          • buzzkillerjsmith

            Fairly depressed. Yep. It is a typical pattern for a Kaiserdoc to bring up the good retirement benefits within 15-30 minutes of starting any conversation.

            Take 30 years, burn them, and then retire. I shake my head.

          • Patient Kit

            That sounds kinda like being trapped in a bad job just to keep the health insurance that comes with it, which is why I would love to see universal healthcare in this country provide access to healthcare for all, disconnected from employers.

          • buzzkillerjsmith

            It is exactly like that, except that retirement benefits take the place of health insurance for the Kaiserdocs.

          • Patient Kit

            Do Kaiserdocs also get good health insurance? I hope they do.

        • buzzkillerjsmith

          Medical school without residency is like a morning without Florida orange juice.

          Why do they do it? $

          • Patient Kit

            So, then you’re saying that some doctors do go into medicine purely for the money they can make with that degree? Good to know. I wonder how many of them do a residency at that point as long as they’ve already gone so far as to graduate from med school? Now you have me wondering how many practicing doctors are in it mainly for the money. I hope it’s a minority. Either way, whether they are practicing medicine themselves or managing practicing docs from their big business perches in Corp Med, MDs who are in it purely for the money are a huge problem for patients (and for docs who aren’t in it just for the money). We need a system in which there is no incentive to become a doctor just for the money.

          • buzzkillerjsmith

            You have to do a residency or at least the first year of it to practice. I guess some go corporate as soon as graduation but I think that would be a pretty small number. Corporations know that recently graduated MDs know very little–or at least they should know. Better to do a cardiology fellowship, work in clinical medicine for a while, and then go corporate.

            The “no incentive” option would not work. People aren’t going to put up with this grief unless the money is reasonable.

            Wall Street. I’m sure there are a lot of smart young folks in finance who would have gone into medicine in the old days.

            Depressing? Losing out on a win again Portugal in the last seconds–now that’s depressing.

          • Patient Kit

            To be clear, I do believe that docs should be well paid for the important work they do. I just hate the idea of people becoming doctors mainly for the money.

            I was still on the beach after a good ocean swim when I heard the screaming and cheering coming from a nearby Russian restaurant when USA scored and went ahead 2-1. Russia had already lost their match earlier today. The ending of the USA-Portugal match was a heartbreaker. I’m rooting for Mexico but I’m rooting for USA too.

      • buzzkillerjsmith

        Well, maybe. But I suspect the lucrative subspecialties are more attractive to those types.

  • southerndoc1

    If you ignore that constant buzz you’re hearing, you’d realize that the number of med students actually choosing primary care residencies is pretty much flat. If you subtract those (particularly in IM and peds) who will sub-specialize or become hospitalists or businessmen/administrators, the number going into clinical practice is probably declining significantly (though the residency programs won’t release those figures).

  • Joe

    Meet the new buzz. The same as the old buzz. As in, worthless. Here’s an absurdity for you. Right now, we are paid to treat sick people. In the wonderland of ACOs, we are paid not to treat sick people.

  • Patient Kit

    I understand your frustration with Kaiser’s “use you up and spit you out” corporate strategy for use of employees because many of us in other fields outside of medicine have been experiencing that kind of corporate exploitation for years. And I understand your anger about the pay difference between primary care docs and specialists and what that says about how your employer values — or devalues — you.

    But how is it that specialists at Kaiser do nothing? I find that hard to believe.

  • joseph badolato

    Sure, primary care is in high demand and more residents are choosing primary care–it’s just that 54% of those who do choose primary care residencies are foreign medical graduates (compared to just 20% of FMG who choose surgical specialties). Putting aside the cultural issues that come from having a soon-to-be majority crop of foreign-trained docs, this sad statistic tells me that primary care is still not “prestigious” enough for our home-grown docs. Sad commentary.

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