Getting back to basics: reform care at the doctor-patient level

For all of the talk about transformational health care reform, one of the most important changes that may occur with President Barack Obama and Congress is a return to basics, a recognition that the relationship between patients and their primary care doctor is the basis of all good medical care.

During his campaign, Mr. Obama observed that “Primary care providers and public health practitioners have and will continue to lead efforts to protect and promote the nation's health. Yet, the numbers of both are dwindling.” His concern is right on the mark.

Studies project a growing shortage of 45,000 or more primary care physicians. This can be attributed to increased demand for primary care associated with an aging population with more chronic illnesses, a sharp downturn in the number of young physicians choosing primary care, and an increase in established primary care physicians that are leaving practice. The Journal of the American Medical Association reports that only 2% of fourth-year medical students plan to practice in primary care internal medicine.

Mr. Obama's recognition of the critical importance of primary care is shared by key lawmakers. In November, Sen. Max Baucus (D-MT), chair of the Senate Finance Committee, released a white paper with his vision of health care reform. He calls primary care the “keystone of a high performing health care system.”

But what will the Obama administration and Congress do? Mr. Baucus proposes several specific ideas to strengthen primary care:

• Reduce payments for overvalued services in the Medicare physician fee schedule and redistribute them to increase payments for undervalued primary care services;
• Increase Medicare payments for evaluation and management services furnished by primary care practitioners;
• Expand Medicare's testing of the Patient-Centered Medical Home to include more practices that demonstrate that patients receive the primary care and care management services that the medical home is designed to deliver; and
• Replace Medicare's sustainable growth rate formula with multiple expenditure targets. Mr. Baucus says this would reallocate resources from high-growth, potentially overpaid aspects of health care to underused, potentially more valuable services such as primary care and prevention.

Other influential lawmakers are considering similar ideas. The Obama administration had not yet released its specific plans at press time, although there is reason to believe, based on the new President's campaign statements, that primary care will be a priority for his administration.

Who will pay?

There is a catch, though, with the proposals to increase payments to primary care physicians. Mr. Baucus' proposal would be budget neutral within total physician payments. Any increase to primary care providers requires a corresponding cut to specialist services. Such redistribution could create significant controversy among physicians.

Every effort over the past 20 years to increase payments for primary care has created enormous controversy within medicine. The American College of Surgeons already opposes efforts to fund primary care by reducing specialty payments.

Even within internal medicine, a budget neutral increase in payments to primary care is controversial, because it would help general internal medicine at the expense of internal medicine subspecialists.

Funding primary care

One way to reduce the opposition within medicine would be to persuade Mr. Obama and Congress that primary care needs more funding. On Dec. 17, ACP sent a letter to Sen. Tom Daschle, the Secretary of Health and Human Services, urging that higher payments for primary care be funded out of the President's economic stimulus plan. We recommended that all primary care physicians receive a 10% Medicare payment bonus for all of their services for the next 18 months, as a first step to broader payment reform.

The letter makes the case that primary care deserves dedicated funding out of the stimulus package based on the evidence, summarized in a new ACP comprehensive literature review, , which shows that primary care consistently is associated with better outcomes and lower costs of care.

ACP also pointed out that without funding to stabilize primary care practices many will close. Small practices struggle to survive because of inadequate access to credit, losses on their own investments, slower collections and more bad debt, and uncompensated care as their patients are unable to pay their bills and the numbers of uninsured increase.

The loss of even one primary care practice in a community puts thousands of patients in the impossible situation of trying to find a new primary care physician, when most of the surviving primary care practices already are at full capacity and unable to take on any new patients.

Finding the dollars will be controversial, but one way or another, primary care needs more money in order to survive. It just doesn't get any more basic than that.