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Primary Concerns

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Beneath the furor, misinformation and political partisanship surrounding our national healthcare debate, there lurks a threat greater than rising costs and perceived loss of rights: When you call to set an appointment with your “regular” doctor, will anybody answer the phone?

“The more family doctors we have, the lower our mortality rate.” —Dr. Marjorie BowmanLong ago, doctors stopped making house calls. Now, the general practitioner could be an endangered species. That may be especially true around these parts, where primary-care physicians cite a laundry list of career killers, including lower insurance payments and higher malpractice costs than in most other areas.

“It’s a perfect storm in Southeastern Pennsylvania,” says Dr. Lucy Hornstein, whose solo practice is based in Valley Forge, and whose blog “Musings of a Dinosaur” dispenses medical advice and sorely needed humor.

Bryn Mawr Hospital’s medical staff president doesn’t offer much reassurance, either. “There’s a brain drain in primary care out of the state and the city,” says Dr. John Hobson.

Hobson attributes the exodus largely to a “migration” from primary care to specialties and sub-specialties. “The average age of individual [primary-care] practitioners in the Main Line area is 55-plus. It should be 38,” he says.

The eye of Hornstein’s perfect storm for family doctors is their third-party reimbursement, which she says falls considerably below the rates paid elsewhere because “a couple of 800-pound gorillas dominate the market.”

Says Dr. Mitchell Kaminski, chairman of family medicine at Crozer-Chester Medical Center and a 2009 Top Doctor: “There’s an imbalance in the amounts of money put toward procedural things and how little, comparatively, is paid for comprehensive primary care.”

Apes and dinosaurs aside, the evolution of primary care (family medicine, general internal medicine and pediatrics) has been shaped by several trends not lost on the medical community or policymakers. The American Academy of Family Physicians estimates that its ranks must increase by more than 60 percent by 2020 to handle the spectrum of needs, including a burgeoning senior population. The American Medical Association forecasts a significant shortage of primary-care physicians in the decades to come if present conditions continue.

Shrinking inpatient work due to hospital or insurance restrictions further depresses income, say some PC doctors, while the sky-high cost of malpractice insurance premiums (Pennsylvania being one of the stiffest states) ratchets up expenses. It’s no wonder, then, that more and more newcomers opt for specialties, where the pay is more and the paperwork less.

“It’s harder to recruit primary-care physicians,” says Mark Schwartz, director of business development for Phoenixville Hospital. “Not as many are going into the field. It’s much more attractive to go into a specialty, with a year or two of extra training.”
 

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The cost of establishing a new primary-care practice is often prohibitive for medical school graduates, Schwartz adds. Typically saddled with considerable debt, new PC doctors then face a “mountain of paperwork” in their daily practice, says Dr. Madalyn Schaefgen, president of the Pennsylvania Academy of Family Physicians. “You have to hire a full-time person [to handle the paperwork].”

Pre-authorizations for X-rays and such, variations among HMO contracts, patients switching plans, and ever-changing prescription benefits are the sort of things that can tax even the most efficient back-office administrator.

“What medicines are approved or generic can change overnight,” says Dr. Marjorie Bowman, department chair of family medicine and community health at Penn Medicine. “We had one instance in which the insurer wouldn’t cover what was a $4 drug at Walmart.”

Schwartz sees family care as a high-stress environment. “It’s an intensive practice to run—you’re dealing with social [as well as medical] issues,” he says.

And many nurse practitioners and physician assistants who could reduce stress levels have been siphoned away by better-paying hospital residency programs, says Bowman. Other nurse practitioners and physician assistants staff mini-clinics, about which opinions differ. Hornstein, for one, has reservations. “Filling in gaps with NPs and PAs doesn’t work,” she says. “They don’t know what they don’t know, and actually order more tests and make more referrals to specialists.”

Regardless of technology and support services, many feel there is no substitute for the PC physician. “We know the patient and do a lot of prevention,” says Bowman. “The more family doctors we have, the lower our mortality rate.”

PAFP’s Schaefgen points to studies that show the U.S. adult mortality rate to be greater than some 40 other countries. “About 40 percent of our doctors nationwide are primary-care doctors,” she says, a figure that compares with 50-60 percent in most of the countries with lower mortality rates.

And proximity is a plus. “If primary-care doctors and specialists live in the same area as the hospital they serve, there is a greater possibility that the hospital will be in the top rank,” says Hobson.

So PC doctors are valued. But with the deck seemingly stacked against them, what’s the incentive to choose that career path?

“We like taking care of patients—that’s the gratification,” says Kaminski.

Bowman seconds that notion, saying the reward is in the human interaction, especially over time. “We can look back over, say, 10 years, and see what’s been accomplished.”

So how do you get more PC physicians practicing? Most agree that any solution must ease the financial burden for med-school grads and promote service in geographic areas of greatest need. A big part of that equation, they say, is the compensation gap. “The relative value scale [determined by the powers that be] should assess how much time goes into various types of service, and pay on that basis,” says Hornstein.
 

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The scale upon which insurers base payment is set by the likes of Medicare and the AMA, and may be adjusted by region. The disparity between specialists and PC physicians goes well beyond this area.

“The undervaluation of primary care is a nationwide phenomenon,” says Dr. Richard Snyder, senior vice president of health services at Independence Blue Cross. “The gap was not so wide years ago, when technology wasn’t so prominent. Techniques and technology are valued higher. But the long-term solution is not to continue what we’ve been doing—all payers recognize that.”

Creative strategies for improving primary care’s financial health are increasing. Capitation programs offered by HMOs offer a measure of stability by paying a monthly fee for every patient assigned to a practice, but quality time may be shortchanged. Now Blue Cross has instituted a pay-for-performance program that rewards high-quality care and accessible service. Known as the Patient-Centered Medical Home, the pilot program joined 220,000 patients with 32 primary-care practices in a bid to boost prevention, improve the treatment of chronic disease, and reduce emergency-room visits and hospital admissions. After the first year, the program reported substantially more patients controlling conditions like diabetes, high cholesterol and high blood pressure.

The Medical Home model utilizes a case manager or health educator in the doctor’s office, electronic records, and frequent doctor-patient communications to better care for patients and encourage them to “take charge of their conditions,” says Snyder, who believes that such efforts signal “better times ahead for family physicians.”

A Medical Home proponent, Crozer-Chester’s Kaminski says the investment in training an assistant to perform necessary tests can pay dividends in the form of improved patient care, better compensation for the practice, and savings for the healthcare system. “If patients consider the office their medical home,” he says, “they’ll go there instead of the emergency room.”

And while a majority of PC doctors still don’t have it, electronic recordkeeping is now essential, says Kaminski. It’s an investment that pays off long-term.

But investment dollars are in short supply these days, especially for medical school grads and those in private practice. PC doctors are sampling additional strategies for the 21st century. Hornstein has considered divesting herself of health insurance contracts—going “off the grid,” she calls it.

Hobson sees some doctors gravitating to a concierge-style practice that forms a roster of patients who pay an annual fee and can see the doctor on a walk-in basis. “You get paid upfront, and have less paperwork and more time with patients,” he says.

Most physicians and analysts agree that, if the conundrum is to be solved, patient expectations must change. “Americans don’t like to be told what to do,” says Hornstein. “They’ll say, ‘I should see a cardiologist.’ Some people come in right before their insurance expires [due to a job layoff or other factors] and say they want to get their money’s worth. That’s how insurance gets expensive.”

“We have to get people to stop automatically referring themselves to a specialist—change the mentality of ‘I can get anything I want when I want it,’” says the Pennsylvania Academy’s Schaefgen. “We do have the best technology, but people must understand that dollars are limited. We have the potential to deliver the best care.”

But, somehow, it often doesn’t get there.
 

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