Senate Hearing Links Physician Payment Rates to Primary Care Shortage

Several witnesses testified before a Senate committee on Feb. 12th that our nation's health care system continues to undervalue primary care services, and that this is leading to a skewed physician payment structure that is rapidly creating a shortage of primary care physicians throughout the nation.

Amazingly, although he agrees with and understands the data, the governments spokesman on this issue reaches an illogical conclusion, however. "When I say primary care services are undervalued, that does not mean that just increasing the prices paid to primary care is the solution," said Bruce Steinwald, director of health care for the United States Government Accountability Office, or GAO, during testimony before the Senate Health Education, Labor and Pensions Committee. "As you are well aware, we face unsustainable trends in the Medicare program and in the health care system as a whole. And, just as payment incentives are misaligned in primary care, they are misaligned in specialty medicine as well."

Yes, that is all true, I guess, but retaining primary care physicians will involve paying them more!

Medicare operates under a fee-for-service system, which rewards doctors based on the volume of services they provide. Medicare is the prime example of "how the system undervalues primary care services," and this discourages medical school students from pursuing a career in the primary care field, and causesthose in practice to restrict who they will see and retire early. These payment disparities have been exacerbated by technological improvements that allow subspecialists to provide more procedure type services in a shorter period of time, which leads them to an increase in payments and income, making these specialities more attractive career options for medical school students. In contrast, primary care physicians rely primarily on face to face time during office visits for their income. This means their ony option to be "more efficient" is to reduce time with their patients, which leads to rushed care and compromised quality.

I agree with the director, when he said, "This undervaluing of primary care services appears to be counter productive given the vast literature describing the relationship between health care costs and quality".

Medical Home Accredidation Process Now in Place

The Patient Centered Medical Home is a medical practice that facilitates a partnership between individual patients, their personal physicians, and when appropriate, the patient’s family. Care is facilitated by information technology, health information exchange and other means to assure that patients get the indicated care at the time and in the way that they need and want it, in a culturally appropriate manner.

The concept of the personal Medical Home reflects input from the American College of Physicians (ACP), American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP) and the American Osteopathic Association (AOA).

Now the National Committee for Quality Assurance (NCQA) has released standards for patient-centered medical homes. This means that health care providers and purchasers now have a means to recognize these practices and assess the add value added to patient care.

At present, few physician offices in primary care specialties, would likely qualify for recognition as a patient-centered medical home under the new NCQA standards. In spite of this fact, however, there is ample evidence that the availability of primary care is crucial to quality health care outcome, and more efficient care. The irony is that primary care is rapidly disappearing from the health care scene, since it not not nurtured and properly paid for.

There is widespread agreement that primary care is in crisis. Medical students often do not choose to practice primary care medicine. Existing doctors are often overwhelmed and patients aren't satisfied. Insurers say they are disappointed with its cost and quality.

The Patient Centered Medical home provides a way to change the status quo by enabling physicians to provide comprehensive primary care through stronger partnerships with their patients. Those that choose to integrate elements of this new model into their practices now have a mechanism to prove this distinction to patients and insurers. In order for these enhanced services to be sustainable, however, this designation must be recognized and rewarded by payers.

I ask all insurers to quickly develop products that support this effort. The time is now. We do not need another set of expectations for primary care physicians that are unfunded.