HHS secretary nominee says primary care docs need a raise

James Arvantes at AAFP News Now reports:

Kansas Gov. Kathleen Sebelius told a Senate committee last week that if confirmed as secretary of  [Health and Human Services], she would work to change Medicare’s payment policies to increase the number of primary care physicians.

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Sebelius, who testified before the Senate Health, Education, Labor and Pensions, or HELP, Committee, here on March 31 as part of her confirmation process, called for “refocusing the payment incentives so that primary care becomes a much more lucrative profession.” There are relatively few health care professionals in preventive medicine compared with the number of subspecialists, said Sebelius, adding “if we focus on prevention and wellness, we will not need as many (sub)specialists.”

While it’s nice to hear someone (potentially) in a position of authority in health care singing the praises of primary care, it may be premature to pop open the champagne.

For starters, it would be encouraging to hear her say that decreasing the burdens of paperwork, malpractice insurance, and third party-payor interference in health care decisions is critical to rejuvenating primary care.  While increasing Medicare payments to PCPs is nice, the fact is that Medicare has an unfunded liability as of 2008 of $36.3 trillion (as tabulated using a 75 year horizon) or $85.9 trillion (using an infinite horizon).  At some point we have to make it less expensiveto practice medicine and not simply make it more “lucrative.”  The payment structure for physicians in general, and primary care physicians in particular, needs to reduce inefficiency, not simply accommodate it.

As far as Medicare being the driving force in any plan to increase primary care physician pay, no one should ignore what has happened at the various banks and private (or once-private) companies that accepted government bailout money.  Their “rescue” by the government turned out to be more of a Faustian bargain.  Don’t think for a minute that government largess will come without strings attached.  Some of those strings are attached already.

Another problem is that Governor Sebelius appears to have drunk the preventive medicine Kool Aid.  While preventive medicine has its place, it is a rather mixed bag with regard to cost effectiveness.  The primary care community should use extreme caution with trying to marry the ideas of primary care, preventive medicine, and lower health care costs in the minds of either the public or politicians.  Primary care and cost effectiveness are often found together; preventive medicine is not always (and probably not usually) the mechanism by which the former leads to the latter.

It’s good news that America seems to be slowly waking up to the fact that primary care has tremendous value and that as a result of allowing it to deteriorate for a generation we have a health care system that is now falling to pieces.  But the primary care community’s response to this should not be one of mindless elation that at last we are being recognized for how valuable our profession is.  Primary care has a long road to travel to get back to the forefront of American medicine.  The journey seems to be getting underway, but there are many obstacles to overcome and pitfalls to avoid. 

Will the Patient-Centered Medical Home save primary care?

Jaan Sidorov at the Disease Management Care Blog isn’t convinced:

There are no surveys of what rank and file community-based primary care physicians actually think about the medical home. We don’t know how well it will address the physicians’ lifestyle concerns or their income expectations.

And just what is it about the medical home that will fix these problems? Just because there is a medical home doesn’t mean high cost radiology services will not continue to come under preauthorization, that drug formularies will not put continue to put certain medications out of reach, that restrictive physician networks won’t be used or that managed care organizations won’t continue to bluntly prod physicians to achieve HEDIS benchmarks. Keeping patients away from the emergency room or the hospital requires a zealous amount of hustle that goes well beyond the 8-5 business day.

The DMCB suspects the support of the rank and file physicians for the medical home is being overestimated.

I tend to agree.  From what I’ve read about the medical home concept, once the jargon is stripped away it sounds suspiciously like what primary care doctors are already doing or at least trying to do.  If we want everyone to have a “medical home,” we’re going to have to stop paying family and internal medicine docs so little money for the considerable amount of time and effort they put into their jobs.

I suspect that is what will eventually happen, although I am a doubtful that the medical home model will be the catalyst.  A more likely incentive for the industry to finally recognize the value of primary care will be the massive influx over the next several years of Baby Boomers into Medicare.  Guess what, folks?  There isn’t going to be a correspondingly massive influx of medical students into primary care.  In fact, there is going to be an exodus of primary care physicians as they retire or cut back on the number of patients they see.  And those of us who remain will not all be accepting Medicare.  And when the tipping point is reached and the health care system finally cries “Uncle!” and agrees to start properly reimbursing primary care docs, there isn’t going to be some vast repository of FP and IM docs who have been sitting around waiting to be called up.  It’ll take quite a number of years to “re-primary care doctorize” American medicine.