A recent Health Care Blog Post explains the looming crisis in primary care. Some background: great health care systems are anchored by primary care physicians (PCPs), the generalist doctor whom your family depends upon for standard medical care. The PCP must have a workable basic knowledge of nearly all medical specialties and be able to diagnose and treat most illnesses. It is the PCPs job to refer patients with more complex medical issues to specialists. Specialists are experts on specific areas of medicine.
Data shows that higher percentages of PCPs are associated with healthier, lower-cost populations. In most developed countries with healthier populations than ours, PCPs (generalists) represent 70-80% of total doctors – while the remaining 20-30% are specialists. In the U.S., not only are the numbers reversed, the trend is getting worse. As PCPs dwindle in this country, wait times for medical attention will increase, quality of talent will drop, and quality of care will continue to drop. What’s causing the change? Well, in a word….money.
I’m not accusing doctors of being greedy – I’m accusing them of being human. Compensation drives behavior. If you don’t believe me, read Freakonomics. Specialists earn, on average, well over twice as much as PCPs. And with the increased risk of socialized medical systems, I don’t know a single medical student or resident who isn’t going to be a specialist of some kind (and I know a lot of them). Many of them simply cannot afford to be a PCP – with hundreds of thousands of dollars of loans to pay off, they stand little chance of ever building any real wealth if they become a PCP. To quote the blog post: “Between 2000 and 2005, the percentage of medical school graduates choosing Family Medicine dropped from a low 14% to an abysmal 8%. Among Internal Medicine residents, an astonishing 75% now end up as hospitalists or sub-specialists rather than office-based general internists.”
So if primary care is so critical to our nation’s health care (outcomes and costs), why doesn’t the market respond by paying PCPs more? The answer is simple: we don’t have a free market in American health care. What we have is Medicare’s Resource-based Relative Value Scale (RBRVS). Originally conceived in the 1980’s by Harvard Economist William Hsiao, the system was originally designed to calculate an accurate way to reimburse physicians for their time spent on medical procedures — and to reduce disparities in the medical specialities. The problem is the reimbursement formularies reward complex medical procedures over pro-active health care management (preventative care), and after 20 years of budget problems, Medicare continues across-the-board cuts to its doctor and hospital reimbursement levels…which penalizes PCPs more than specialists because of lower reimbursement levels to being with. In fact, in January of 2008, an inefficient Medicare will enact a 10.1% cut in physician reimbursement rates. (Medicare’s costs are skyrocketing – at current trend levels they will account for 20% of our nation’s GDP by 2050).
So why a reimbursement system that favors specialists to generalists? Well, apparently Congress approves 90% of the legislation recommended by the American Medical Association(AMA). The AMA represents a surprisingly small percentage of American physicians. This is reflected in its 30-member committee (called the RUC), comprised mostly of specialists, whose job it is to lobby Congress. “In other words – and it is important to be clear about this – the premeditated actions of the specialist-dominated RUC, operating under the auspices of the AMA and in alliance with [Medicare], appear to have played a direct role in the current primary care crisis by driving policy that financially favored specialty care at the expense of primary care. Equally important, this relationship has been key in establishing drivers of our health systems relentlessly explosive cost growth with its attendant impacts on the larger US economy.”
Two things will help solve the problem. Better representation of primary care physicians on the RUC, and a transparent, non-Medicare-dependent free market for health care.
Laissez-faire Healthcare Blog 