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Monday Mar 06, 2017

Primary Care Needs a Raise -- All of Us

We deserve a raise. The lifetime income gap between primary care doctors and subspecialists is a shocking $3.5 million.

But if you're a family doctor who feels underpaid, don't expect much sympathy from the public. It's hard to ignore the litany of mainstream news articles characterizing doctors' "bloated salaries" as being the scourge of health care. Although most of these stories fail to distinguish subspecialists from primary care physicians, it's still important to reframe the discussion of primary care compensation.

Whenever there is a discussion about compensation, there is the uncomfortable reality that everyone has a different opinion regarding what people "deserve." Do we compensate for training and subsequent expertise? Do we compensate for hard work? Do we compensate for taking on a job no one else wants? Do we compensate to recruit more talent? Or should health care workers simply get paid what the free market calls for?

Investing in primary care would do more than give primary care physicians a salary raise. Here are four major benefits of improving payments in primary care:

A Decrease in Health Care Costs
The ability of primary care physicians to lower overall health care costs has been demonstrated in several studies. One primary care physician per 10,000 people can decrease hospitalizations by 5.5 percent, ER visits by 11 percent and surgeries by 7 percent. Through care coordination, we can save part of the $210 billion per year wasted on unnecessary or duplicative tests. And through providing evidence-based preventive health care, primary care physicians can save the U.S. health care system $3.7 billion, researchers estimate.

We are able to do all this even in a broken system where the potential of primary care isn't realized yet. Only 5 percent of health care spending goes to direct payment for primary care. That should be closer to 10 percent to 12 percent to realize primary care's full potential.

If primary care physicians were paid what we are worth, there would be more of us to continue driving down overall costs. But in this current system, the United States faces a projected shortage of 52,000 primary care physicians by 2025.

A Raise for Everyone
Changing health care payments wouldn't just mean a raise for primary care physicians. It would translate to a raise for the entire hard-working -- and also undercompensated -- health care team it takes to support primary care, including nurses, medical assistants, phlebotomists, referral coordinators, care coordinators, health coaches, physician assistants, practice administrators, etc.

The economic impact of family physicians is often overlooked. One family physician creates roughly 23 jobs in a community and generates $889,156 in income.   

In this era of team-based care, every member of the team adds value in high-performing clinics, and this should be reflected in their compensation.

Modernization of Health Care Delivery
Value-based payment models are gaining popularity among hospitals, payers and doctors. With the shift away from fee-for-service, we now see an increased emphasis on keeping patients healthy. Various public and private payment systems are tackling care delivery differently, but we are seeing more points of access for patients, whether this is through telehealth, extended hours for primary care, or even the ability to email or call doctors. After all, health care shouldn't start and stop only within the walls of a doctor's office.

When primary care payments increase, family physicians no longer have to worry about uncompensated care in evolved payment models.

Improved Quality of Care
And, of course, the most important role we have as primary care physicians is caring for our patients and improving their quality of life. One primary care doctor for every 10,000 people can decrease mortality by 5.3 percent. Compared to subspecialists, primary care physicians achieve similar health outcomes for conditions such as hypertension or diabetes, but we are able to accomplish this with fewer office visits, a lower percentage of tests per visit and lower hospitalization rates.   

As our health care systems looks for value -- to improve outcomes at reduced costs while keeping doctors and patients happy -- there is no more direct route for an immediate return on investment than primary care.

Natasha Bhuyan, M.D., is a board-certified family physician in Phoenix. You can follow her on Twitter @NatashaBhuyan.


"Primary Care Needs a Raise -- All of Us"

Which is why so many of us find the AAFP's enthusiastic support for MACRA, which will give a nice pay cut to a huge number of family physicians, absolutely incomprehensible.

Posted by R Stuart on March 09, 2017 at 10:18 AM CST #

I submit it is really so easy. But yet so hard. When family physicians make 80% to 100% of what consultants make, the dearth of primary care, family physicians will disappear.
The BMJ had a missive describing why GPs in The Netherlands had so much greater job satisfaction than GPs in Britain.
The basic answer was that in Britain the British Medical Association negotiated for all doctors put together. The family doctors were thrown in with all the consultants. In contrast, in the Netherlands family doctors formed their own separate negotiating body. They could stand up to those who wanted them to be overworked and under paid as a unique and separate unit.
That is what we need in the United States. Essentially, we need a family medicine union (or something very much a kin to a union) that negotiates for family medicine doctors, and only family doctors, in a tough way. We must demand payment that is not dependent on arbitrary, often capricious meeting of targets.
When that happens, American healthcare will be transformed, America's health will dramatically improve, and the primary care shortage will dissolve.
Medical students are at least as smart as Willie Sutton, the famous bank robber from decades ago. If we were to paraphrase him regarding medical student choice of specialty: why are you choosing to go into a consultant specialty field? Answer: because that's where the money is. (When Sutton was asked why he robbed banks, he replied, "That's where the money is.")
In reality I don't think this is selfishness. Instead it is paradoxically perhaps the only way to truly transform American healthcare and build a solid reliable base of primary care.

Posted by Brian Budenholzer on March 09, 2017 at 07:32 PM CST #

There is no evidence basis for a direct relationship between outcomes and higher levels of primary care. Saying this countless times at meetings does not make it so.

Correlation is not causation and there are hundreds of variables that correlate in the same directions often with much higher correlations - especially child well being, Gini Index measures of inequality, and various demographics.

Increased payments for primary care could influence improvements in health, education, economic, and societal outcomes by increasing the dollars sent to counties in need of same. These increased dollars can shape a lessening of disparities - disparities that do influence outcomes.

A move away from property tax based education with a shift to state predominant funding would also decrease disparities. Once again this is not necessarily about the additional teachers or assistants. It is about the dollars specific to the communities of need that influence local determinants.

Health care and education spending are two of the top four economic drivers where most Americans are most behind. Social spending is another.

Social security, SNAP, disability payments are also population based in distributions and can influence disparities. Not surprisingly these are also under attack by those who have other plans to save dollars for those of higher concentrations and spend less where lower concentrations are found.

Dollars actually getting to communities of need rather than diverted to privatization, demonstrations, best practices, grants, academic settings, or consultants would help.

As noted, HITECH to ACA to MACRA has been a disaster in direct costs with specific impacts upon family physicians who are 50% small and solo practice based. The punishments continue as scarce dollars have been forcibly removed from most needed health care with impacts upon the dollars remaining in the communities. Education measurement focus has resulted in much the same increase in disparities by design. Primary Care Medical Home also ships dollars outside to places of concentration. Dollars need to stay home within practices and communities most behind for outcomes impact.

An understanding of the local, personal, and community factors (social determinants, community resources, behaviors, environments) as predominantly shaping outcomes precludes support of the following as significantly influencing outcomes
1. Additional primary care workforce as a direct influence
2. Pay for Performance (may worsen outcomes due to penalties)
3. HITECH to ACA to MACRA digital clinical manipulations
4. Primary Care Medical Home
5. Certifications or MOC

Disparities are created by
1. Lower payments for primary care, especially family practice services
2. Lowest payments for primary care services where most needed
3. Lowest payments for small and rural and less organized by payers who say take it or leave it without the ability to negotiate
4. Highest payments and escalation clauses sending ever more to largest systems and practices
5. Highest costs of delivery for those smaller shaped also by discounts given to those largest
6. Movements to mail order pharmacies with closures of local pharmacies along with compromised payments to small and independent pharmacies
7. Lesser payments for basic hospital services that dominate small and rural hospitals

Based on physician distributions and specialties, about $29,000 per person is spent in 79 top concentration counties where 10% of the population enjoys 3 times greater health spending per person compared to 2621 lowest physician concentration counties where only $3500 per person is spent in these counties for 3 times less than average and a 9 times disparity. This would be an even greater disparity when adjusted for the overutilization in top concentrations and the suppressed utilization of lower concentration settings.

Graduate medical education with only 6% of positions found in lowest concentration counties contributes. About 115 physicians per 100,000 are found in lowest concentration counties and 150 residents per 100,000 are found in 79 top concentration counties. Spending designs are quite interesting when examined from the perspective of lowest concentration settings.

Posted by Robert C. Bowman, M.D. on March 10, 2017 at 02:17 AM CST #

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