Boston Tea Party for family physicians

A California family physician, and frequent contributor to the AAFP practice management listserv, recently noted: "On April 1st United Healthcare reduced our reimbursement schedules to 2008 rates." [For background, read the post by Kent Moore.]

"So, the company that has hired TransforMed to help them become more PCMH friendly has concluded that being friendly means an 8 percent reduction in our 99213 rates," he writes. "The AAFP has written letters. ... Why haven't I received a written letter from the AAFP whereby they suggest a nationwide boycott against UHC?"

His frustration is palpable, and understandable. When it comes to a national response, what should the AAFP do?

The times they are a changin', and we'd better broaden the discussion.  Let's start with postulates.

First: There are not enough primary care physicians to provide cost-effective, quality service to the American population. Even if you add in nurse practitioners and physician assistants, it's still not close. And  if education policy and funding changed immediately, it won't be close for at least a decade. 

Second: In a free market, the price of any scarce commodity, good or service rises. Medicine is far from a free market, but neither has it been nationalized by a socialist state, yet. This means, by (normally) inviolable laws of economics, that family practice ought to be in the catbird seat.

Third: For the last two decades, the inflation-adjusted income of generalists has been stable, while that of specialists has risen dramatically. This has priced primary care out of the market for medical students. Furthermore, the rise of specialist income bears no relation to the difficulty or demands of their occupations; it is wholly a function of pricing decisions emanating from a Council of Elders responsible to Medicare and the American Medical Association. (See "What Every Physician Should Know About the RUC.")

Fourth: The hardest jobs in medicine are those of general surgeons, general internists and family physicians. Some of the work of these physicians could, it is true, be supplanted by ancillary personnel. But nearly all the work of many highly paid specialists could be similarly supplanted. Could a dexterous high school graduate perform colonoscopies? Of course; it is a simple manual exercise. How often does the nurse anesthetist ($120K/year) call in the anesthesiologist ($400K/year)? Hardly ever. But no "physician extender" can juggle the complex mix of stuff that comes through my door every day like I can. 

Now, granting that, how in the world has primary care been painted into this corner?

One hypothesis is that we are represented by the worst negotiators since Neville Chamberlain met Hitler and proclaimed "Peace in Our Time." This requires believing that the American Academy of Pediatrics and the American College of Physicians are also limp-wristed at the long table. Could be. I hear that surgeons can be really nasty people in a closed room.

Another hypothesis is that primary care, representing the largest groups of American physicians, nevertheless has a minority of votes on the Relative-Value-Scale Update Committee. The natives were restless at the 2008 Congress of Delegates in San Diego, insisting that the Academy consider other strategies, including withdrawing from the RUC. An AAFP director responded that "the Academy has no intention of rushing headlong into any situation that might prove untenable."

If family medicine is sliding into the abyss – well, we wouldn't want to do anything untenable, would we?

A few months ago, I read The Strategy of Conflict by Thomas Schelling, a 1960 book on game theory that won him a belated Nobel Prize in 2005. It considers nuclear war at length, but we won't go there. More to our situation, he spends a chapter discussing labor-management negotiations and makes a fascinating point. (Just to be clear, despite what the law says about our being independent competitors, we're labor.)

When a union chief sits down with a CEO, he has an ace in the hole if he has lost control of his membership. If the members are rioting at the gates, he can credibly say, "Look, Mr. Big, I'm trying to negotiate in good faith and make compromises – but those people are crazy mad. They've had it. I can't tell them what to do. Nobody can tell them what to do. If you don't make concessions now, they're going to burn the damn place down."

It's an interesting idea. The AAFP isn't a union, and it can't threaten a strike. But what would happen if month after month more and more family physicians were opting out of, say, Medicare? Not because the AAFP told us to – they wouldn't – but because we've had it, too.

Just a thought. Here's how.

Posted at 08:30AM Apr 23, 2009 by Doug Iliff  |  Comments[7]