Who cares?

An article in the New York Times on April 26th ("Shortage of Doctors an Obstacle to Obama Goals") was full of fascinating quotes from the best and brightest of our solons. Taken as a whole, and assuming their mouths bear even a tangential relationship to their minds, it verifies my April 23rd comment that family practice ought to be in the catbird seat when it comes to the negotiating table.

If you don't have time to read the whole thing in the New York Times, here's a sampler:

We’re not producing enough primary care physicians. The costs of medical education are so high that people feel that they’ve got to specialize. (President Obama)

The primary care physician workforce shortage is reaching crisis proportions. (Sen. Orrin Hatch, R-Utah)

Primary care physicians are grossly underpaid compared with many specialists. (Sen. Max Baucus, D-Montana)

Maybe they're just posturing, which would be habitual. Or maybe it really is dawning on them that there isn't enough primary care capacity in the the country to do what the president wants to do. And this would be the fault of ... whom? 

Well, the Relative Value Scale Update Commission (RUC), for starters – an AMA goon squad dominated by procedurists, which calls the shots with the federal Center for Medicare & Medicaid Services, which is wholly responsible for the increasing spread between primary care and specialist incomes. The Times article says the Medicare Payment Advisory Commission, a congressional advisory committee, has recommended a 10 percent increase in primary care payment at the expense of the specialists.

The specialists beg to differ. 

Now the food-fight begins. And it's about time. This one could be fought in public, rather than behind closed doors in a mahogany-paneled conference room. This is a fight the AAFP ought to win.

Who cares?

Let's look at some numbers. There are roughly 220,000 generalists in active practice in the United States, and 400,000 specialists. Of the generalists, more than 90,000 are family physicians, 60,000 of whom are "active" AAFP members. So roughly one in three physicians are generalists, one in seven are FPs, and one in 10 are active members of the Academy. Furthermore, most Americans see one of these generalists every year, and rely on these physicians to shepherd them through a health care system they find perplexing, if not frightening.

That ought to add up to a heckuva lot of clout, but it doesn't. There are lots of reasons.

Not long ago, the four generalist societies got together to figure out an action plan. Rather than howling for financial incentives and administrative simplification for their overworked constituents, they signed onto a concept called the Patient-Centered Medical Home, with a burden of bells and whistles only a bureaucrat could dream up, and love. It might be a painful net gainer for the 25 percent of family physicians laboring in a group of eight or more, but for the rest of us, it just looks like pain, period. Clearly, it was pain to the 36 practices participating in the TransforMed national demonstration project, according to the researchers' first report.

But those of us in the trenches share the blame. When the RUC meets, the specialists have spent a fortune to demonstrate why their procedures are going to save the world. We don't contribute the money that is necessary for effective lobbying.

And then there's the issue of apathy, or resignation. I recently read that almost a third of family physicians had never heard of the Medical Home. If true, that's almost unbelievable. You'd think from reading a few excellent blogs from family physicians (see bar to right) that we know the score; but we're talking mostly to each other, and a relatively small coterie of enthusiasts.

So who cares?

Posted at 03:12PM May 12, 2009 by Doug Iliff  |  Comments[3]