Anti-primary-care editorial borders on comical

A recent op-ed piece published in Emergency Medicine News is being described in the blogosphere as "an adolescent tirade," "cringe-inducing," "destructive ranting at its worst" and even "bordering on comical" were it not so full of contempt for the nation's primary care doctors.

The author, Jonathan Glauser, MD, who works at Case Western Reserve University and the Cleveland Clinic, attacks current initiatives aimed at improving the funding and the delivery of primary care on these grounds:

"If ever there was a group that has failed in providing care, it is our primary care system. To fund such a venture for groups that are singularly inept at performing anything of value to society is pure folly and a waste of precious health care dollars."

Apparently, neither Glauser nor the editors at EM News are aware of the more than 100 peer-reviewed studies demonstrating that a strong primary care base is critical to a cost-effective, functional health care system. They must also be unaware of the payment inequities that have hamstrung primary care physicians for more than a decade and are now catching up to us in the form of a primary care shortage.

Glauser's diatribe, rich in anecdote, continues:

"I have my own ideas about what primary care should accomplish, but foremost among them is to see patients in a timely way when they get sick as opposed to the dermatologist who schedules an appointment three weeks later, by which time the rash has disappeared. Or how about having the diagnostic and therapeutic skills to intervene in some way when the acutely ill patient does show up? Or caring for patients regardless of their ability to pay. After all, the people who sustain strokes, MIs, and aortic dissections because of untreated conditions of some sort (hypertension, diabetes, hyperlipidemia) are the ones most likely to benefit from preventive services."

Yes, it's true that the primary care specialties need to do better (so do the non-primary-care specialties, by the way, especially the ones who practice in hospitals, according to the IOM). What the writer fails to realize is that family physicians, under immense time and cost pressures, have led the way in advancing concepts such as same-day appointments and effective chronic disease care. They have also continued to provide charity care out of their own pockets – not their hospital's deep pockets. 

Primary care physicians may be tempted to lash back at those hurling insults at them, but instead they should be heartened. As talk of increased primary care funding makes its way into budget-neutral health care reform proposals, such as the proposal by Sen. Max Baucus, the attacks are sure to get uglier. They signal that disruption is under way in our health care system. And isn't it about time?

Note: The AAFP has issued a response to the editorial. Read it here.

Posted at 09:23AM Dec 31, 2008 by Brandi White  |  Comments[0]

Is the retail clinic boom over?

Here's some good news for family physicians: Only 1.2 percent of U.S. families reported visiting a retail clinic at some time in the past 12 months and only 2.3 percent of families reported ever having visited one, according to a survey conducted by the Center for Studying Health System Change. The survey was conducted between April 2007 and January 2008 and was sent to approximately 18,000 people in 9,400 families. The response rate was 43 percent.

The survey notes that the boom of retail clinics, which FPM covered, appears to be slowing or over. At the end 2005, only 60 clinics existed in 18 states. One year later, 800 clinics could be found in 23 states. In December 2007 the growth had slowed, and only100 more clinics were established that year in 30 states. As of May 2008, 70 clinics in 15 states have closed and MinuteClinic, the largest retail clinic chain, announced it would be reducing its expansion plans.

Why the change in momentum? "Retail clinics have turned out to be more complex and costly to operate than expected, and some doctors in traditional physician practices are responding [to the competition] by extending their own office hours and doing more same-day scheduling," according to a post on The Wall Street Journal 's health blog.

So, it's possible that the popularity of big-box medicine has reached its height, and the competition didn't hurt family practices after all. But are you prepared for what comes next?

Posted at 04:47PM Dec 23, 2008 by Lynn Hamilton  |  Comments[2]

Medicare beneficiaries can't find doctors. Is that bad news?

I hope no one will call me for piling on if I follow Leigh Ann's entry about the 2007 PQRI mess with another on Medicare woes, but I'm struck by the recent flurry of stories about Medicare beneficiaries having a hard time finding doctors who are accepting new Medicare patients. Monday's Washington Post Story may be the one with the highest profile. It cites the report that probably stimulated most of the coverage:

While statistics are not available for the D.C. region, the Medicare Payment Advisory Commission reported last week that nearly 30 percent of the 2.6 million Medicare beneficiaries seeking a new primary care physician between September 2007 and October 2008 had trouble finding one, up from 25 percent in 2005. To encourage primary care doctors to accept new Medicare patients, the commission recommended to Congress in June that it increase payments to those practitioners by redistributing payments for specialized care.

But the Post story about Northern Virginia has company across the country – for instance in Southern Utah (the Spectrum & Daily News), Oklahoma (The Oklahoman), and as far away as Fairbanks, Alaska (the Daily News - Miner).

Then, of course, there's Massachusetts, where the shortage of primary care physicians willing to take new Medicare patients is just part of the problem. An NPR story highlighted the Mass. mess a week or two ago.

Stories like these are replete with anecdotes of patients calling practice after practice looking fruitlessly for a doctor, getting regular care from the emergency department, and so on, but they also share what seems to be a growing awareness of the underlying problem: that primary care physicians are underpaid, overworked and fed up. In fact, it's hard to avoid the sense that the light is dawning across the country – that people are coming to realize that universal coverage won't solve anything without universal primary care, and that to get more primary care physicians, we may need to work them less, pay them more, and let them do their jobs. Wouldn't that be nice?

Posted at 03:48PM Dec 12, 2008 by Bob Edsall  |  Comments[2]

PQRI: Medicare struggles to get it right

The Centers for Medicare & Medicaid Services (CMS) have just released a report detailing experience with the Physician Quality Reporting Initiative (PQRI), the program that aims to link payment to quality of care by offering a modest incentive payment (2 percent of allowed Medicare charges in 2009) to physicians who successfully report quality measures to CMS. Since CMS began accepting data for the PQRI in July 2007, the program has been the subject of increasing criticism as growing numbers of physicians have been denied incentive payments.

Of those who participated in the program, just over half met the requirements for receiving an incentive payment, the report says.

The report also explains that implementing the PQRI by the legislatively mandated date (the Tax Relief and Health Care Act of 2006, enacted on Dec. 20, 2006, required implementation by July 1, 2007) “required rapid finalization of the detailed specifications for 74 clinical quality measures (covering hundreds of procedure and diagnosis codes), the development of an expanded infrastructure to support the reporting system and extensive outreach to more than 700,000 professionals about the requirements they needed to follow to submit data on quality measures.” In other words, the agency didn’t have enough time to get it right. The report goes on to detail plans to resolve the “unanticipated issues” that arose.

“CMS is committed to a successful PQRI program,” according to the report. We’re not sure whether this is good news or bad news. What do you think?

Posted at 05:25PM Dec 11, 2008 by Leigh Ann Backer  |  Comments[3]

Caring for a population ... one patient at a time

Something about population-based care seems inconsistent with family medicine, at least on the surface. If you wanted to improve the health of populations, you would have gone into public health, right? Surely most family physicians are attracted to the specialty by the prospect of caring for patients -- by the prospect of meaningful, long-term relationships with patients as individuals, not the satisfaction of keeping faceless throngs happy.

I was reminded of this by a recent comment on one of my blog entries. Kin Snyder, MD, asked, "What happens to the individual patient in a population-based care scenario? Patients will still want to see ‘my doctor’ when things are going bad for them. They don't want to be known as registry # XXX." Indeed. Nor do family physicians want to spend their lives taking care of registry numbers.

I think this image of population-based care may sell it short, however. Used properly and wisely, it doesn’t turn patients into registry entries; it turns them into healthier patients. The trick is to manage populations and care for individuals.

The locus of care is the exam room, the bedside or the delivery room; that’s where patients are cared for and doctor-patient relationships are built. The trouble is that this caring and relationship-building proceeds one patient at a time, while 1,500 or 2,000 or 3,000 patients think of you as their doctor.

True, the main goal of population-based care may be to increase the percentage of that population who have the interventions they need, but in the process, it helps you keep in touch with them. If having a diabetes registry, for instance, helps you and your staff to get Harry Smith in for his follow-up appointment more regularly, it doesn’t make Harry into registry #XXX; it puts you and Harry together in the exam room when otherwise you might not see him from one year’s end to the next. What’s wrong with that?

Posted at 03:42PM Dec 10, 2008 by Bob Edsall  |  Comments[1]

Reforming health care insurance isn't enough

Liberals and conservatives alike seem to agree on one thing when it comes to President-elect Obama's health care reform proposal: It would succeed at reducing the ranks of the uninsured – by 26.6 million, according to one estimate.

Expanding health insurance coverage is a good thing, but make no mistake: It won’t fix our health care system. As blogger KevinMD noted in an open letter to Obama (and McCain), “Implementing your plan without a solid primary care foundation will doom your proposal to failure.”

After all, what good is it to insure more people if a) you don't have enough primary care doctors to care for them and b) the primary care doctors you do have are underpaid and overburdened? A recent ACP white paper explains the seriousness of the problem, citing a predicted shortage of 35,000 to 44,000 primary care physicians by 2025 unless immediate steps are taken to make primary care more attractive to medical students and more sustainable for practicing physicians. The white paper goes on to summarize 20 years of research demonstrating that primary care produces better outcomes at lower costs. (The AAFP also has an online summary of the literature.) The inescapable conclusion is that primary care is the key to a functional health care system and strengthening it should be the starting place for meaningful health care reform.

So how do we create a strong primary care foundation? For starters, we need to “pay more for what we want more of, and less for what we want less of,” to quote Newt Gingrich. In other words, pay more for primary care, particularly prevention and care coordination. FPM recently published a simple proposal from one family physician for moving the physician payment system in this direction. And the AAFP and other primary care organizations are working to bring about a medical home care management fee, among other ideas.

Of course, despite the evidence cited above, policymakers may not recognize the value of primary care until they have to – when the Boomers swarm Medicare and we really feel the sting of the primary care crisis. As blogger Dr. Bobbs warns, "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."

Posted at 10:19AM Nov 26, 2008 by Brandi White  |  Comments[1]

Increasing primary care shortage predicted for U.S. health care

Nearly half of doctors, most of them in primary care, plan to reduce the number of patients they are seeing or stop practicing entirely within the next three years, according to a  survey released yesterday by The Physicians' Foundation.

Approximately 12,000 physicians responded to the survey, which was mailed to 270,000 primary care physicians and 50,000 non-primary care physicians nationwide.

"Going into this project we generally knew about the shortage of physicians; what we didn't know is how much worse it could get over the next few years," said Lou Goodman, PhD, president of The Physicians' Foundation.

The Physicians’ Foundation was founded in 2003 as part of a class-action lawsuit settlement between physicians and private third-party payers.

Posted at 09:47AM Nov 19, 2008 by Lynn Hamilton  |  Comments[1]

The NEJM "perspectives" on primary care

I don't think of the New England Journal of Medicine as a champion of primary care, so it was nice to see that today's issue carries a section of "Perspective" articles on the future of primary care, including one by well-known family physician Thomas Bodenheimer, MD, and another by Barbara Starfield, MD, MPH, whose research in primary care has helped advance family medicine. The fact of the articles was more pleasing than their content, which basically went over the ground we've covered before – the irrational imbalance between primary care and the limited specialties in the United States, the importance of some sort of payment reform, the likelihood that the future of primary care lies in care teams, registries, population-based care, electronic medical records, and lessons we can learn from other countries.

The articles didn't offer anything new, but they might be worth scanning; they're freely available from the NEJM Web site. Bodenheimer's piece did give a concise description of what the future practice might look like, and you'll find occasional sentences that outline the problem neatly, such as Starfield's comment that "most approaches to reform do not distinguish the use of primary care services from that of specialty services, despite the underuse of the former and overuse of the latter" - a truth amply demonstrated by the recent election, in that neither party's platform recognized that reform of health care financing without reform of health care delivery fixes nothing.

Posted at 03:41PM Nov 13, 2008 by Bob Edsall  |  Comments[2]

Small change in Medicare participation among FPs

The AAFP tracks Medicare participation among its members. Data from the AAFP's 2008 Practice Profile Survey found that 27 percent of family physicians are not accepting new Medicare patients, although the vast majority, 92 percent, continue to serve as Medicare participating physicians. In the past four years, the percentage of family physicians accepting new Medicare patients has decreased from 80 percent to 73 percent. However, the percentage who continue as participating physicians in the program hasn't changed significantly, despite growing criticism of the fee schedule among primary care physicians.

Medicare participation is higher among rural physicians than others by both measures, especially in acceptance of new Medicare patients: Eighty-three percent of rural physicians reported accepting new Medicare patients compared with 70 percent of other physicians. Family physicians in rural communities may feel more pressure to continue seeing Medicare patients. As Dr. Diane Fabricius of Oak Ridge, Tenn., wrote in FPM earlier this year, "I am part of the infrastructure of our small medical community, and I am not sure that it will hold if I resign from Medicare completely."

Posted at 03:23PM Nov 12, 2008 by Leigh Ann Backer  |  Comments[0]

How to get a 5.1 percent "raise" from Medicare

The Centers for Medicare & Medicaid Services released its 2009 physician fee schedule last week, and there's actually some good news: You could get a 5.1 percent pay boost from Medicare next year. But here's the bad news: You'll have to jump through a few more hoops in order to get it.

The potential 5.1 percent increase has three components:

First, there's a 1.1 percent update to the physician fee schedule, which all physicians will receive. This update was required by the Medicare Improvements for Patients and Providers Act of 2008, which averted a 10.6 percent decrease in physician payments.

Next, there's an incentive payment of 2 percent of your total Medicare allowed charges during 2009 if you use a qualified electronic prescribing (e-prescribing) system to transmit your prescriptions to pharmacies. You will also need to report one of three G codes with your claims to indicate either that you used e-prescribing for all medications prescribed during the visit (code G8443), you did not prescribe any medications during the visit (code G8445), or you did not use e-prescribing because the law prohibits it for the specific type of drug prescribed (such as a controlled substance), the patient requested it or the e-prescribing system was temporarily down (code G8446). If this sounds like too much trouble, note that if you don't switch to e-prescribing, your allowed Medicare charges will be reduced by 1 percent starting in 2012 and by 2 percent starting in 2014, when the incentive payments go away. But don't let that taint your view of e-prescribing. As family physician Ken Adler recently wrote in an article for FPM, "E-prescribing has come of age and is truly a win for everyone – patients, payers, pharmacies and physicians" because of the patient safety and other benefits it offers.

Finally, there's a 2 percent incentive payment if you successfully report measures under the Physician Quality Reporting Initiative (PQRI), which was launched in 2007. For 2009, there are 52 new quality measures to choose from, bringing the total number of measures to 153, but you only have to report on three measures 80 percent of the time. For an overview of how the PQRI works, see Measuring for Medicare: The Physician Quality Reporting Initiative.

If you have any e-prescribing or PQRI tips that you'd like to share with your colleagues, please post your comments below.

Posted at 05:24PM Nov 06, 2008 by Brandi White  |  Comments[2]

A welcome note

Welcome to "Noteworthy," the Family Practice Management staff blog. We chose the name to convey what we hope to offer you here: news, observations and online "finds" that are well worth your attention but beyond what we can cover in FPM – "all the news that won't fit print," so to speak. We like the name too because it suggests the brevity of notes; we'll keep our entries short, to the point and useful. Well, mostly useful. No doubt some will be more interesting than useful, or more amusing, or just plain infuriating. This is a blog, after all, not a journal, and we'll try to hold ourselves to a lower standard.

Posted at 01:33PM Nov 05, 2008 by Bob Edsall  |  Comments[0]