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."
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.
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.
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."
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.
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.