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Wednesday, December 31, 2008

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.

Tuesday, December 23, 2008

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?

Friday, December 12, 2008

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?

Thursday, December 11, 2008

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?

Wednesday, December 10, 2008

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?

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