President Obama discusses family medicine – and he gets it

Speaking at a town hall meeting on health care in Raleigh, N.C., yesterday, President Obama was asked by the wife of a family physician what he would do to address the hardships of family physicians and entice more students to enter the specialty. He replied by emphasizing the value of family medicine and primary care, and had this to say:

"When we pass health reform and more people have access to the system, it is going to be vital that we increase the number of primary care physicians. The best way for us to do it is two-fold. One is to change how we reimburse ... so that the incomes of primary care physicians are more comparable with specialists. The second thing is to provide scholarships and financial incentives for young medical students who are willing to go into primary care."

View a short video clip here or the entire video here. (The above quote appears at the 36:40 mark.)

Posted at 10:52AM Jul 30, 2009 by Brandi White  |  Comments[0]

Obama: "We're not producing enough primary care physicians"

A New York Times story this week suggests that the Obama administration understands that a shortage of primary care physicians could undermine health care reform. Family physicians, particularly those in rural and urban areas, know this all too well. Others need look no farther than Massachusetts, where a plan for near-universal coverage has been unfolding over the last three years, to see that without significantly greater numbers of primary care doctors, the expansion of coverage that Obama has championed is likely to drive costs higher.

A study last year predicted a shortage of 35,000 to 44,000 adult care generalists by 2025, and that was before expanded coverage was the realistic possibility it seems today.

Federal officials are considering several proposals for dealing with the growing shortage, according to the New York Times article: increasing enrollment in medical schools and residency training programs, encouraging greater use of nurse practitioners and physician assistants, expanding the National Health Service Corps, and increasing Medicare payments to primary care physicians. If the latter has to be done in a budget-neutral way, at the expense of payment to specialists, look for dysfunction in the house of medicine, or worse. “A civil war among physicians seems inevitable,” blogger KevinMD predicts.

Posted at 10:03AM Apr 30, 2009 by Leigh Ann Backer  |  Comments[1]

Good things happen when we increase access to primary care

ABC News recently highlighted the Mayo Clinic's efforts to increase access to primary care and reduce inappropriate use of the emergency department and urgent care among its employees. Mayo created a new department "for the whole family" that combines family medicine, pediatrics and internal medicine, it invested in six new family medicine centers, it opened an express care clinic in a shopping mall, and it used PAs and NPs to see patients at night and on the weekend.

The result? Between 2006 and 2008, Mayo's insurance costs for its employees increased 0 percent. For the average employer, insurance costs increased 5 percent to 7.7 percent per year during the same period.

ABC News medical editor Tim Johnson had this to say:

"Hooray for the Mayo Clinic, but the trend in the country is going in the wrong direction. Most industrialized countries have a balance of 50 percent-50 percent, generalists and specialists. In this country, it’s 70 percent specialists, 30 percent generalists. We’re heading in the wrong direction. Primary care is going down the tubes in this country, and that means we can never have true health care reform unless we change it."

When asked by anchor Charlie Gibson “Why is primary care so critical to saving money?” Johnson replied:

“Because these are the doctors and associates – nurse practitioners and physician assistants – who know the patient and the family, who follow them, who can therefore make wise decisions about what to spend money on, what not to spend money on, how to use preventive medicine, how to control and coordinate chronic disease, and that all saves money. Costs go down, and quality goes up.”

Watch the video here.

Posted at 09:18AM Apr 13, 2009 by Brandi White  |  Comments[0]

The 2009 Match results are in, and they're not good

Countless studies have demonstrated that a strong primary care workforce is essential to a high-quality, cost-effective health care system. But the latest Match numbers are out of step with that premise. Instead, they show a disappointing dip in the number of students choosing family medicine.

The number of positions filled by family medicine residency programs decreased 3.2 percent this year to 2,329 positions, according to preliminary information from the 2009 National Resident Matching Program. The number of family medicine positions filled by U.S. seniors decreased 7.4 percent, to 1,083 positions.

AAFP President Ted Epperly, MD, had this to say: "This decline has nothing to do with the value of primary care and everything to do with a system that claims to support primary care but fails to actually act on its pronouncements."

He added, "Research has demonstrated unequivocally that the world’s successful health care systems depend on primary care. With a ratio of 70 percent subspecialists to 30 percent primary care physicians, the American health care system is upside down. No health care reform can succeed unless we bring both financial and actual access to the primary care physicians that provide more than 80 percent of all health care services Americans need."

A 2006 AAFP workforce report indicated the United States would need 139,531 family physicians by 2020, which means it must graduate 4,439 family physicians each year. "In our current environment, the nation is attracting only half the number of future family physicians that we will need," said Epperly.

Here's how several other specialties fared in the Match:

• Internal medicine-primary filled 18 fewer positions (-7.6%),
• Pediatrics-primary filled one more position (1.3%),
• Internal medicine-pediatrics filled 13 more positions (3.7%),
• Anesthesiology filled 44 more positions (6.1%),
• Diagnostic radiology filled six fewer positions (-4.0%),
• Emergency medicine filled 89 more positions (6.1%),
• Obstetrics-gynecology filled 28 more positions (2.4%).

Posted at 03:15PM Mar 25, 2009 by Brandi White  |  Comments[0]

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]

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]

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]