During a lull in the exam, I turned to him and asked, “Dick, I'm the CEO of Blue Cross. What do I need to know?” He paused, looking down. Then his cheek started to twitch. I actually saw him lose his temper for the first time in 25 plus years. “Jim, you want straight? What the bleep are you doing to us? A monkey can do a colonoscopy and yet they make four times what we primary care doctors make. What you are doing is a disgrace.” He was some pissed!!
I then had lunch with Dr. Al Puerini, a highly regarded PCP of 30 years with a full practice. I asked him how much he netted before taxes, and when he told me, I was appalled. He made some aside about it not being about the money, but it IS in part about the money. He also told me about how difficult it was to recruit new PCPs in RI.
Those two encounters started me down my path of alarm about the future of primary care. Rhode Island is a small (40×30 mile, one million population) microcosm of the country. While we have our accents and quirks, and people still think we're overrun by the mafia, we're not all that much different. Just wicked smaller. Our PCP population was aging and shrinking rapidly. The best and brightest from Brown Med School and others of its ilk were decidedly not swarming into primary care. Practices could not recruit new members. We were, and still are, in a crisis that is nation-wide.
And it didn't stop with just the poor PCP reimbursement. PCPs cannot survive financially without untoward volume. This has all sorts of negative consequences. Moreover, on the totem pole of respect, PCPs do not seem to rank high for reasons that I simply cannot fathom. It seems that the more “miracle machines” a physician uses, the more respect he or she gets. While the poor PCP does what we in the billing world refer to as “E&M” (Evaluative and Maintenance). The look-you-in-the-eye, known-you-for-years sort of thing. In other words, taking basic tests and extrapolating health trajectories. Wading into gray areas. Knowing the patient and her family, and making informed prognoses. All difficult stuff. Not something that shows up on an LED screen. Ahhhh….judgment and perspective.
A little aside. It seems as if politicians, the media, and even participants cannot help but to “cartoonize” the players in healthcare. Obama and Pelosi did it as a way to get passage of the ACA. I mean, when the President calls you “evil,” it does smart a bit. And during my tenure as CEO of a health insurer, I was accused of many things that were rather startling to my family who thought they'd known me better.
Even today when I write articles for THCB and others that are in any way critical of physicians, I get the usual angry knee-jerk response from physicians who absolutely must believe that I have no understanding of the value of physicians and the pressures they operate under.
But my story continues. Energized to do something on a number of fronts regarding primary care, I called a meeting of my rating group (you know, the actuarial, underwriting, sales, provider “relations”) and I ask them to explain to me why PCP reimbursement was so low. A variety of non responsive responses were given, and I ended up concluding that it was because we could. We could keep PCP reimbursement low because most PCPs (at least then) were onesies and twosies with no negotiating leverage, while specialists tended to group together to share “machines” and gain clout. Sigh.
So then, armed with the knowledge of what PCPs were paid in Massachusetts, our richer neighbor just to the north, I announced that we would achieve “parity” in four years, parity being defined as keeping up with the current Massachusetts PCP rate for E&M codes. That required us to increase what we paid PCPs almost 50% over four years to cover the historical difference plus ongoing increases.
The pushback I got from my staff was startling. “That will make us uncompetitive.” “That is too inflationary.” “Our job is to keep fees as low as we can so that our premiums are as low as possible.” Etc.
Finally, having had it with all the negativity, I ordered the trusted actuary who I'd worked with as outside counsel in rate cases for decades to tell me what the impact of such an increase (50%) would be on overall premiums. The result? Less than 1%!!! The moral? Office visits NEVER break the bank.
Well, we reached parity with Massachusetts after five years (yeah, I know). We also did major funding, technology grants, nurse practitioner hires, etc., for PCP patient centered medical homes. While I know there is some controversy about how well PCMHs have done, I remain optimistic, just as I do with ACOs. And lastly, we funded a loan forgiveness program for PCPs entering their practice in RI.
How much did it help? Some, I think. Are PCPs happy today? In Rhode Island, I think a bit more today. We have two large practice groups which seem to be thriving, and some smaller regional (if you can use that term for RI) groups who appear to be doing well. Linkages with hospital systems seem to be taking place. [About time.]
Yet, unless we can relieve PCPs from the burden of volume, we are destined to have disenchanted, angry, and burnt out PCPs. The problem is so bad that even YouTube has something on it.
And so, with a dwindling PCP population and ever increasing numbers of newly insureds as a result of the ACA, clearly there is a need. Likewise, with the aging of the Boomers, we will see more and more patients with 3 or more chronic conditions. There will always be a need for the PCP, the one who sits face to face with the patient and his family and counsels. And while nurse practitioners can carry much of the load (I use a NP as my PCP with the VA, but that's another story for another day), they cannot replace the PCP MD.
Insurers are to a significant extent to blame. Stephen Schimpff, MD, has run a series of incisive articles on the subject and a book. It would be well to heed his warnings. He largely blames payors, and concludes that neither insurers nor the government can (will?) change the current situation. His primary (so to speak) observation is that we've required PCPs to allot too little time per visit to truly be evaluative. When one has to see 25 patients a day to earn a decent living, one has to cut corners and overuse specialists, with cost consequences. I would hope that insurers and the federal government both can take steps to change all of this.
There have been articles on THCB on this subject in the past. As this blog ends, I challenge other contributors to THCB to develop ideas on how we can invigorate primary care and get med schools to produce more top flight physicians who enthusiastically opt for primary care. This is an almost holy mission, and hence my tongue in cheek title for this blog.
Perhaps Andy Slavitt might have a few words to share with us. He seems to share my views about primary care. Actually everyone does, but that hasn't seemed to have made enough of a difference….yet.
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