Just a simple vanilla blog site from a physician

Primary Care Physician

The health care debate has demonstrated several cogent facts principal among them is that there is a shortage of primary care physicians. Some estimates put this as high as 40,000 fewer primary care physicians than are needed.  The experience in Massachusetts has shown that as more people are covered more primary care physicians are needed. As uninsured in Massachusetss fell from 13 to 7% wait times for primary care visits have jumped from a few days to weeks if not months according to a recent New York Times article.

In my opinion politics will prevent any major health care reform that will significantly impact this problem over the next 18-24 months, if ever. There simply are too many special interests and other orgnizations that benefit too much from the current model of care.

So what short term measures can be taken that don’t require special legislation but could improve the availability of Primary Care services in this country?

Primary Care and all phyhsicians be salaried

Most physicians are current compensated based on some form of volume sensitive measures.  These include fee-for-services rendered in which case physicians will increase their reimbursements by doing more for a patient whether or not it is medically warrented. Even in large groups the physician’s reimbursement is based on productivity that is measured by either Work Relative Value Units (WRVUs) which are directly tied to the volume of services they order whether or not their annual day-to-day pay is directly affected by the patient loads and services rendered.  
Keeping track and monitoring these services involves particularly elaborate relationships between what a physician documents, codes for Evaluation and Management (E&M) services, orders tests and services, documents CPT (Current Procedural Terminology) codes or other sources of volume-based measurements.  This leads to large overhead costs for physicians and 3rd Party Payers that doesn’t contribute at all to patient care.  An average Primary Care Physician must bill out over $400,000 a year in order to break even in most organizations.
Eliminating or reducing this practice has the potential to free up countless minutes, if not hours a day that could be devoted to seeing new patients.  Organizations like Cleveland Clinic and Mayo Clinic have experimented with salarying physicians and have documented reduced the total cost of medicine significantly compared to other institutions that continue the current paradigm.

PCP physicians need to give up inpatient services

Primary Care Physicians need to give up their hospital priviledges. All too often clinic care is delayed because the physician is caught up rounding in the hospital and encounters delays.  Every minute they spend in the hospital is a minute they cannot provide Primary Care services in their clinics.  Hospital care is not primary care by definition and current pressures on hospitals to process patients and discharge them as rapidly as possible require hourly interventions which a physician in the clinic cannot provide without detracting from their clinic services.  Simply eliminating their hospital care would add perhaps as much as a day a week for new or other types of clinic visits per primary care physician and cut into the shortage of clinic spots available.

PCP physicians should treat their entire practice instead of individual patients

Focusing their attention on their entire pool of patients to increase the percentage that are immunized, adhering to medications, and assuring all are getting preventive care has the potential to reduce the number of unnecessary clinic visits and may even improve the health of the community whereas continuing to serve only those that come to the clinic for acute care needs has little or no impact on the health of the community.

Routine follow-up and low level care should b provided by physician extenders

Once a patient is seen by a primary care physician and a plan of care is created, routine follow up care should be provided by physician extenders. Yes, the physician should touch the patient on these visits and assure that they are adhering to the plan but not be dragged into extended documentation or billing procedures for that visit. They should concentrate their attention on complicated patients, new patients and those requiring special services.

Too often we see physicians in large groups that are reimbursed by WRVU criterial "packing" their schedules with easy-to-see follow up patients for 1, 2 and 3 month follow ups in which no major medical decisions are made. Yet, these patients can be billed out as mid to complicated care for reimbursement reasons and could be seen by lower level providers.

Doint so would open up significant blocks of time for the Primary Care physicians to see new and complicated patients thereby reducing some of the shortage of primary care physician visit times.

Not doing so will continue to allow retail clinics who are staffed by nurse practitioners to provide this care which is not integrated into the primary care physician’s patient pool.

Immediately forgive medical school debt for those entering and practicing primary care

While this option may not be availabel for many solo or small group practitioners, larger entities ought to immediately pay off the medical school debt of those who have chosen primary care.  Servicing the large (average $140,000) school debt is given as one of the primary reasons medical students and residents avoid primary care.  Eliminating this would immediately benefit those that are currently in the field as well as dramatically increase the number of students choosing primary care in the next 18-24 months.  There are many mechanisms for doing this and it is true that many rural areas are already providing this as an enticement for primary care physicians to choose to locate in rural areas.  However, this should be a standard national policy.

These are just a few of the things that can be done relatively quickly that would increase the effective availability of primary care physician services in this country.  There are others but it all boils down to the money so the attention should be focused on reducing the negative impact to individuals who choose this if it is a national prioriy to increase the volume of primary care services in this country.


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