Primary care’s eroding earnings: Is Congress concerned?

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Original Research

Primary care’s eroding earnings: Is Congress concerned?

J Fam Pract. 2008 September;57(9):578-583

By

Brian Yoshio Laing, MD

Barely. Our study suggests that our best hope for change is to work with lawmakers who want to reform Medicare’s Sustainable Growth Rate

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References

1. Bodenheimer T. Primary care–will it survive? Ann Intern Med. 2007;146:301-306.

2. Phillips RL. Primary care in the United States: problems and possibilities. BMJ. 2006;332:151.-

3. American College of Physicians. The impending collapse of primary care medicine and its implications for the state of the nation’s health care. January 30, 2006. Available at: http://www.txpeds.org/u/documents/statehc06_1.pdf. Accessed April 10, 2007.

4. Ferrer RL, Hambidge SJ, Maly RC. The essential role of generalists in health care systems. Ann Intern Med. 2005;142:691-699.

5. Macinko J, Starfield B, Shi L. Quantifying the health benefits of primary care physician supply in the United States. Int J Health Serv. 2007;37:111-126.

6. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83:457-502.

7. Parchman ML, Culler S. Primary care physicians and avoidable hospitalizations. J Fam Pract. 1994;39:123-128.

8. Baicker K, Chandra A. Medicare spending, the physician workforce, and beneficiaries’ quality of care. Health Affairs [Web Exclusive]. April 7, 2004;W4-184-197. Available at: http://content.healthaffairs.org/cgi/content/abstract/hlthaff.w4.184. Accessed July 30, 2008.

9. Bindman AB, Grumbach K, Osmond D, et al. Primary care and receipt of preventive services. J Gen Intern Med. 1996;11:269-276.

10. Safran DG, Taira GA, Rogers WH, et al. Linking primary care performance to outcomes of care. J Fam Pract. 1998;47:213-220.

11. Stewart AL, Grumbach K, Osmond DH, et al. Primary care and patient perceptions of access to care. J Fam Pract. 1997;44:177-185.

12. Bodeheimer T, Berenson RA, Rudolf P. The primary care-specialty income gap: why it matters. Ann Intern Med. 2007;146:301-306.

13. Tu HT, Ginsburg PB. Losing ground: physician income, 1995-2003. Tracking Rep. June 2006;15:1-8.

14. Rosenblatt RA, Andrilla HA. The impact of US medical students’ debt on their choice of primary care careers. Acad Med. 2005;80:815-819.

15. Newton DA, Grayson MS, Thompson LF. The variable influence of lifestyle and income on medical students’ career specialty choices. Acad Med. 2005;80:809-814.

16. Pugno PA, Schmittling GT, Fetter GT, et al. Results of the 2005 national resident matching program: family medicine. Fam Med. 2005;37:555-564.

17. Garibaldi RA, Popkave C, Bylsma W. Career plans for trainees in internal medicine residency programs. Acad Med. 2005;80:507-512.

18. West CP, Popkave C, Schultz HJ, et al. Changes in career decisions of internal medicine residents during training. Ann Intern Med. 2006;145:774-779.

19. Medicare Payment Advisory Commission. Report to the Congress: Medicare Payment Policy. March 2006. Available at: http://www.medpac.gov/publications/congressional_reports/Mar06_EntireReport.pdf. Accessed April 25, 2007.

20. Ginsburg PB, Berenson RA. Revising Medicare’s physician fee schedule–much activity, little change. N Engl J Med. 2007;356:1201-1203.

21. American College of Physicians. The Advanced Medical Home: A Patient-Centered, Physician-Guided Model of Health Care. 2006. Available at: http://www.acponline.org/advocacy/where_we_stand/policy/adv_med.pdf. Accessed May 13, 2007.

22. Steiner BD, Denham AC, Ashkin E, et al. Community care of North Carolina: improving care through community health networks. Ann Fam Med. 2008;in press.

23. Freudenheim M. Trying to save by increasing doctors’ fees. The New York Times. July 21, 2008. Available at: http://www.nytimes.com/2008/07/21/business/21medhome.html?_r=1&scp=1&sq=Trying%20to%20save%20by%20increasing%20doctors%20fees&st=cse&oref=slogin. Accessed August 1, 2008.

24. Orzang P. CBO. “Medicare’s Payments to Physicians: Option for Changing the Sustainable Growth Rate,” testimony before the Committee on Finance United States Senate. March 1, 2007. Available at: http://www.senate.gov/~finance/hearings/testimony/2007test/030107potest.pdf. Accessed May 13, 2007.

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Practice recommendation

Write your senator and congressional representative about the need for Medicare payment reform that addresses the primary care/specialist payment gap. Let them know, too, if you are no longer able to accept Medicare patients due to reduced payments.

Abstract

Purpose: Despite increasing data demonstrating the positive impact primary care has on quality of care and costs, our specialty faces uncertainty. Its popularity among medical students is declining, and the income gap is growing between primary care and other specialties. Congress has the power to intervene in this impending crisis. If we want to influence lawmakers’ actions, we need to know how they are thinking about these issues.

Methods: Using a set of questions covering several physician payment topics, we interviewed 14 congressional staff aides (5 aides on Medicare-oversight committees, 9 general staff aides) and one representative from each of 3 governmental agencies: the Medicare Payment Advisory Commission, Congressional Budget Office, and Government Accountability Office.

Results: Interviewees revealed that issues in primary care are not high on the congressional agenda, and that Medicare’s Sustainable Growth Rate (SGR) is the physician-payment issue on the minds of congressional staff members.

Conclusion: Attempts to solve primary care’s reimbursement difficulties should be tied to SGR reform.

The viability of primary care in the United States is in question, attributable in large part to declining provider payments in the face of rising medical school debt and fee-for-service pressures to increase patient volume.^1-3 Congress—which has authority over Medicare and its price-setting function for provider reimbursement overall—is seemingly unaware of the problems facing primary care, including barriers to payment reform. The future of our specialty may hinge on our ability to persuade Congress that these problems are dire. A growing body of evidence supports the essential and integrative function primary care plays in health systems, and its positive impact on quality of care and costs.^4-6

The confused order of things now

Advantages of primary care are proven. Regions with higher ratios of primary care physicians relative to specialists have lower rates of hospitalizations, lower Medicare costs, and higher quality of care.^7,8 People with a primary care physician are more satisfied with their care and more likely to receive preventive services and better chronic disease management.^9-11 Most countries that have built their health care systems on a strong foundation of primary care demonstrate better health outcomes, fewer health care disparities, and lower costs.^4,6 Thus the waning of primary care presents risks to both personal and population health.

FAST TRACK

When adjusted for inflation, primary care income fell 10% from 1995 to 2004

Still, society undervalues primary care. Despite evidence of the benefits just cited, the income disparity between primary care physicians and specialists continues to grow, discouraging medical students from entering primary care careers.¹² The Medical Group Management Association shows that between 2000 and 2004, the median income for a family physician increased 7.5% to $156,000; for invasive cardiologists, 16.9% to $428,000; and for diagnostic radiologists, 36.2% to $407,000. Adjusted for inflation, primary care income fell 10% from 1995 to 2004.¹³

No wonder students shy away from primary care. Though there is little public sympathy for the financial woes of primary care doctors, lower incomes are contributing to a drying of the primary care pipeline.^14,15 The number of US medical school graduates choosing family medicine residencies dropped by 50% between 1997 and 2005.¹⁶ From 1998 to 2004, the number of internal medicine residents choosing careers in primary care plummeted from 54% to 25%.^17,18 This waning interest in primary care coincides, unfortunately, with the aging of the US baby boomers and an increasing prevalence of chronic disease.

How Congress could help fix the disparity

Medicare reimbursement has 2 components that Congress could amend to narrow the payment gap and help open the primary care pipeline: the Sustainable Growth Rate (SGR) and the Resource-Based Relative Value Scale (RBRVS) process.

FAST TRACK

Staffers from rural districts noted that constituents are having difficulty finding primary care doctors who take Medicare

The SGR formula sets a target for Medicare physician expenditures each year. Recently, physician expenditure growth has exceeded the target and, by law, the difference is subtracted from the fees paid to all physicians. According to the Medicare Payment Advisory Commission (MedPAC), much of the excess spending has come from rapidly increasing volumes of procedures used by specialists.¹⁹ The SGR system therefore disproportionately penalizes primary care physicians because payments to all physicians are cut regardless of which specialties are responsible for excess spending.

RBRVS is the system of relative values applied to every procedure and office visit. The Relative Value Units (RVUs) for each procedure or office visit are multiplied by a conversion factor determined by the SGR formula. RVUs are largely governed by the Relative Value Scale Update Committee (RUC), which advises the Centers for Medicare and Medicaid Services (CMS) on revisions to physician reimbursement.