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

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References

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

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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.

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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.

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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.

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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.

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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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The RUC reviews the relative value scale at least every 5 years. Though primary care physicians provide about half of Medicare physician visits, they represent just 15% of the RUC’s voting members.¹²

The committee’s reevaluation process tends to raise some RVUs without sufficiently deflating others.²⁰ The resulting overall inflation of fees forces CMS to reduce payments equally to all physicians, meaning primary care is again disproportionately penalized. Moreover, both Medicare and private insurance companies follow the RUC’s recommendations.

Influencing Congress: Where to begin? As Congress escalates its deliberations on Medicare physician spending, we investigated how key legislators perceive issues in primary care and physician payment.

Methods

To better understand perspectives of congressional committees with jurisdiction over health care spending, we conducted semistructured key informant interviews in March 2007 with 14 health staff aides to members of Congress who have jurisdiction over Medicare. Interviews were done face to face and lasted 30 to 60 minutes.

FAST TRACK

According to one Capitol Hill veteran, the CBO believes that even if primary care extends a person’s life, this may not necessarily save money

The congressional committees with jurisdiction over Medicare physician payment are Senate Finance, House Ways and Means, and House Energy and Commerce. Each committee has 1 majority and 1 minority staffer specializing in Medicare part B, which includes physician payment. Of these 6 specialized staffers, 5 agreed to participate in semistructured interviews. Other staffers were contacted by using a purposeful sampling technique known as “snowballing” or chain-referral, whereby participants with whom contact has been made refer the researcher to other potential interviewees. This process yielded another 9 interviewees to total 14.

The aides identified several other information sources, and we interviewed 1 staff member each from 3 of these sources: MedPAC, the Congressional Budget Office (CBO), and the Government Accountability Office (GAO).

Interviews covered several topics, including views on the state of primary care and physician payment (TABLE). Three researchers separately reviewed the interview notes to identify and compile themes.

TABLE
6 Questions we asked the congressional staffers

1. What are your views on the current state of primary care in the United States?
2. When considering legislation to improve health care in the United States, how—if at all—does primary care factor into your vision?
3. If there is legislative movement to change the Sustainable Growth Rate and Resource-Based Relative Value Scale systems in the next year, what should the goal be?
4. What is your sense of other health legislative assistants’ understanding of primary care?
5. Who are you hearing from on issues of primary care? Who are you not hearing from?
6. What are the best sources to learn about these issues?

Results

Of the 14 congressional staffers, 8 were Republican and 6 were Democrat; 5 were committee staff and 9 were general staff. Committee representation was fairly even among staffers: Senate Finance (4), House Ways and Means (5), and House Energy and Commerce (5). Range of experience on Capitol Hill was 3 months to 9 years.

Some staffers are empathetic, others unaware. Most respondents expressed concern about the decreasing number of students entering primary care careers and the potential impact on patient access to care. One staffer acknowledged, “the way our reimbursement system works, primary care is not an option for students…reimbursement is so low…the number of primary care physicians is going down relative to other specialties.”

FAST TRACK

Research shows that primary care-oriented systems reduce preventable hospitalizations, which decreases costs

Another participant added that most staffers “recognize a role for primary care. It’s also tough because of how strong the specialty community is.” One staffer advised, “The Alliance of Specialty Medicine goes along with the AMA, trying to represent a coordinated front…I don’t see this much coordination around primary care.”

A few staffers did not understand the definition of primary care or did not know which physician groups represent primary care.

Legislation to improve US health care—and primary care. Participants varied in their input on this subject. One staffer stated that primary care is “important but rarely singled out…usually the goal is broader reform so [primary care] is still a goal, but unstated.”

Some committee staff described the need to incentivize greater use of primary care and increase coordination of care. A few proposed reevaluating RBRVS to help primary care, and they spontaneously raised the Medical Home concept as a way to encourage growth of primary care. The Medical Home involves pairing each Medicare beneficiary with a patient-centered practice that meets certain criteria including continuity with a personal physician, care coordination, quality assurance, increased access, and specific payment.²¹ A pilot project in North Carolina that incorporates the Medical Home is saving the state about $162 million annually.^22,23 One staffer championed primary care, but pointed out that a critical barrier preventing Congress from investing in it is the CBO, which is not convinced that primary care can save money over the long term.