Is Primary Care Dead? And Do YOU Feel Fine?

From "Musings of a Distractible Mind":

Notice the subtle strife between internal medicine and family medicine, with the assumption that family physicians see less complex patients.

Notice that some primary care physicians are doing well...also note that this is in the Southeastern US, where reimbursement rates are higher overall.

What do You Call a Doc Who Spends Enough Time with Each Patient?

From Kevin, M.D.:

"What do you call an internist who spends enough time with each patient?"

Poor!

(Love the first comment..."What do you call a 50-year-old obstetrician? A gynecologist!")

Down with the Anti-Vaccinists!

I've said it before...

The anti-vaccinists are selfish bastards, that think nothing of leeching off of the rest of society. Belgium has taken a hard stand on this, and rightfully so, jailing Belgians that refuse polio vaccine.

Polio is a horrible disease. The World Health Organization's efforts at eradicating it started in 1988, and they've done a pretty damn good job: 99% reduction.

Both medical experts and bioethicists agree:

"...unlike other medical problems, in which rejecting treatment only affects the individual, refusing a vaccine for a transmissible disease like polio puts others at risk as well."

"Ethicists argue that people who refuse vaccinations are taking advantage of everyone else who has been vaccinated. Once the majority of a population is vaccinated, there are few susceptible people the disease can infect, thus lowering the odds of an outbreak.

People who refuse to be vaccinated are 'free riders,' Harris said. 'They can only afford to refuse the vaccine because they are surrounded by people who have fulfilled their obligations to the community.'"


So, listen up you fucking selfish dumbshit anti-vaccination cocksuckers! Just because you're rich enough to both "afford" and waste the luxury of health care in this country doesn't give you the right to potentially inflict harm on the rest of the population.

...and once and for all, despite the media bullshit, vaccines don't cause autism.

Bite me...self-indulgent assholes.

Want to Combat Retail Clinics? Strike While the Iron's Hot!

The public is still testing the waters on retail clinics.

I can't blame them. "Rollback Prices" are great, but what about when they apply to your health?

In any case, this WSJ article reinforces the fact that the timing may be just perfect for physicians to reinforce their differentiation. (Beyond "we get more than 2 weeks of anatomy"!)

It's actually probably worth a small premium...creative scheduling in traditional primary care practices to offer extended hours, combined with clear & concise pricing brochures could be all it takes.

In any case, just remember that timing counts.

Health Care Competiton in The Simpsons

So, I started this post just looking for a picture of my hero, Dr. Nick Riviera.

But in the process, I found and learned so much more.

In an insightful piece published in the Canadian Medical Association Journal in 1998, two physicians analyze the medical care received by Homer J. Simpson and his family.

Which is the better physician, in terms of balancing cost and quality, Nick Riviera, or Dr. Julius Hibbert?

Oh, who the fuck am I kidding?! I don't care. Dr. Nick kicks ass.

Read the CMAJ article comparing these two physicians for the Simpson family here.

AMA Banned from Hearings: I Don't Care

Here's the deal.  The AMA has been banned from the hearings dealing with the impending 10.1% Medicare cuts will happen or not.  Apparently, they've just pissed people off.

I don't care.  I've always felt the AMA sucks ass, and that it could never adequately represent me and my colleagues.  In fact, if they were involved in these hearings, I still believe that they more strongly represent subspecialists.  

The AAFP and ACP got it covered, among a number of other good organizations.

With that said, I really hope they can achieve a complete formula fix instead of another patch. 

God help everyone on Medicare if they don't.

Does Preventive Care Save Money?

OK, the perspectives piece "Does Preventive Care Save Money? Health Economics and the Presidential Candidates" does raise an interesting question. 

In this case, the authors have raised the question based on the hypothesis that the statements and claims being made presidential candidates are perhaps a bit too broad.

Maybe.  I actually think this was a pretty crappy article overall...I get the point.  But it really trashes prevention in the areas where there are huge savings (brushing over the economic impact of some high-impact USPTF recommendations).  I also think it doesn't go far enough in telling the hard truth for docs and the public:

• Not all "screening tests" currently in use meet the criteria for ideal screening tests.  
• Screening tests should be use appropriately.  The authors say that "...screening costs will exceed the savings from avoided treatment in cases in which only a very small fraction of the population would have become ill in the absence of preventive measures."  Well, then, this doesn't quite meet the criteria for the ideal screening test.  The 80-year-old man doesn't need a PSA, and his wife doesn't need a pap smear.  Similarly, people shouldn't be ordering CA-125 tests for women to screen for ovarian cancer.  Strap on some balls, and tell your patient they don't need the tests.
• The public tends to think we have the ability to detect anything early and cheat death if it's caught early.  As a society, we need to get a grip on our mortality, and on what is and is not possible.
  
• The concierge physical market isn't doing any favors here.  Lots of high-cost tests without proven outcomes set the expectations for all patients that they need these things when, in fact, they may actually cause harm
  
• People need to be clear on the definitions of primary care and prevention.  Yes, prevention is part of what we do.  But it's not just prevention of heart disease, it's also prevention of the avoidable ER visit or hospitalization.  Access to primary care is clearly tied to reductions in these areas.
  
• Everyone is dancing around the fact that we'll have to ration resources more.  No, Mr. Johnson, you can't get a fucking MRI for your back given your symptoms.  And no, you can't fucking sue me for saying so.  (OK, so the candidates are just trying to get into office right now...but someone's got to be saying it!)

The authors actually provide some misleading information.  Although they didn't list the 279 preventive measures that they refer to, the authors do present some of the measures used in their tables.  The quality of some of the studies used for the analysis is really shoddy.  Take the "high" versus "low" intensity smoking relapse-prevention programs, for example.  The high intensity program sent 7 mailings to patients, while the low intensity approach sent one single booklet.  First of all, neither approach works that well!  If it were to be compared to a more effective approach (regular access with a primary care physician, support groups, etc.), I wonder if the results would be different.

And screening for medium chain acyl-coenzyme A dehydrogenase deficiency in newborns?  Since when is that a useful screening test worthy (in terms of ideal screening test criteria) of application to all patients?  I think the real issue here is that when it comes to babies, people have a real hard time rationing care (not to mention the medico-legal pressures).

It's not a horrible article.  It raises a point.  But don't fucking dance around the issues.  This is a perspectives piece, and some leeway is allowed.  We're not doing the public any service by sugar-coating the real issues.  

More on SGR...and How It Contributes to Growing Disparity Between Specialist and Primary Care Reimbursement

From the Health Affairs Blog..."Splitting the Sustainable Growth Rate..."

"...Lost in this debate is an appreciation of how the SGR approach has contributed to a large and widening gap in earnings between specialists and primary care physicians, an income gap that is a major contributor to the dwindling number of physicians entering careers in primary care, putting the foundation of the American health care system at risk...."

Yes.  We've argued about whether or not this pay differential is real and whether it's justified.  And primary care physicians (like me) continue to be pissed.  Fuck everyone.

Well, I think this author does a great job of analysis, as well as recommending a logical and feasible solution.

I'd love to know what I'm missing here....would it put specialists at more risk?  Fuck yeah.  But the same would apply to PCP's.

Fair.

Medicare Advantage Plans are not All the Same

There's a lot of pressure on Medicare Advantage plans.

Lots of people see a substantial amount of subsidization for these plans.

In fact, a bunch of these MA plans were instructed to halt all marketing activities last year, based on the finding that the costs of those plans was significantly higher.

It's worth looking closer here.

The Medicare Advantage FFS plans are actually the plans with the higher costs, as they really aren't managed tightly.  The MA plans that have been managed via risk-sharing (capitated) arrangements have demonstrated approximately 19% lower costs.

These plans are not all the same, and legislative approaches must recognize this fact.  

MA plans are not all the same, and it would be a shame for the plans that have risk-sharing contracts to be lumped in with the PPO plans.  The risk arrangements produce better outcomes at lower costs precisely because the primary care physicians are taking the risk, and are thus rewarded/penalized for their ability to truly coordinate care.

Don't kill this.   

More Cost-Shifting

More cost-shifting adaptations in NYC emergency departments.

Too bad that the bigger issue is that many patients shouldn't end up in the ED anyway.  If only there were primary care incentives to help.

Primary Care Must Be Central in Health Care Reform

Props to Kevin: "Primary Care is Damn Cheap and Can Solve Our Health Care Woes"

Racial Disparities in Health Care--Having Coverage Isn't Enough

Having coverage isn't enough to eliminate racial disparities in health care. A racial disparities study seeks to dig deeper.

Physicians as Secret Agents--Is Your Information Safe?

What a fucking fiasco. You've got to read this article about Blue Cross of California's request to have have docs help them in dropping patients.

Here's the deal. Wellpoint (owners of Blue Cross of California) has sent a request out to primary care physicians to pro-actively review the charts of patients and to forward on any information that may indicate a pre-existing condition that was not disclosed by the patient. They want the docs to take time to review records, but more importantly, to review the information of new enrollees.

Of course, it's to help them find a reason to drop patients from coverage.

My issues with this:

• Since when does the primary care doc become the tool for enforcement? Fuck this. Can you imagine what it does to the physician-patient relationship? Would you want to reveal everything to your doc if you knew they might report it to your insurer?
  
• We as primary care physicians get shit like this everyday....we're asked to audit charts and complete forms to help the health plan comply with HEDIS reporting requirements, to help them keep their costs down, to help them achieve "marketable" outcomes. Of course, paying for our time is out of the question, as is sharing the benefit of achieving these results. Again, fuck this. Civil disobedience by either invoicing them (if the contract allows) or by shredding / burning the requests sounds like a good idea.

The morons in the PR department are gonna get what's coming to them. They're trying to say that they're doing this to help out the large medical groups--but it doesn't take a rocket scientist to know that the new enrollees' information isn't with the new PCP, but rather the old one!

Fuckin' idiots.

Even if you paid primary care docs to do this shit, they wouldn't ethically do it.

Good post at The Health Care Blog on this too.

A Medical Home Costs Money

A medical home is a great concept, and it's right in line with the true role of primary care.

It's also going to take money to do it right....most of the work involved is not compensated currently.

Here's an article about a Medicaid pilot program in Illinois that pays $2 pmpm (per member, per month) for the service.

Bite me.

OK, I do want to be fair--this is most definitely a step in the right direction. But for it to be meaningful, it also depends on having a substantial number of "members" (Medicaid recipients as patients). And as everyone knows, the larger the percentage of your payer mix that is Medicaid, the less solvent your practice becomes.

Not to mention the fact that the other payers need to also pay their fair share...is this doc going to provide medical home services to some but not other patients? It's a logistical nightmare.

So right direction, good intent, but still "kinda pitchy dog....no to Hollywoood".

How to Live to 90

It's not about how many heart imaging studies you can have done.

It is about lifestyle choices, especially after age 70.

Talk about getting the most "bang for your buck".

Bush Budget Reveals $178 Billion Cut in Medicare Spending

From the Kaiser Daily Health Policy Report on Feb 5, 2008:

"....President Bush on Monday released a $3.1 trillion fiscal year 2009 budget request that would reduce Medicare spending by $178 billion over five years, the Baltimore Sun reports (Hay Brown, Baltimore Sun, 2/5). Over 10 years, the budget request would reduce Medicare spending by about $560 billion....In an effort to reduce Medicare spending growth, the budget request 'asks doctors and hospitals to hold the line on what they charge the elderly for medical care' and maintains that 'cuts in Medicare can be painless -- even lowering premiums that seniors pay by capping what doctors and hospitals can charge...'"

Fuck you.

And good luck finding a primary care doc...they get hurt disproportionately.

You know, this is actually the tip of the iceberg in terms of what we can expect to see as a result of diverted funds due to war spending.

Again, fuck you and the one that made you.

The AMA is Killing Primary Care (Not Quite Dead Yet?)

There's a lot that the public doesn't see.  In fact, most physicians don't know the intricacies of what's going on that is slowly leading to their demise.

There was a great article that describes the disparity of income between primary care physicians and specialists, and the broader impact this has on our health system.  It also uncovers how the AMA is killing primary care systematically.

Brian Klepper did a great job with this back in December, and I think it's worth checking out his post on the subject.

Bottom line:

• The AMA has played a significant role in the destruction of primary care.
  
• The RUC (Relative Value Update Committee) of the AMA that heavily influences reimbursement rates is predominated by interventional and procedural specialists.
  
• Some say that the secretive nature and the dynamics of the RUC smack of anti-competitive behavior.
  
• The Centers for Medicare & Medicaid Services (CMS) listen to the RUC recommendations.
  
• Primary care specialities are paid much less, to the point of not being able to survive.
  
• Medical students don't want to go into primary care, because they have no chance of paying off the $100k to $200k in debt they've incurred.
  
• Society suffers.  The healthiest countries have 70-80% of physicians in primary care, and 20-30% are specialists.  It's reversed here.
  

Read Brian Klepper's post here.

If you're not pissed after reading it, check to see if you have a pulse.