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Rebuilding Primary Care: A Call For Federal Action (Part 2)



January 27th, 2009

Editor’s Note: There is widespread agreement that the nation’s primary care infrastructure is woefully inadequate. For example, at the Senate hearing on his nomination to be Secretary of Health and Human Services, Sen. Tom Daschle spoke of health care as a pyramid, with primary care at the bottom and specialized care at the top. He stated: “Every country starts at the base of the pyramid with primary care, and they work their way up until the money runs out. We start at the top of the pyramid, and we work our way down until the money runs out. And the money runs out. And so few people get good primary care and wellness. And so we have to change the pyramid. We have to start at the base.”

Below, in the second part of a two-part blog post, Kevin Grumbach, one the nation’s leading experts on primary care and the health care workforce, sets forth a plan to revitalize primary care in the United States. In part one of the post last week, Grumbach discussed some of the reasons for the deficient state of primary care, as well some of the consequences of this situtation and its impact on efforts to expand coverage.

At the federal level, a bold initiative is urgently needed to revitalize primary care. This initiative needs to be comprehensive, not piecemeal, and simultaneously address physician payment reform, the practice infrastructure, the training pipeline, and research needs. Although Congress and the new administration face the daunting challenge of a large federal deficit and economic recession, many elements of a primary care renewal initiative could be implemented in a budget-neutral fashion, and other elements require only small amounts of new investment relative to the overall size of the federal health care budget.

Physician Payment Reform

Medicare not only is the nation’s largest health plan in its own right, but also sets the trends for physician payment policies used by private health plans. Medicare should revalue its payment policies to reverse the widening gap between primary care and specialist compensation. As recommended by the Medicare Payment Advisory Commission (MedPAC) in its June 2008 report, Congress should significantly increase Medicare fees for primary care services.

MedPAC also recommended that Medicare implement more demonstration projects for enhanced primary care payments, such as care coordination fees, for practices that adopt medical home innovations. Given the existing evidence on the value of primary care and the urgency of the primary care crisis, Medicare should not limit this initiative to small demonstration projects and wait years for more evidence to be accumulated, but should immediately scale up the medical-home payment policy for nationwide implementation and provide much greater emphasis on new forms of primary care payment that shift from a pure fee-for-service, visit-based model to one compensating practices for comprehensive, whole-person care, including care provided outside of a traditional face-to-face visit.

The Centers for Medicare and Medicaid Services (CMS) should work with organizations such as the National Committee for Quality Assurance and primary care professional societies on certification standards to assure that practices are held accountable for the standards that merit enhanced payment. Additionally, Congress should require that private health plans participating in the Federal Employees Health Benefit (FEHB) program adopt similar enhanced payment models for primary care, and should also insist that state Medicaid programs include some type of medical-home payment program as a condition for receiving federal matching funds.

Finally, Congress needs to modify the rules of the Medicare Sustainable Growth Rate (SGR) so that primary care physicians are not financially penalized for inflation in physician payments that are caused by excessive growth in expenditures on imaging, diagnostic procedures, and other non–primary care services. Under the current SGR policy, Congress sets a target for the rate of growth in overall Medicare physician expenditures, with fee levels being reduced if the target is exceeded. Between 1997 and 2006, growth in expenditures for primary care–oriented “evaluation and management” services accounted for only 14% of the overage in expenditures, with non–evaluation and management services accounting for the remaining 86%. Because the SGR feedback loop formula is based on total physician expenditures, the SGR triggers across-the-board fee reductions for all services, irrespective of the degree to which a category of service contributes to the overage.

A fairer approach to the SGR would create separate categories for evaluation and management payments and other physician payments to calculate annual fee updates. Adjustment to the SGR could be prospectively implemented in a relatively budget-neutral fashion, addressing future rates of payment growth rather than a redistribution of existing payments. Payment enhancements for primary care medical homes would require new dollars, but the North Carolina Medicaid program experience indicates that these new costs are likely to be offset by savings in expenditures for emergency department and hospital services, providing better value for the money spent.

The Practice Infrastructure

The federal government has a key role to play in catalyzing nationwide adoption of interoperable electronic health records (EHRs) in the ambulatory care sector — an information-age infrastructure investment akin to previous federal investments to build interstate highways and hydroelectric power. Health systems in much of the developed world are already far ahead of the U.S. in widespread deployment of information technology (IT) in primary care offices, largely due to direct government funding and support for this capital improvement. In the pluralistic U.S. health system, a single, government-purchased IT system for all primary care offices is probably less viable than government financing of diverse EHR systems with government-regulated standards for interoperability across practices and different sectors of the health system. President-elect Obama has pledged a $50 billion investment in new health IT, and this investment should pay particular attention to the needs in ambulatory care.

The second major infrastructure initiative should draw from another successful government model: the Cooperative Extension Service administered by the U.S. Department of Agriculture. The Co-op program, enacted in 1914 as collaboration between the federal and state governments, agricultural experts at land-grant universities, and farmers, created a network of agricultural field educators in every county in the nation to provide technical assistance to local farmers, contributing to the increase in agricultural productivity in the U.S. The Co-op program is still active.

Congress should launch a Primary Care Cooperative Extension Service, with family doctors rather than family farmers as the target audience. This program would link local practitioners with regional centers of excellence in primary care, perhaps based at land-grant universities, with the collaboration of other organizations with expertise in primary care delivery such as the Institute for Healthcare Improvement, TransforMED, and professional societies, to provide the hands-on technical assistance needed for widespread adoption of innovative practice models to modernize the primary care medical home.

For example, these Primary Care Co-ops could facilitate training of practice staff in chronic care programs, application of IT to create patient registries for panel management to improve delivery of chronic and preventive care, and same-day “open access” appointment scheduling models. These Co-ops could work synergistically with regional Medicare Quality Improvement Organizations. Financing of these Primary Care Co-ops could come from a mix of federal and state government funds, along with a surcharge on private health plans that stand to benefit from having more effective and efficient primary care networks for their subscribers. A modest investment of $100 million annually would provide $10 million to operate 1-2 Primary Care Co-ops in each of the ten Health and Human Services regions.

The Training Pipeline

The one existing federal program specifically dedicated to supporting the training of primary care physicians and physician assistants is Section 747 of the Title VII program of the Public Health Service, administered by the Health Resources and Services Administration. This program provides grants to health professional schools and primary care residency programs to support the education of primary care physicians and physician assistants, with an emphasis on producing graduates who will care for underserved populations. Section 747 funding was reduced from $92.4 million in fiscal year 2003 to $48.0 million in 2008 — a reduction equivalent to about two hours’ worth of government spending on Medicare. Twenty-five years ago, in the heyday of medical school expansion, Congress appropriated $2.7 billion (in 2008 dollars) for all Title VII health professions programs.

Although the Office of Management and Budget has questioned the effectiveness of the Title VII program as a whole, several recent studies have demonstrated successful outcomes from the Section 747 grants program. Graduates of medical schools and residency programs that received Title VII grants at the time these students and residents were in training are more likely to enter primary care, practice in an underserved area, work at a community health center, and join the National Health Service Corps (NHSC) than their counterparts who did not attend Title VII–funded schools and programs. A Title VII Section 747 funding level of $200-$300 million per year would restore the integrity of this program and allow it to reach many more students and residents. A renewed Title VII program should challenge training institutions to prepare primary care clinicians to be leaders in implementing innovative new models of primary care and developing more patient-centered medical homes. The Title VII budget is also dwarfed by the $8.8 billion Medicare spends annually on graduate medical education payments — almost all of which flow to hospitals sponsoring residency programs, tying funds to hospital-based settings emphasizing specialty training and hospital service priorities rather than primary care training in community-based ambulatory settings such as community health centers. Congress should implement the recommendations issued in the Nineteenth Report of the Council of Graduate Medical Education in 2007. These recommendations call on Medicare to “broaden the definition of ‘training venue’ (beyond traditional training sites),” “remove regulatory barriers limiting flexible GME training programs and training venues,” and “make accountability for the public’s health the driving force for graduate medical education.”

The final key element of an educational pipeline strategy is to increase funding for the NHSC to provide debt relief to more medical graduates as an incentive for them to enter primary care careers. Although the NHSC should not lose sight of its principal charge, which is to use service obligation to place health professionals in communities with the greatest unmet need for these clinicians, an expansion of the number of NHSC positions should be coupled with greater flexibility in the administration of NHSC awards. One important modification that would work synergistically with more flexible Medicare GME policies in support of community-based primary care training would be to allow physicians teaching and supervising students and residents in underserved clinical settings to be eligible for loan repayment, even if the physician performs less than the 30 hours per week in direct patient care currently required of NHSC participants. Another consideration would be to allow primary care physicians to qualify for partial loan repayment if they could demonstrate that they had some minimum level of uninsured and Medicaid patients in their practice, even if the practice was not located in a federally designated shortage area. Creating a more robust NHSC is another area where some combination of financing from federal and state governments along with matching contributions from private health plans would be an appropriate mix. In 2006 there were over 4,200 vacant positions in underserved areas for NHSC physicians, yet only 1,200 NHSC physicians available to fill these slots. A tripling of the NHSC budget, from $155 million to $465 million annually, would fund about 3,400 additional health professionals annually for a three-year primary care service obligation.

Research

Elias Zerhouni, until recently the director of the National Institutes of Health, explained prior to stepping down from his position in September 2008 that “our goal at NIH is to usher in an era where medicine will be predictive, personalized and preemptive.” Central to this vision is mapping individuals’ genomes and using this information to tailor clinical interventions, such as emphasizing aggressive cholesterol reduction for a patient with a high genetic predisposition to coronary heart disease or selecting a blood pressure medication based on a patient’s pharmacogenetic profile. However, when the public is asked about its view of personalized medicine, they indicate that they want a relationship with a health care professional who treats them as a whole and unique person and not merely as the sum of their personal genomic microarrays. One might question, then, why an agency pursuing a vision of research in the service of personalized health does not have an institute dedicated to research in the care of the person as a whole. The NIH comprises various institutes organized around individual organs and diseases, such as the National Institute of Diabetes and Digestive and Kidney Diseases and the National Heart, Lung, and Blood Institute. Congress should call on the NIH to establish a new NIH Institute of Primary Care Research, awarding research grants to advance the science of whole-person care and community-engaged, translational research conducted in primary care settings. This initiative should be closely linked with the NIH’s Clinical Translational Science Award Roadmap program, and coordinated with practice-based research and prevention programs at the Agency for Healthcare Research and Quality (AHRQ) and the Centers for Disease Control and Prevention (CDC).

Conclusion

Rebuilding the crumbling primary care infrastructure is a priority for health reform in the United States. The nation will not be able to meaningfully improve access to care and build a better-performing health system when its foundation of primary care is so fundamentally unsound. Finding the funds to invest in a primary care revitalization initiative is a matter of political priorities, not lack of potential available resources in a health system that spends $2 trillion annually. A recent study concluded that Medicare would save $21.9 billion annually simply by directly negotiating with pharmaceutical companies using the same type of Federal Supply Schedule pricing policies employed by the Department of Veterans Affairs and Department of Defense. A small portion of such a Medicare pharmaceutical savings dividend could fund much of the new cost of a primary care initiative. Responsibility for investing in a renewal of primary care is not solely the responsibility of the federal government, but renewal is unlikely to occur without strong leadership from the federal government.

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  1. There They Go Again on the Medical Home | Diario BV
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6 Responses to “Rebuilding Primary Care: A Call For Federal Action (Part 2)”

  1. Kevin Grumbach Says:

    Several of the comments about my blog rightly call attention to the diverse groups of health professionals working in primary care and the need to rethink the roles and tasks performed by the different members of the primary care team. Some of the criticism of my blog as being overly physician-centric is legitimate. Nurse practitioners and physician assistants are key contributors to the primary care workforce, and research has shown that these health professionals perform as well as physicians in many of the tasks of primary care, and may do better on some aspects such as patient education. But the primary care system is broken just as much for NPs and PAs as it is for physicians. For PAs, you can take the recent trend in the percent of new graduates entering primary care and superimpose it on the trend for the percent of medical school graduates entering primary care–it’s the same steep drop. Data are less clear for recent NP graduates, but there is suspicion that a growing percent of these clinicians are also entering specialty practice areas. I would agree with the thrust of Plotzker’s observations, which is that payment reform is only part of the solution and probably the bigger challenge will be to redesign primary care practices to achieve what I referred to in Part 1 of my blog as the “innovative models of team care required of a 21st Century, patient-centered medical home.” Of course, resources are needed in primary care to fuel practice transformation. Investment in practice improvement would make primary care a more hospitable and satisfying career for clinicians for all stripes–physicians, nurse practitioners, PAs, and other professionals and staff collaborating in these practices. The type of model Physasst proposes, with primary care physicians serving as circulating consultants for NPs and PAs may be one alternative for redesigned practices, but I see many other types of redesigned team models evolving including ones that have physicians, NPs and PAs all sharing in directly delivering clinician-level services with other team members such as medical assistants and health coaches taking on more of a delegated role in routine chronic care and preventive care services.

    Hal Luft’s comments address a different issue, which is ways to finance coverage of primary care services. As is typical when Dr. Luft and I join in debate over health care financing, I agree with about half of what he proposes. His work on investigating variation in health care costs based on episodes of care has been helpful in demonstrating how most of the high variation, high cost expenses occur out of the primary care sector, with expenditures on preventive care and non-acute ambulatory care services being more predictable and less costly. I tend to agree with Dr. Luft that these distinctions should be more fully appreciated in discussions of financing reform. Where we tend to part company is over the question of whether to create tiered premium systems for financing primary care, with patients bearing different levels of direct responsibility for premium payments based on the type of primary care coverage option they select . My own preference is to promote universal access to primary care through a public benefit approach, and use more supply-side directed strategies such as provider-targeted incentives and control of capacity to address potential overuse of referral services, imaging, etc. among primary care clinicians.

  2. richard plotzker Says:

    My thanks to the two nurse practioners for their insight. In a few weeks we have our ACP regional annual meeting. This year’s guest of honor is a former president of the organization, a primary care internist at a premier university center who has been at the forefront of trying to make primary care more appealing to its practitioners and more accessible to the patients. I will remind him that allies are lurking but not always recognized to the extent befitting their efforts.

    I think the two posters raise an interesting question, namely how much training is really needed to do the things asked of us and when do we get overqualified. This weekend on call I saw a patient who had treatment of a multinodular goiter six months earlier who was admitted to the hospital for something else. As best I could tell, the endocrinologist never saw her. There is a computerized note from one of the center’s nurse practioners, certainly a decent note, indicating that she had run the situation by the endocrinologist at the initial visit and they decided to wait on treating. Four months later there is a computerized note describing a telephone call between the endocrinologist and a family member getting a progress report, then deciding to proceed to radioiodine. The primary physician was somebody from the FP clinic. I could certainly understand her being a bit annoyed having referred somebody to an expert but getting the actual care done by somebody who is really a diabetes nurse educator with less experience in thyroid disease than the person making the referral. I’d wonder a little about my colleague sending somebody off for something irreversible without ever having tried to examine the thyroid himself.

    So when is somebody properly qualified, overqualified or underqualified? As an attending physician should I even bother to give residents my insights into diabetes or review articles on pheochromocytomas when the education that they acquire and the exams they must hurdle with a measure of terror provide little separation between the type of work they do and what others do?

    I think the first on the scene for much of primary care will continue to be the RN’s and it is going in that direction for a fair amount of specialty care as well. In both realms it seems to be defaulting in that direction largely by the unwillingness of the physicians to do straightforward or preparatory work themselves. So let the NP’s take histories and the cardiologists do caths if that’s how everybody likes their teams assembled. It may be better for the public to just develop assessment and treatment guidelines, then let everybody follow them irrespective of the academic pedigrees that brought them in contact with the patients.

    Some institutions have been slow to adapt to this reality. Medical schools and residencies will have to change. If training physicians for primary care has become a dead idea better defaulted someplace else then my esteemed colleagues at the ACP will need to recognize that the niche for their members is patient complexity and not necessarily ready patient access in high volume. The residency system will have to change as well. There is no point in intimidating a medical school graduate by the American Board of Internal Medicine by leveraging his elibibility to engage in hospital care when somebody else who would likely score even less gets past the credentials committee.

    rich the furrydoc

  3. physasst Says:

    Well, a complete overhaul in CMS reimbursement for cognitive services is essential. My feelings, are that even with this, physicians will continue to avoid primary care. Obviously, as a PA, I have a vested interest in seeing my profession flourish, so there is bias there. I feel however, that in the future, we will see primary care clinics almost exclusively staffed by PA’s and NP’s, with 1-3 circulating “consultants” (MD’s) who would not have a patient calendar or schedule, and would simply be available to provide some level of supervision, and would be available for immediate consideration should the midlevel encounter those occasional patients that are very complicated and require some additional help. This would accomplish several things. It would increase patient access, although we would need to drastically increase PA/NP recruiting, and provide incentives for them to practice in primary care, it would decrease expenditures, as PA’s and NP’s cost less, and it would still provide optimal care as there would be some physician collaboration and oversight.

  4. florencelives Says:

    With all due respect, your post is topheavy on the physician end of things without even acknowledging the work of nurse practitioners and physicians assistants in providing primary care, especially in underserved communities.

    I’ve been doing this work for nigh on 20 years, and we need to deal with the full spectrum of health care providers who are out there RIGHT NOW doing the work of primary care.

    Throwing more money/support to MDs may be part of the solution, though I think it would take a lot more than that for primary care to gain any status in a medical hierarchy that reveres specialists and subspecialists.

    This is no time to relegate an important part of the primary care workforce to invisibility.

  5. rmplotzker Says:

    As an endocrinologist who did internal medicine for eight years before bailing out in the late 1980′s, I would like to expand the comments beyond one of money and reimbursement to how the physician spends his waking hours, and frequently some hours that were not meant to be waking.

    In 1993 the New England Journal ran a series of comments called something like problems in primary care where a handful of program directors wrote essays on how to make careers in primary care more attractive to their residents, who were then training at the most competitive programs in the US. The comments included not only income but educational debt, control of lifestyle, coping with capitation and DRG’s that were first being introduced and erosion of autonomy which attracted these immensely talented medical graduates into the profession in the first place. In addition there were issues of mastery of a body of expanding clinical science that few generalists could hope to attain and limited peer and public recognition for the efforts expended. We fast forward fifteen years and the NEJM again ran a symposium of problems with primary care, this time not from the residents’ esteemed professors but from purported to be primary clinicians but judging from their titles, never had to pay the office rent or tap into the line of credit to meet payroll or phone bill, let alone take a call from the answering service at an inconvenient time to personally deal with an insulin misadventure. These people have buffers, whether residents or nurse practitioners who function as human shields so the research functions of their positions can proceed.

    One of the posters in Part I of this essay requested a distinction between subspecialists like myself who function by evaluating patients in the exam room from those whose patients are more typically covered in sterile drapes. Economically I am very much like the primary physicians, in fact much more like them than I am like either the health care researchers of NEJM 2008 who come in the guise of primary physicians or the program directors of NEJM 1993. What differs is how much I enjoy being with the patients, mastering a certain body of medicine though limited, acquiring a reasonable measure of regard from within the medical community for the specialized skill that I’ve been priviledged to attain, not having to be the first one on site when a medical mishap occurs and not having my work follow me home. My primary brethren, which could have been me had I not made an escape effort two decades back, by and large have a lot more hassle than me and much less of what a former governor of California once termed psychic dollars.

    I think if the public really wants to make direct patient care an attractive endeavor for somebody to pursue from residency completion to retirement, their public officials and the leadership of medicine will need to take a much broader look at reality than tossing a few extra shekels at the disaffected MD’s. If you were to spend an hour looking at the postings of physicians in office practice on their website, a place like Medscape’s Physicians Online, you will encounter a lot of unhappy campers who have exchanged patient care for processing their patients through the system as quickly as they can do safely, read maybe a quarter of what they think they should, spend some of that patient time on the phone with an insurance clerk of two digit IQ to justify a medical decision that any experienced peer would find self-explanatory, finally ending the day with a phone call at midnight of an out of range blood sugar where the nurse making the call lacked the insight to assemble the background information needed to assess the isolated number which she conveyed but will now take five more minutes of rummaging through the chart and computer to resolve. That is primary care, the same stuff that the residents observed happening in 1993 that remained integral to the careers in 2008 of those who heeded their distinguished professors’ advice to stay with internal medicine or family practice or pediatrics.

    Go fix the money disparities. This is long overdue. But if you fix only this, the graduates of American medical schools will still shun the opportunity to devote their talent and energy to primary care.

    rich the furrydoc

  6. Hal.Luft Says:

    It is unusual for me to take a more extreme position than my long-time colleague, Kevin Grumbach, but his thoughtful proposals to enhance the role of primary care practitioners do not go far enough. Increasing fees for primary care is a critical first step, paying something extra for providing a medical home is necessary, as is covering the upfront investment costs of implementing electronic records. To realize the potential of primary care, however, the delivery system should be redesigned to place primary care practitioners (PCPs) in the center of how ambulatory care is organized and financed. (With the rise of hospitalists, inpatient care is increasingly “separable” and is best organized around care delivery teams composed of physicians and the hospitals in which they care for patients.)

    By having a universal pool (1) pay directly for inpatient care with an expanded DRG payment covering all the associated costs and (2) make available payments to cover the ongoing costs of chronic illness management, the risk associated with the occurrence of expensive illnesses is pooled. What remains is the cost of treating minor acute problems and the small amounts we spend on preventive care—these are easily age-sex rated. There is substantial variability across physicians, however, in the costs incurred by their patients for these minor interventions, and more importantly, the ongoing management of their chronic illnesses. With the risk of occurrence offset by the universal pool it is possible to design “premiums” that reflect the differential practices and fees of each PCP and the other providers seen by that PCP’s patients.

    PCP-based premiums eliminate the need for external fee constraints, formularies, or approvals on the use of tests and imaging. Everything can be covered, but it is up to the clinicians to decide when to use what for whom. Spending more time face-to-face, or on the phone, with a patient may eliminate the need for an immediate (and expensive) test. This can be reassuring to both patient and physician and reduce the patient’s overall premium while increasing PCP income and practice satisfaction. PCP-based premiums shift the economic consequences of clinician’s choices—it will no longer be the case that one can argue that good care simply requires tests or drugs the insurer won’t pay allow. Clinicians will need better information on what works and doesn’t, based not just on the narrow set of patients in formal trials, but on the broad mix of patients in usual practice who often have multiple problems, difficulty adhering to regimens, and varying preferences. We now have the ability to capture the necessary data and convert it to information useful for community-based practitioners. A new financing model will create the demand for such information; a redesigned system can supply it.

    Our rush to maintain coverage for those put at risk by the current financial crisis is appropriate as part of a stimulus package. The long-term rate of growth in health expenditures, however, is unsustainable and will not be addressed by simple expansions of coverage in the existing delivery system. We can address many of the fundamental problems with an increased focus on primary care, but to do so, we need more than just a re-jiggering of fees and computers on clinician’s desks. I have laid out such a plan in Total Cure: The Antidote to the Health Care Crisis, Harvard University Press, 2008. It addresses all the components of a system-wide change needed to get us on a more sustainable, higher value and less expensive path. We need to consider everything from information access to medical education, from malpractice coverage to employer compensation plans, and perhaps most importantly, the new roles of primary care and specialty practice.

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