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.

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

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.

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

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.