The Crisis in Primary Care

Hope everyone had a nice 4th of July!  I think I may have to be just a holiday blogger.  I get all of these ideas, but it seems I need these three day weekends to find the time to put my thoughts together into an entry for you all.  So my last posting started to tackle some of the components of the Patient Protection and Affordable Care Act (ACA) that the American College of Physicians (ACP) feels will help attract more medical students into choosing careers in primary care.  I wanted to address the other cause of the primary care shortage in this posting, which is retention.

There are a lot of frustrated primary care doctors out there these days.  My last posting provided an overview of the challenges a primary care doctor faces.  In addition to being a multi-tasker extraordinaire, primary care physicians have been facing increasing amounts of paperwork and regulations to be in compliance with everything from insurance companies, malpractice providers, professional organizations, and the government.  The rules change quickly, and the challenge of keeping up can be daunting.  Too many primary care doctors are deciding it’s not worth it, and are leaving the field.  

The ACA will enable millions of uninsured Americans to have health insurance, but this insurance will most likely be an extension of medicaid, or HMO plans, which many privately owned primary care practices do not accept.  Hospital owned clinics can afford to see patients with these insurance types, because even if they lose money in their primary care divisions, they can make that up with the services that those patients utilize throughout the rest of the organization.  Community health centers also play a very important role because they are mostly government funded, which enables them to provide a high level of care for medicaid patients.  Many primary care doctors have been hesitant to be “employed” by hospitals or community health centers, though, because of the loss of autonomy that path requires.  Since many primary care doctors will choose to continue to run their own practices, it is important that these doctors be able to afford to take care of the millions of uninsured Americans who will now be enrolled in Medicaid under the ACA.  With only 2% of graduating medical students choosing to practice in primary care, it’s important that we keep our current primary care providers motivated to stay on the front lines where they can care for the American public.


So in this photo you see me and my ACP colleagues with Representative Walsh whom we talked with in May.  In addition to Representative Walsh, I spoke with the senior aids for Representative Quigley, Representative Roskam, and Senator Durbin.  We asked these legislators to support and fund the following programs within the ACA so that Americans could feel more confident that after the millions of uninsured gain coverage, that there will still be primary care physicians for them to see.

Fixing the Flawed Payment System

Eliminate the Medicare Sustainable Growth Rate (SGR) and

Transition to Better Payment Systems for Physicians

  • The SGR is a major component of the formula the Centers for Medicare and Medicaid Services (CMS) uses to calculate physician payments for providing services to Medicare patients.  It is based to the Gross Domestic Product (GDP) and not on actual health care practice costs.
  • The SGR has produced steep cuts in physician compensation for services to Medicare patients.  The SGR is a target for expenditure on physician services.  If actual expenditures exceed the SGR, which they have every year since the formula was created, physicians’ payments are cut.  Because healthcare costs are going up much more rapidly than the GDP, physicians are facing deeper and deeper cuts to their re-imbursements every year.
  • If the SGR payment system is not replaced, Medicare physician payment rates will be cut about 40% by 2016.  Practice costs will rise nearly 20% during this time.  The baby boomers have just started enrolling in Medicare.  In the next 5 years there will be an additional 6 million seniors enrolling in Medicare.
  • The problem is that there is a huge national deficit with no money to fix the SGR.  We at the ACP spoke with our representatives about enacting legislation that in the absence of permanently replacing the current flawed Medicare SGR payment system, would at least enact legislation to provide the following three things
    • Stable payments for all physician specialties for at least 5 years while providing higher updates for undervalued primary care services
    • Requirements that different payment models be pilot-tested on a voluntary basis during the 5 year period of stable payments the above legislation would provide
    • Designation of a specific transition period for broad adoption of the new models that have been shown to be the most effective based on the pilots

Mandatory Funding for the Medicaid Comparability Program

  • Medicaid primary care payments are always significantly less than Medicare payments.  In some states, they can be less than half the Medicare rates.  This means that for the same service, a primary care doctor receives significantly less for the same work if they see Medicaid patients.
  • The Medicaid Comparability Program ensures Medicaid payment for visits and vaccinations by primary care physicians will be no less than 100% of the applicable Medicare rates.  
  • Mandatory funds have been provided in the ACA to fully implement this program at no cost to the states.

    Leveling the Playing Field

    Congress should ensure continued mandatory funding for the Medicare Primary Care Incentive Program (PCIP) through at least 2015 while enacting further reforms to support the value of primary care.  

    • A new report by the Council on Graduate Medical Education (COGME) recommends compensation to primary care physicians be increased to 70% of the average payment for other physician specialties in order to retain a sufficient supply of primary care physicians.  
    • PCIP begins to address inequities in payments for primary care physicians by providing a 10% bonus payment for designated primary care services provided by internists, family physicians, geriatricians, and pediatricians.  
    • While the PCIP falls considerably short of COGME’s recommendation, it will result in the largest sustained increase in payments to primary care physicians in decades.


    Planning for the Future

    Congress should ensure continued mandatory funding at the current levels authorized by the ACA to allow the Center for Medicare Services to fully implement the Center for Medicare and Medicaid Innovation.  Dedicated funding is needed to ensure that the new Center has the resources needed to accelerate broad pilot-testing and adoption of new payment and delivery models to achieve the following goals 

    • Improved access to primary care services
    • Improved patient outcomes
    • Achievement of better value for beneficiaries and taxpayers
    • Ensure that physicians and other clinicians and providers can count on the funding being maintained for their participation in and for the duration of any models funded by the Center


    Continued mandatory funding Patient-Centered Outcomes Research Institute

    • The ACA establishes a non-profit, tax exempt corporation, known as the Patient-Centered Outcomes Research Institute (PCORI) to provide comparative effectiveness information to assist patients, clinicians, purchasers, and policy makers in making informed health decisions.
    • The function of the institute is solely informational.  It is specifically precluded from making mandates regarding coverage, reimbursement, or other policies for any public or private payer.
    • As much as $700 billion of health care spending per year is wasted on tests and procedures that do not improve health outcomes.  Hopefully PCORI could provide information that would improve patient care, while reducing unnecessary health care spending.


    So hopefully a few of you out there have managed to get through this very dense synopsis of what we at the American College of Physicians believe the ACA will provide to the American people if certain programs are funded.  Clearly there also are many key areas of health reform that the ACA does not address.  There are also policies within the ACA that should be improved or revised, but we at the ACP strongly feel that we should not throw the baby out with the bathwater.  The aspects listed in both my last posting and this one are important advances to ensure access to primary care for all Americans.  Hopefully I’ve inspired at least a few of you to inform your friends and families of these important issues that the ACA adresses, or maybe even to write a note to your congressmen in support of funding these provisions within the ACA.


    About Kara Nance MD

    Kara Nance, MD FACP currently works in private practice in Rolling Meadows, IL. Dr. Nance approaches the care of her patients with a very holistic attitude that targets the many factors that contribute to overall wellbeing. She is a mother of 4 young children, and often brings her personal life experiences into play when helping her patients solve problems relating to life balance. In addition to her clinical practice, Dr. Nance is passionate about electronic medical records and the establishment of electronic health exchanges. She consults with local physicians, hospitals, and medical groups about transitioning over to electronic medical records. Kara also participates in advocacy activities relating to primary care. As a Fellow in the American College of Physicians and a member of the ACP's Northern Illinois Council, Dr. Nance frequently travels to Washington to lobby for important issues in health care reform.
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    2 Responses to The Crisis in Primary Care

    1. Michele Hauser says:

      Thank you again for so clearly explaining the aspects of the ACA that need funding from the doctors’ perspective. I am sure all Americans want to fix our system (even those who seem the most obstinate in blocking progress), but it is complicated so most only know the "sound bites" about it that they hear via the media. If all doctors would inform their patients as you are doing, much progress could be made as people understand more.

    2. Lee Trevor says:

      Good explanation on what is happening. Patients need to be informed on what is happening in the medicl field. We don’t get to hear as much in the newspaper articles. Thank you for helping us to understand what challenges the doctors face.

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