The Disappearance of Primary Care
As Uwe Reinhardt, the Princeton University economist writes, “Surely there is something absurd when a nation pays a primary care physician poorly relative to other specialists and then wrings its hands over a shortage of primary care physicians.”(1) Improving Medicare in preparation for an expanded Medicare-For-All can start here.
It is generally understood that any solution to the high costs and compromised quality and access to our medical system will depend on developing an adequate primary care base. Over the last 16 years the number of U.S. medical graduates choosing family practice residencies has dropped from over 50% to 8% (1500/year). Among pediatric and internal medicine residents only 2% will go into primary care. The rest are going into subspecialties. Half of the family practice residencies positions are being filled by graduates of foreign medical schools.(2) 21% of the U.S. populations live in physician shortage areas where primary medical care is badly needed. Now, with the Affordable Care Act, there will be an increasing demand for primary medical care because of increased insurance coverage. The aging population and aging family doctors will add to this need. It has been estimated that we will need to add an additional 52,000 primary care doctors by the year 2025.
So why do we face the disappearance of primary care physicians? It starts with money, of course. Costs for medical school leave school loans averaging $140- to $200,000. Then just as the student starts his/her 3 year residency program the loans start accumulating interest. After that the income from family practice is half that of the procedure oriented specialties. As with the rest of our society higher income implies higher status. This concept carries over into most medical schools where the family practice program is treated as an afterthought (although there is more lip service these days). The result is that any initial interest in family practice is soon suppressed.
Please bear with me for a brief history of the physician pay discrepancy.
One of the many ironies in our health care crisis is the role the American Medical Association has played in killing off primary medicine. This, of course, has been done with the approval of Congress and the Center for Medicare & Medicaid Services (CMS). Since 1991 Medicare fees for physicians have been based on the Resource-Based Relative Value Scale (the RBRVS). This system places high value on procedures and tests and low value on the thoughtful diagnosis, coordination and the caring for patients in their vast variety of medical needs. The values are applied to the items in the Current Procedural Terminology (CPT), a book published by the AMA for which it receives millions in royalties.(3) In1991 the AMA formed the Relative Value Scale Update Committee (RUC) to advise CMS on updating the relative value units. Because the CMS accepts 90% of its recommendations physician pay is essentially determined by this committee. This allegiance by CMS is unbelievable considering that the AMA represents only about 17% of practicing physicians in the U.S.(4) And the 31 member RUC has only 7 members representing primary care.(5) Until recently the membership on the committee has been undisclosed. And the minutes and proceedings of the committee were still kept secret. Under pressure the RUC is now releasing minutes but not the voting records of individual members. It should be noted that private insurers use the same relative value system but may pay somewhat more than Medicare by using a different conversion factor (with the same bias toward expensive procedures). Any permanent solution to this problem will require a different payment system for physicians. At the present time there is no unified and effective force that can address and solve this workforce problem.
So we have a non-representative medical organization (guild) designing a national physician payment plan that has effectively put primary medical care out of business. We might ask how they obtained so much power. The answer, one suspects, might revert back to the money. Since 1990 the American Medical Association has spent $30,097,082 on political contributions and $286,377,500 on political lobbying.(6) It would have been nice if this money had been spent on developing a primary care based universal health system for the United States.
It is time to move beyond the incrementalism of SGR and RBRVS debates, the no-value-added administrative costs and insurance company profits and the complexities of a 2900 page lobbyist-written health care law (Obamacare), the restricted access to care and the defects in quality care when compared to other countries. It is time for medical system reform powered by single payer financing. This would be improved Medicare for all. This is urgent. We have already lost almost a whole generation of primary care physicians.
- Uwe E. Reinhardt The Little-Known Decision-Makers for Medicare Physicians Fees. http://economix.blogs.nytimes.com/2010/12/10 /the-little-known-decision-makers-for-medicare-physicans-fees/
- National Resident Matching Program. Results and Data 2013 Main Residency Match. http://www.nrmp.org/data/resultsanddata2013.pdf
- Why The American Medical Association Had 72 Million Reasons To Help Shrink Doctors Pay. http://www.forbes.com/sites/aroy/2011/11/28/why-the-american-medical-association-had-72-million-reasons-to-help-shrink-doctors-pay/
- American Medical Association Membership Woes Continue. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3153537/
- Replace the RUC. Adding Seats: The RUC’s Slight of Hand http://www.replacetheruc.org/2012/02/14/ adding-seats-the-rucs-sleight-of-hand/#more-
- Opensecrets.org. The American Medical Association. Heavy Hitter http://www.opensecrets.org/orgs/summary.php?id=D000000068&cycle=A