Massachusetts health reformers charged with bringing costs down….often come back to the role of the primary care doctor. If patient care is coordinated by a central physician, they say, then waste should go down and patients might even stay healthier. Many primary care doctors agree with this theory…..but only if they see some serious changes in their working conditions. Karen Brown reports on one campaign to make that happen.
For several years now, primary care doctors have been leaving the profession because they say they make much less money than specialists, they have more paperwork to do, and they're expected to see more patients in less time — among other stressors. So in many states, including Massachusetts, it's getting harder to find a primary care doctor.
“The number of residents coming out in primary care specialty has been between 3 and 4 fold less than it has been in the past and ten fold than it has to be to have a functional health care system,” says Daniel levy, a Northampton-based internist who represents the Massachusetts chapter of the American College of Physicians. The organization recently released a ten-point plan that aims to make primary care attractive again.
“The primary crisis has been largely vetted as a problem in reimbursement, and there are problems in reimbursement,” says Levy, “but there are a lot of other issues in terms of how physicians do what they do, how they are graded by hospitials and insurers, how they are treated in the legal system, and how they interact with colleagues.”
The 10-point plan does call for an influx of funding into primary care practices. But it also calls for what they consider a fairer method of evaluating doctors' performance. Doctors have been livid about the insurance practice of tiering…or rating doctors based in part on how much money they spend on patients….and whether patients meet certain medical benchmarks. Levy says doctors are expected to approach healthy middle-aged patients the same way they approach, say, a very sick 78-year old.
“And if you grade pp how well they handle that 78 year old, based on assumptions how well one should treat healthy midlife adults, they will invariably come up short,” says Levy. “This is very frustrating to doctors who treat sicker patients, those who treat patients who are socially complex, the homeless, non english speakers.”
Primary care doctors — as well as policy makers — are looking closely at the idea of global payment, where insurers pay a lump sum to care for a patient, rather than a fee for every visit or procedure. Global payment has been championed by Governor Deval Patrick as a way to cut down on unnecessary procedures and improve overall health — although the legislature adjourned for the year without acting on the governor's bill. Doctor Levy says global payment has the potential to be better for primary care doctors and patients, because it encourages coordination among medical providers — and it would compensate doctors for counseling their patients, not just poking and prodding them.
“Global payment is definitely a goal. I think the problem with global payment is deciding how global should be made and what systems will be in place to monitor how well it works.”
The American College of Physicians' proposal also includes putting more effort into recruiting primary care doctors, offering loan forgiveness for medical students who enter the specialty, and reforming the liability system in massachusetts so doctors are less vulnerable to malpractice lawsuits . But even with better working conditions, Levy concedes that a reformed health care system must eventually come back to money.
“If you want a more integrated, more quality conscious primary care system, you have to pay for it. You can't take physicians who are being run ragged….and have them all of a sudden start to manage a social worker and translator and home services and imagine that can be done with the same budget that you were using five years ago.”
Of course, if more money goes to primary care, analysts say, it must come from somewhere else….whether it's specialists or hospitals, consumers or insurance companies. So far, no one has quite worked out an equation that satisfies everyone.