Primary care seeks more pay, respect for undervalued services

Despite improved efficiencies, it's a challenge for New Hampshire internist Fred Kelsey, MD, and his eight partners to see enough patients to break even while still giving them the care they deserve.

The time and financial pressures lead to physician burnout, resulting in Mid-State Health Center in Plymouth, N.H., having the same difficulty that others around the nation have faced in recruiting young doctors. The pool of applicants has shrunk as fewer U.S. medical graduates choose careers in general internal medicine, opting instead for higher paying specialties or specialties with fewer hours.

"The No. 1 dissatisfaction of primary care physicians is the time pressure," Dr. Kelsey said. "We need time to take care of these people. We can't talk faster, and patients can't learn faster. We need time."

But that time isn't reimbursed by health insurers or Medicare. Now American College of Physicians leaders are proposing a way to change that. The ACPis among several physician associations that hope through change they will be able to re-ignite waning interest in specialties crucial to the health care system as it cares for a growing and aging population. They also hope new models will improve the care physicians can give to chronically ill patients.

On Jan. 30, ACP leaders called for a national Medicare demonstration project that would test a new model of care that links higher reimbursement to the time-intensive care that produces healthier patients. ACP calls the model the "advanced medical home" and wants the Centers for Medicare & Medicaid Services to launch a pilot project on it by 2007, a request CMS says it would consider.

Under the initiative, the primary care physician would become the patient's central coordinator, said ACP President C. Anderson Hedberg, MD. Physicians working in an advanced medical home would have an electronic medical records system capable of prompting them when patients need specific tests, among other things.

Doctors also would be paid for:

• Time spent evaluating and managing patients, such as educating them about diabetes or hypertension.
• Care given via e-mail or telephone.
• Electronic health records used to track quality improvement.

"We want to put the promise of this model in the context of Medicare and other payers changing how they reimburse doctors," said Robert Doherty, ACP's senior vice president.

Changing the payment system will enable small practices, not just large groups, to make these changes, Doherty said.

Herb Kuhn, director of the CMS Center for Medicare Management, said a pilot was possible.

"We're excited to see this proposal and are enthused that the ACP has brought its ideas and energy behind this," Kuhn said.

Updating primary care

The Medicare pilot is one of several ACP proposals aimed at revitalizing internal medicine by making it professionally and financially satisfying. Other items on the agenda include reforming how Medicare determines the value of physician services; combining pay-for-performance programs with reimbursement reforms so doctors are paid for doing better, not doing more; and replacing the Medicare sustainable growth rate with an alternative that would assure predictable fee updates.

The ACP looked at the American Academy of Pediatrics medical home model of care for children with genetic or chronic illnesses that AAP developed in the 1960s. By the 1990s the pediatrics academy had established a national center to train pediatricians on how to put the medical home model into practice.

The American Academy of Family Physicians also has done pioneering work in patient-centered practice models in recent years, including a model to improve efficiencies in the office setting.

The pressure is on to change. In 2005, family medicine saw its eighth straight year of losses in the National Residency Matching Program. Only 82% of family medicine positions were filled, with 41% going to U.S. allopathic seniors. Internal medicine did somewhat better with 97% of its positions filling in 2005, 56% of them by U.S. allopathic seniors.

The ACP's proposed pilot is similar to the AAFP's Future of Family Medicine project. Both propose reshaping the primary care practice. However, the ACP's model hinges on funding the changes through higher Medicare payments. Larry S. Fields, MD, president of the AAFP, supports the ACP's proposals. If successful, the proposed Medicare demonstration project could ultimately help improve family physicians' pay as well.

"We deserve to get paid for what we do, and to make this kind of thing work you need to be paid for reviewing patients' data, communicating with them on the phone, everything you do, not just the face-to-face time in the office," Dr. Fields said of the ACP plan.

Physicians are interested in the AAFP's effort to overhaul family medicine, he said. About 400 practices applied for 20 slots that are open for the AAFP's pilot of its "personal medical home" model. The pilot program aims to restructure practices using team-based care, with electronic medical records as the central nervous system. The increased efficiencies are expected to raise a practice's total income 26%, according to the AAFP.

From the trenches

The ACP is basing its advanced medical home model in part on what's called the chronic care model, something the Group Health Cooperative in Seattle has already put into practice.

Eric Larson, MD, MPH, medical director for the Center for Health Studies at Group Health, said patients and physicians within Group Health can tap into an electronic medical record system to check test results or refill prescriptions, allowing physicians to manage more details of their patients' care.

For example, a hypertensive patient trying out a new medication can e-mail her blood pressure readings to her physician. If it looks like the dosage or medication needs to be changed, the transaction can be done by e-mail instead of a face-to-face visit.

Under the current payment system, physicians in small practices can't afford to adopt a chronic care model, Dr. Larson said, unless they also change to a boutique-style model. Group Health has more than 800 physicians, which gives it economies of scale.

"We need to figure out a way to deliver the continuity and coordination that emphasizes good primary care and not be hostage to brief visits," said Dr. Larson, who is also past president of the Society of General Internal Medicine and has chaired an SGIM committee on the physician work force.

"The ACP is saying this is a good way to give care," he said. "We need the policy-makers to give us an opportunity as physicians to demonstrate this."

Back in New Hampshire, Dr. Kelsey said it's a struggle to stay profitable. His practice at one point lost $800,000 a year.

He would be glad to be part of an ACP advanced medical home demonstration project if it made financial sense for his group. While he questions whether the model would work over the long haul, he is still optimistic.

"The idea is a really good one," Dr. Kelsey said. "We're really interested to see what happens next."