Lawmakers warned primary care can't absorb ACA expansions

Testifying at a Senate hearing, physicians call for payment reforms as well as additional support from teaching hospitals and the AMA-convened RUC.

By — Posted Feb. 11, 2013

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To adequately prepare for 30 million people who will gain insurance under the Affordable Care Act, primary care needs an overhaul that puts those physicians on more equal ground with specialists, witnesses told a Senate panel on Jan. 29.

The law authorizes the expansion of Medicaid and the creation of marketplaces to buy affordable private insurance. But coverage alone does not necessarily guarantee access, said Sen. Bernard Sanders (I, Vt.), who chairs the Senate Health, Education, Labor and Pensions primary health and aging subcommittee.

About 45,000 people die each year in the U.S. because they do not have health insurance and they don't get to a doctor on time, Sanders said, citing statistics from a report he released at the hearing. “The Health Resources and Services Administration says we need 16,000 primary care practitioners to meet current health care needs,” but those ranks have been shrinking, he said.

Fewer than one in three doctors practices primary care, compared with half of all physicians 50 years ago, according to the report. Over 52,000 additional primary care physicians will be needed by 2025, more than a decade after the ACA's major coverage reforms take effect. Yet in 2011, only 7% of the 17,000 students graduating from medical school had chosen a primary care career. Growth in the number of physicians “is mostly due to a rise in specialists,” Sanders said.

Sanders and witnesses before the panel emphasized that graduate medical education programs typically don't promote primary care. Medicare, for example, has fostered growth of residencies in specialty fields, providing as much as $10 billion each year to teaching hospitals without providing any emphasis on primary care, he said.

The culture of medical education simply doesn't support it, said Fitzhugh Mullan, MD, a professor of health policy and pediatrics at George Washington University in Washington. Medical students and young physicians want to choose careers that offer a better quality of life than primary care, he said.

The National Health Service Corps has done much to boost the work force in health care shortage areas by helping to repay loans for new doctors who practice there, but the program will need to expand to accommodate newly insured individuals under the ACA, Dr. Mullan said. Another initiative, the Teaching Health Center Program, authorized by the ACA to promote training physicians in community-based primary care settings, has major implications for reform efforts, he said.

“To date, 22 THC residency programs training 140 residents are up and running.” Yet its status as a demonstration means that funding runs out in 2014. Dr. Mullan suggested that Congress make the program permanent.

Additionally, “if we increase hospital reimbursement for primary care physicians in training over specialists in training, we will have more primary care physicians,” testified Claudia Fegan, MD, chief medical officer of the John H. Stroger Jr. Hospital of Cook County in Chicago.

Primary care says it's not paid enough

Efforts to target medical students and residents for primary care training will not succeed without payment reforms, however, said Andrew Wilper, MD, MPH, an assistant professor of medicine at the University of Washington School of Medicine in Seattle.

Primary care doctors often don't get paid adequately for the time they spend with patients, Dr. Wilper said. For example, an ophthalmologist can bill the same code as a primary care physician for a 10-minute exam with very little follow-up needed. However, the primary care doctor billing with the same code “generally spends 25 minutes with [a] patient face to face, has 25 to 30 minutes postcare documentation and follow-up and 25 to 30 minutes between visits. … But reimbursement for these two services are identical,” Dr. Wilper said.

1 in 3 doctors practices primary care medicine today, down from half of all doctors 50 years ago.

He and others at the hearing mentioned the influence that the American Medical Association/Specialty Society Relative Value Update Committee, known as the RUC, has on physician pay. The committee's recommendations on how to pay for different physician services are accepted by the Centers for Medicare & Medicaid Services at least 90% of the time and are followed by many private insurers. The panel is dominated by specialty physicians, Sanders said.

The RUC in particular “wields tremendous influence over Medicare payment rates,” Dr. Wilper testified. “One estimate has the RUC directing $54 billion in federal spending annually. Yet the group has no government oversight.” He said the RUC offers changes to payment rates in a way that favors surgeons and other specialists. Primary care doctors on average get paid 30% to 60% less than subspecialists, he added.

In her testimony, Dr. Fegan asked that the AMA increase primary care representation on the RUC.

RUC Chair Barbara Levy, MD, said such steps already have been taken. In 2012, the committee added two primary care seats, one for a representative from the American Geriatric Society and the other a rotating seat for an actively practicing primary care physician. CMS also adopted RUC recommendations to create care coordination codes that recognize the additional work primary care health care professionals often do, such as transitioning patients to different care settings, she said.

The panel “is an independent group of physicians from many specialties, including primary care, who use their expertise on caring for Medicare patients to provide input to CMS,” Dr. Levy said. More than 300 experts participate in a typical meeting, and information on the panel is publicly available, she said.

Specialty doctors also face shortages

The primary care shortage has gotten a lot of press, especially with respect to the ACA and the aging of the population, said John A. Wilson, MD, professor of surgical sciences and vice chair of the Dept. of Neurosurgery at Wake Forest University School of Medicine in North Carolina. He also is the chair of the Washington committee for the American Assn. of Neurological Surgeons and Congress of Neurological Surgeons and is its physician representative for the Alliance of Specialty Medicine.

But it's not just primary care facing a shortage, Dr. Wilson said. The Assn. of American Medical Colleges also has predicted an comparable shortage of certain specialists, such as cardiologists, gastroenterologists, neurosurgeons, and surgical specialists in particular. “So no matter how you look at it, a shortage of that magnitude of any of these critical specialties is going to affect the health care of the U.S. population,” he said.

Addressing the payment issues raised at the hearing, Dr. Wilson said the criteria for evaluation and management documentation and coding by doctors is the same, regardless of the specialty. An ophthalmologist might be able to do a single-system examination of the eye, “but if it's a comprehensive exam that's going to result in high-level E&M code and reimbursement, it's going to take the specialty physician just as long as a basic full exam would take a primary care specialist.”

In a statement, the Alliance of Specialty Medicine urged the Senate panel to hold a similar hearing on the work force needs of specialists.

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How many U.S. doctors practice primary care?

The American Medical Association's 2010 Physician Masterfile estimated that more than 246,000 primary care physicians were practicing in the U.S., although the Agency for Healthcare Research and Quality said the number was closer to 209,000 after adjusting for several factors, such as excluding some retired physicians and those who now practice in non-primary care settings.

Family medicine: 79,831

General internal medicine: 71,487

General pediatrics: 44,933

General practice: 9,557

Geriatrics: 2,999

Total: 208,807

Source: “Primary Care Workforce Facts and Stats No. 1, The Number of Practicing Primary Care Physicians in the United States,” Agency for Healthcare Research and Quality, October 2011 (link)

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External links

“Primary Care Access, 30 Million New Patients and 11 Months to Go: Who Will Provide Their Primary Care?” Senate Health, Education, Labor and Pensions Subcommittee on Primary Health and Aging, Jan. 29 (link)

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