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    Simple steps can protect, expand primary care capacity

    Alan Sager, PhD, is a professor of health policy and management and director of the health reford program at the Boston University School of Public Health. He recently spoke with Medical Economics Editor-in-Chief Lois A. Bowers, MA, about how the need for more primary care can be addressed.

    Q: One of your areas of interest is preserving physician services in the healthcare system. What are some of the biggest challenges in that area?

    A: Primary care often resembles the weather in that we talk about it a lot, but we don’t do much that’s effective to either preserve or expand the capacity and availability of primary caregivers in the United States.

    Internationally, when we compare our country with the average rich democracy, the members of the Organization for Economic Cooperation and Development, we seem to have only about half as many primary care physicians (PCPs) per 1,000 [citizens] as is found in the rest of the world. We’re at about 0.8 PCPs per 1,000. That’s a pretty dramatic number that’s received far less attention than it deserves.

    The great share of people who make decisions are not yet worried about their own personal access and their families’ access to primary care. They’re typically people who either know a lot of physicians or know people who know a lot of physicians who are able to make a phone call and perhaps help an adult or child gain access to a family doctor. They’re not aware of how many people lack that access and don’t have someone they can call.

    Q: What are some of the other challenges?

    A: We may not realize how easy it is,  in some respects, to take substantial steps to protect and expand primary care capacity.

    Let’s say we wanted, hypothetically, to obtain 300,000 full-time-equivalent PCPs in the United States, which would drop panel size to about 1,000 patients per practicing patient-care PCP. And let’s say we pay them $300,000 each after practice expenses but before taxes.

    That sounds like a lot of money, but it’s $90 billion, just over 3% of healthcare spending, or less than 6 or 8 months’ increase in healthcare spending. Other countries aim to spend close to 10% of their health dollars on primary care.

    Rhode Island—interestingly, the only state with a healthcare commissioner—seems to have been pushing private payers toward expanding the share of their revenue going to primary care. That’s a concrete step that could be taken, and it doesn’t require much money.

    This approach really is very different from the ideas we keep recycling, such as loan forgiveness. Let’s say a person comes out of a residency with $200,000 of medical school debt. That’s only about 1 year’s salary differential between a physician in general internal medicine or family practice and an interventional cardiologist or diagnostic radiologist or lots of surgeons.

    Too many people assume that the salary differentials are products of legitimate free market sources and that if the market throws up those dollar figures, we can do little but respect them. If there were a functioning free market in this area of healthcare, I might say the same thing, but there isn’t. And sadly, there’s not much of a free market in most of healthcare.

    Given the cost of making primary care much more financially stable and attractive, the nonlegitimacy of the current salary differentials, and the enormous gap between the United States and other countries as to the availability of primary care, and also given the critical importance of primary care in preserving access, coordinating care, ensuring continuity and appropriateness of care, and also holding down costs, it’s remarkable that we’ve been proceeding for so many decades without taking effective action.

    Q: What can PCPs do to emphasize their value in the healthcare system?

    A: A brief conversation with every potential influential patient would help activate the necessary political and financial support. And maybe they could have a handout available that summarizes key points, an international comparison, how much good primary care with a panel size of 1,000 would really cost, and how hard it is to provide good primary care, especially to panels of 2,500 to 3,000—this is particularly true in the states that are expanding coverage under the 2010 reform law to lots of previously uninsured people.

    Q: So do you think accountable care organizations (ACOs) are part of the solution?

    A: Many Americans live, say, along the Ohio, Missouri, Mississippi rivers and their tributaries, and many people who live in those communities take water from the river. Everyone who drinks that water knows that it’s far safer, more efficient, and less expensive to clean up chemical discharge and sewage discharges before they enter the river rather than to try to clean all the water in the rivers.

    If we don’t control healthcare costs upstream—by making decisions about how much to spend, how to establish budgets that ensure that every needed hospital has sufficient revenue to cover the cost of efficiently provided care, how to pay doctors, and how to pay for prescription drugs and nursing homes and other caregivers—in ways that are reasonable and establish a fundamental caregiver/clinical access/financial equilibrium, the chances of doing that downstream are about as challenging as trying to clean up the Mississippi River in New Orleans.

    We try all sorts of expedients. We’re recycling managed care with a few of its more manifestly noxious components removed. Having learned that financial incentives to overserve result in overservice, and then figuring it’s OK to repropagate financial incentives to underserve without anticipating underservice, strikes me as wreckless folly.

    Those financial incentives work OK in institutions that have grown up with them, like Kaiser, HMOs, and the Veterans Affairs [system], but that’s because everyone understands how much money is available and understands the need to winnow out unnecessary care. What works in those institutions can’t be expected to work across a very diverse and complicated nation.

    Q: What can PCPs do to help control healthcare costs, and how can they get in a better position to do so?

    A: We can choose different approaches. When a physician has time to explain his or her judgment in a cooperative care-planning discussion with the patient and explain “I’m liberated to think clinically because I’m financially neutral,” it is an enormously valuable foundation for containing costs in clinically and humanly responsible ways. This can occur without a huge managerial, financial apparatus like an ACO. Another approach would be to have a primary care-based ACO, where money was poured into three “watertight” compartments—one to pay PCPs, another to pay specialists, and a third to pay hospitals, labs, imaging, long-term care, meds, and the rest.

    A cluster of PCPs could decide how to carve up the money in some proportion to effort, quality of care, patient satisfaction, and other factors. They would not stand to benefit by withholding care or by overproviding care, and they could help shape access to the other services for which everybody knew that only so much money was available, creating on a small scale the kind of clinical access/financial/professional equilibrium that other countries achieve upstream.

    It’s very hard in today’s world for PCPs to swim vigorously against the current or even tread water, because so many financial pressures work to their disadvantage, especially in the fee structures that exist, unless the new Medicaid adoption of Medicare [reimbursement] for 2 years spreads widely. But as we know, the Medicare fees for primary care are no bargain. Medicare fees are highly prejudicial against primary care in ways that no market forces or grounded research can justify.

    We’re not going to durably fix any of our cost, coverage, or appropriateness of care problems unless we rebuild a very solid and durable foundation of primary care, one that re-establishes and sustains pride and satisfaction and income under circumstances that liberate PCPs to do what their patients need.

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