Steps toward a solution: Time to put Single Payer back "on the table"

During the health reform debate, one option we were assured was never seriously “on the table” was “single payer”, or Medicare for All. President Obama, who as a senator had indicated his support for this solution, backed away from it as fast as he could. In this he was undoubtedly encouraged by his many advisors, who have also encouraged bank bailouts, “compromise” on the debt ceiling, etc. (see June 18, 2009,“No Single Payer”: Sebelius – making policy for the powerful).  This is not to say that there were not supporters of single payer within government; there were and are. HR 676, “The Improved and Expanded Medicare for All” act, principally sponsored by Rep. John Conyers of Michigan, had nearly 100 co-sponsors in the House. Sen. Bernard Sanders of Vermont introduced a single-payer bill  in the Senate. Vermont, in fact, has become the first state to move toward a form of single payer on a statewide basis.

As anyone who has been reading this blog for any amount of time knows, I am a strong advocate of single payer. (A few of the many MSJ references: April 28, 2011 Perception and reality of economic inequality; July 22, 2010, Improving quality and access still requires coverage for all;  April 10, 2009, Does the nation need a clear policy on a right to basic health care?).

My reasons for support of single payer are several:

1. It covers everyone. No one is left out. There is no complex system of “these people get coverage this way, those people get coverage that way, and those people (too bad) are left out altogether.”


2. It provides a uniform benefit package. Everyone can get the care that they need, without concern about whether they are covered. In our current system, even many people who are insured have inadequate coverage. In addition, to the extent that the society decides to limit access to unproven or detrimental (see #5 below) or even “too expensive” care, no one gets it.


3. It saves money. Off the top, it saves the profit being taken out of the system by insurance companies and other for-profit businesses. It saves even more money by eliminating all that being spent by those companies to deny care claims and by providers of care to try to get paid (see A Modest Proposal: Bribe the Insurance Companies, August 23, 2009).


4. It puts us all in it together. This is a core method of ensuring social justice. The more educated and empowered among us will work to make sure that they get good care, and this benefits everyone.


5. It provides the basis for ensuring quality, by having a degree of control over what gets reimbursed, and therefore what gets done. It may not ensure quality by itself, but it is almost a necessary component.

In 1964, President Johnson signed the Medicare Bill in Independence, MO, giving cards #1 and #2 to former President Harry Truman, who had fought for national health insurance in the late 1940s and lost, and his wife Bess.Forty-seven years later, Medicare has proven its importance in providing a single-payer program for seniors. It is the largest payer in the country, and the rates that it pays for services determine those paid by other insurers. While expanding Medicare to everyone should be the centerpiece of health policy, it has instead become the target of proposals to cut coverage to those who already receive it, particularly from the right. This has led to a lot of bad ideas from politicians such as Rep. Paul Ryan and Sen. Joseph Lieberman (see Medicare: We need to expand it, not cut it!, July 1, 2011).

The “poster child” for a single payer system is Canada, which has had it since the early 1970s. Based on the principle of social solidarity, not often apparent in the US, the Canadian federal government set the criteria for the program (which is also called “Medicare”) and the individual provinces set the specific terms and fund it. There is local (provincial) autonomy within the boundaries established by the federal government (see December 14, 2009, Tommy Douglas and the Canadian Health System;  May 27, 2010, Universal Coverage and Primary Care: The US needs both). Several recent articles have addressed the degree to which changes in the primary care system to create “medical homes” in Ontario, Canada’s largest province, have enhanced the quality of patient care, access of patients, lowered cost, and increased the income of primary care physicians (see Rosser et al, “Progress of Ontario's Family Health Team model: a patient-centered medical home” [1]). It is critical to note that this Family Health Team program was really only possible on such a scale because Ontario, like the rest of the country, has a single-payer system.

The importance of increasing, or at least not decreasing, the income of primary care physicians relative to other specialist, has been addressed in several other posts. What about all physicians, as a group? The AMA and other physician groups were, after all, largely responsible for the defeat of Truman’s national health insurance program and were major opponents of the US Medicare and Medicaid programs. Surveys by Physicians for a National Health Program (PNHP, see especially “Single Payer National Health Insurance”) have shown increasing support for single payer among the physician community, with universal health coverage being supported by a majority of US doctors in 20 (Support for national health insurance among US physicians: 5 years later[2]).

A new study may help to persuade physicians that single-payer systems are actually in their financial interest. Writing in August 2011 in Health Affairs, Morra and colleagues report that “US Physician Practices Versus Canadians: Spending Nearly Four Times As Much Money Interacting With Payers”[3] (hyperlink to abstract). The title basically says it all. While both Canadian and US physicians spent time (translated into money!) interacting with insurers, the single payer in Canada and hundreds of payers in the US, about patient benefits and payment, the staff of US physicians spent 10 times the amount of time in such activities as did their Canadian counterparts. The authors estimate the cost to US physicians at $82,975 per physician per year, nearly 4 times the $22,205 cost to Ontario physicians. In addition, these costs fall disproportionately highly on small physician practices, which are more likely to be primary care. They conclude that “If US physicians had administrative costs similar to those of Ontario physicians, the total savings would be approximately $27.6 billion per year.”

From a financial point of view, we have an apparent dilemma in the US. The cost of Medicare is very high and creates financial threats to the economy. The reimbursement from Medicare to providers is often too low to make them a desirable payer. But there is a solution. It involves getting control over costs. First, do not pay for harmful or questionable interventions, do not pay major markups to generate excessive profit for private companies, and use the large scale of government purchasing to get good prices for drugs, unlike the boondoggle of Medicare Part D, the prescription drug program in which Medicare pays retail prices to pharmaceutical companies.

The solution is also to emphasize more primary care and prevention (October 18, 2010 Lower Costs in Grand Junction: More Primary Care, Less High Tech). The next steps will be harder, for they will involve making difficult decisions about the cost/benefit ratios of different types of care, particularly as the availability of new, expensive, high-tech interventions provide allure, if not always results.

The way not to do this is for policies restricting access for a part of the population (working and poor people) to be made by another part of the population (big businesses, politicians, and lobbyists) who will not be affected by those decisions. A single-payer system in which we are all covered by the same benefits does not automatically save money, but at least makes it possible.

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[1]; Rosser WW et al, “Progress of Ontario's Family Health Team model: a patient-centered medical home”, Ann Fam Med. 2011 Mar-Apr;9(2):165-71.

[2]Carroll A, Ackerman R “Support for national health insurance among US physicians: 5 years later” Ann Int Med 1Apr2008;148(7):566-7.

[3] Morra D, et al, “US Physician Practices Versus Canadians: Spending Nearly Four Times As Much Money Interacting With Payers”, Health Affairs August 2011 vol. 30 no. 8 1443-1450.

EMRs and Primary Care: The good, the bad, and the challenges

One of the centerpieces of health reform as promulgated by almost everyone, and very much the Affordable Care Act (ACA) is the use of electronic medical records (EMR, also called, in a more inclusive formulation, electronic health records, or EHR). The Health Information Technology for Economic and Clinical Health Act (HITECH) specifically addresses specifications for EMRs. Demonstration of effective use of EMRs, including “e-prescribing” (in which prescriptions are routed electronically directly from the physician’s office to the patient’s pharmacy of choice), maintenance of patient registries (who in your practice has diabetes?) and compliance with a set of quality measures (What percent of the people in your practice with diabetes have had their sugar measured? What percent are in control?) account for a great deal of the added payment for chronic disease management, as well as payment for patient-centered medical homes (PCMH).

EMRs are a good thing for many reasons. At the simplest level, the fact that the records are on-line, rather than in paper charts, means that they don’t get “lost” and any doctor can see the notes of any other doctor. A number of years ago, prior to going to a real EMR, a large public hospital with many clinics where temporarily lost charts often meant that patient notes generated in one clinic visit were unavailable to another clinic, scanned literally millions of pages into a very basic EMR. While having none of the advantages described below, even this primitive method was a real step forward for them in being able to access the records. At their best, EMRs allow effective communication between doctors in a practice. For large multispecialty practices, this can also be between different specialists, and can even be integrated with the hospital’s medical record so that information from hospitalizations is immediately available in the same “chart”. The more that information is put in “digitally retrievable” format rather than free text, the more easily and thoroughly that a patient’s health trajectory can be understood. This is not only for numeric values, such as lab results and blood pressures that can be displayed on a flowsheet or graph, but even for history and physical items: Was that heart murmur present at the last visit? What is the history of the different medications that the patient has been on? Patient registries, as noted in the first paragraph, become an effective way of evaluating and improving the care given in the entire practice, not just for one patient, and are almost impossible without an EMR.

EMRs are not problem-free, however. The most common issue for physicians is that charting takes longer; filling in all this data takes time. This is worst when a new EMR is implemented, as old data has to be input (and this can even be when changing EMRs, not just going from paper, since of course they rarely “talk to” each other), but continues to be, on average, more time consuming than paper charting. In part, this may be because the notes are “more thorough”, or, looking at it the other way, that paper chart notes were inadequate. But it is also because the very structured nature of the EMR requires that a significant number of things be  entered/clicked (even to indicate “not applicable” or its digital equivalent) that would have appropriately not been mentioned in a paper note. Much of this added documentation goes beyond the information necessary to provide medical care for the patient, but is required to comply with government regulations and ensure that the document is “legally” sound. (It is a time long since the medical record existed solely as a reminder to the physician of what s/he had done for the patient in the past!) In addition, some of those regulations require the physician, as opposed to another health professional such as a nurse, to personally document certain items in the record, often to a degree that seems unreasonable to physicians.

There is an ironic turn to this. Most discussion in public policy circles is directed to increased inter-professional function and team work, as characterized by the patient-centered medical home. In part, this is because the current and projected shortage of primary care physicians means that there is no way that they, working alone, will be able to meet the health needs of the American people; if they are already working on a “hamster wheel” (see Family Medicine in the Era of Health Reform - 3, May 23, 2011), the changes described by Phillips (see Primary Care, Medical School Debt, and US Health Needs: Analysis from the Graham Center, May 30, 2011 ) and discussed in detail by Margolius and Bodenheimer[1], will increase the burden beyond any hope of sustainability. In addition, an effectively functioning team of health professionals (including nurses, pharmacists, social workers, and others[2]) makes for higher quality care. This is very clearly articulated in Dr. Atul Gawande’s recent address to the Harvard Medical School commencement, “Cowboys and Pit Crews” published on his New Yorker  blog. The irony is the increased requirements mentioned above, sometimes explicitly stated in law, but often in federal regulations and most commonly by Medicare “carriers” and interpreted by institutional compliance officers, have increased what the physician, him or herself, needs to document in the medical record (and, by implication, have actually done him or herself). These requirements both decrease effective team function, and increase the burden of electronic charting.

Thus, the ability of the EMR to record, and hopefully make retrievable, large amounts of data, raises the expectation that that data will be inputted, and also allows monitoring to ensure -- in the cases where lawyers or compliance officers have concern – which individual is doing it. In any new technology that increases the ease of accomplishing something, or the availability of a person or data, there is the corresponding tendency to expect it; this often has the ironic effect of increasing, rather than decreasing, workload. The internet and email allow us to work from home; cell phones, pagers, and email all increase our availability even when not at work or at home. This allows us more flexibility, but it has also led to the expectation of immediate access and, for many professionals including physicians, the virtual elimination of the concept of “work” versus “off” hours. The electronic medical record allows me to chart from home – or anywhere I can get an internet connection – and so I do.

The introduction of a new EMR, already a complex, difficult and daunting process, is also often used to change workflow, the processes by which the work of the practice is accomplished. This is virtually always a mistake, for providers and staff must now learn not only how to navigate and document in a new and strange systems, but to do things in a completely different way. The changes may be desirable, or they may not be, but certainly will require time and effort to identify whether they are, work it out, and “get it right”. Thus, it is greatly preferable to change that workflow prior to institution of the EMR (or if necessary after it is successfully adopted); the alternative is that learning new processes, especially when they are poorly conceived, gets lumped in with and blamed upon the EMR, increasing resistance to its adoption and potential benefits.

An interesting, and perhaps important, sidelight of the introduction of the EMR in our family medicine clinic was that the implementation team, composed of experts from the computer company and “superusers” of nurses from our group practice, saw how much more complicated the practice – and thus the documentation – is in primary care than in other specialties. In most sub-specialty practice, a few diagnoses -- and thus a few types of workflow and documentation strategies -- account for almost all visits, while in primary care the breadth of encounters (acute/chronic, prevention, adult/child/pregnancy, medical/psychosocial) in a single session, combined with the complexity of dealing with multiple chronic conditions based in a variety of organ systems rather than one, is actually breathtaking (see, for example, Primary Care: What takes so much time? And how are we paying for it?, May 21, 2010, "Uncomplicated" Primary Care?, Oct 8, 2009). Contrary to what they had been led to believe, they discovered that primary care was harder and more complex and more difficult to document – and of course required seeing more patients in shorter amounts of time for less reimbursement (which also leads to an ability to afford fewer support staff). This team, at least, gained a new respect for what primary care practice involves.

As we inevitably and inexorably move to reliance upon EMRs, we must be on guard to resist all the temptations to load every possible expectation upon them, and upon the providers who use them. They have enormous potential to not only increase quality but to increase teamwork and communication, and to even be labor-saving, but only if used wisely and judiciously.

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[1] Margolius D, Bodenheimer T, “Transforming primary care: from past practice to the practice of the future”, Health Aff (Millwood). 2010 May;29(5):779-84.

[2] Even, for example, lawyers. A number of practices, particularly in academic medical centers (including our family medicine clinic at KUMC) have legal partnerships where lawyers (often from Legal Aid) and law students help patients with legal problems they could not otherwise get help with, right in the clinic. It is amazing how often a person’s health improves when they no longer are as worried about their immigration status, getting evicted, receiving benefits, or the implications of divorce, among other issues.

Would free medical schools increase primary care?

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An op-ed by Peter B. Bach and Robert Kocher in the NY Times March 28, 2011, “Why medical school should be free”, makes a strong argument for just that. They acknowledge that this might seem unreasonable given the fact that physicians, regardless of specialty, make so much more that the average American; indeed are “all but 2 of the 15 highest paid professions”. This data is from the Bureau of Labor Statistics, published just a week earlier. An article by Harry Bradford in the Huffington Post, “America’s 10 best paying professions: Bureau of Labor Statistics”, that indicates that 9 of those top 10 are physicians, surgeons and dentists, with CEOs the only non-medical profession cracking the group, and that at #9, ahead of psychiatrists (#10) but just behind family and general practitioners (#8). The actual numbers from BLS may be suspect; while $174K for FPs may be close to correct, there is no where I know of, one could hire an anesthesiologist for anything close to as little as $220K (or radiologist or orthopedist or surgeon).

So why shouldn’t students pay to get into such lucrative professions? After all, other schools, professional and non-professional, cost money; this is true whether the degree is in law, business, engineering and accounting, which all pay relatively well, or  music, art, teaching and social work, which pay much more poorly. What is special about physicians that should make them be able to go to school for free, as do, say, firefighters and police? Bach and Kocher argue that the high cost of medical education, with students currently averaging over $150,000 in debt and rising, contributes significantly to both the shortage of primary care physicians that this country desperately needs and will continue to need in increasing numbers, and the cost of health care, with physicians entering the specialties that make lots of money by doing lots of highly-reimbursed procedures, many of which may not be medically necessary. As discussed in the recent blog piece Primary Care, Medical School Debt, and US Health Needs: Analysis from the Graham Center (May 30, 2011), the shortage of primary care doctors is projected to significantly increase as a result of the aging of the population, the influx of formerly uninsured people through ACA, and the fact that students are entering primary care at a rate too low (just over 20%) to even replace the already-too-low percent of the physician workforce that is now primary care (just over 30%), not to mention raise it to the necessary 40%-50%. By making medical school free, and thus eliminating this debt burden, students who were interested in primary care would have far less disincentive to entering the field – and earn very good livings, as what is currently the 8^th most highly paid profession.

Going beyond this, Bach and Kocher suggest a creative method of financing the estimated $2.5 billion that this would cost (based on average current medical school tuition): charging for post-graduate (residency) training in non-primary care specialties. Medical school graduation (unlike most other schools, including graduate schools) does not prepare one to be a doctor; rather it prepares the student to be trained in a medical specialty (residency). Residents are not charged tuition, but are instead paid as workers (although it is often considered an educational “stipend”; labor law decisions have varied from state to state). Under this proposal, students entering primary care residencies would continue to receive the stipend, while those entering other specialties (in which they could expect to make a great deal more money) would actually pay (they suggest $50,000 a year, in current $) that would be put into a pool to cover the cost of medical school tuition. The actual process of collecting this money and transferring it to the medical schools, as well as controls on methods of gaming the system (for one, they note, medical schools raising the tuition as students no longer have to pay it themselves) would have to be fairly complex. Nonetheless, this is a great idea; if medical school and residency together are the educational requirement for practicing medicine, then the basic education would be free to the student while entry into higher-income specialties would require additional years of, essentially, tuition. There would be no restrictions imposed upon student choice, but the financial incentives would significantly switch from the “voodoo” workforce policy Dr. Phillips identifies (see May 30, 2011 blog) to one that is aligned with desired outcomes.

A particularly attractive aspect of this proposal is that it would not further add to the debt burden of lower-income students seeking to become primary care physicians; in the May 30, 2011 blog I quote E. Grey Dimond, founding dean of the University of Missouri-Kansas City Medical School (now the highest-tuition school in the US) saying “Farm kids in Missouri from little towns that need doctors can’t pay what we have to have.” Under the system proposed by Bach and Kocher, those farm kids – and kids from underserved urban areas – would have a chance to gain a medical education and return to serve their communities.

The other ostensible benefit, decreasing medical costs, is not likely to come from this policy alone, however. Indeed, those students entering those more highly paid specialties would wish to maintain their incomes at high levels to justify the additional cost of their education. If there indeed are many procedures being done which are not medically indicated, and there is evidence that there are (see, for example, Rita F. Redberg’s Op-Ed piece in the NY Times “Squandering Medicare’s money”, May 25, 2011), the way to reduce them is to place further restrictions on them and decrease the amount that they are reimbursed by Medicare and other payers. This would further decrease the financial incentive to choose these specialties instead of primary care.

An alternative, however, is to continue to pursue – and exacerbate – “voodoo” workforce policy. The AMA’s “RUC”, described in Outing the RUC: Medicare reimbursement and Primary Care, February 2, 2011, which is only willing to consider increased payments for primary care if the entire pie is increased thus permitting other specialists to not make any less, is a great example of how to do this. Another is the policy of “balanced benefits” contained in two bills, the Medicare Patient Empowerment Acts, introduced in the House by Rep. Tom Price and Senate by Sen. Lisa Murkowski, and strongly endorsed by the AMA, and described in detail by Dr. Don McCanne’s “Quote of the Day” on May 27, 2011.Hidden by the high-sounding names, this bill would destroy Medicare as it currently exists, and replace it with a de jure, as well as de facto, two-class system of health care. Under the current Medicare law, physicians who accept Medicare have to accept the amount Medicare pays for a given service, plus the amount that Medicare determines to be patient responsibility, as payment in full.  Under these new bills, Medicare patients could see physicians who do not now accept Medicare, use their Medicare benefits to pay the what it pays, and then pay out of pocket the difference between that and the doctor’s charge. Essentially, this would turn all but high-income Medicare beneficiaries into the equivalent of Medicaid recipients.

It is a vile proposal, which would harm most Medicare patients and pad the incomes of physicians. It is more than embarrassing that it has been so strongly endorsed by the AMA and many other physician groups, who are clearly in the business of increasing the income of their members rather than benefiting patients. Dr. McCanne notes that the American Academy of Family Physicians and the American College of Physicians (internists) are conspicuously absent from the group of endorsers. For that he, and I, and the members of these organizations, are grateful. The AMA and the other endorsers of the Price and Murkowski bills deserve the strongest condemnation from Medicare beneficiaries, their families, and the American people.

Primary Care, Medical School Debt, and US Health Needs: Analysis from the Graham Center

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Bob Phillips MD, Executive Director of the Robert Graham Center, the American Academy of Family Physicians’ (AAFP) DC-based policy center, gave one of the plenary speeches at the recent annual meeting of the Society of Teachers of Family Medicine (STFM). His talk, available at the Family Medicine Digital Resource Library (www.fmdrl.org) presented a great deal of data regarding the current, and anticipated future, state of the US primary care workforce. There are currently 222,308 primary care doctors (FPs, GPs, general internist, general pediatricians and geriatricians), or one for every 1358 people, and an additional 86,000+ NPs and PAs in primary care, for a total of about 308,000, or about 1 primary care provider for every 1000. This is not a bad ratio, looking at the nation as a whole, but geographic distribution is another matter, with the ratio of primary care providers (PCPs) to person ranging from 500:1 to 5,000:1 in various primary care service areas (PCSAs); the nearly 5000 PCSAs with a shortage have a deficit of over 54,000 PCPs, which is equal to the “surplus” in the 1,600 or so PCSAs who have higher ratios. And, of course, those underserved PCSAs comprise the vast majority of the US geographic area (see figure).

Phillips and colleagues estimate that we will need an additional 50,000-60,000 primary care physicians by 2025. The largest cause of the growth is, of course, the projected growth in the US population, but it is augmented by the aging of that population (older people require more health care services) and, significantly, the increase in the number of insured-and-thus-likely-to-access-health-care created by the new coverage provisions in the Affordable Care Act (ACA). This portion of the increase is smaller, but unlike the gradual growth resulting from the other two causes, will “hit” all at once in 2014, and our primary care workforce is in no way prepared to meet it. This lesson was emphasized by the experience that Massachusetts had when it introduced near-universal coverage; in addition to adding more people to the “insured pool”, the group that is added has pent-up health care needs. Moreover, the currently uninsured are largely clustered in areas with the lowest current PCP:population ratios, so that what will happen when they gain insurance is that they will end up seeking primary care in the emergency room. While the Graham Center estimates a need for an additional 8,500-10,000 primary care doctors, given what Dr. Phillips calls our “voodoo” workforce policy -- which not only does not incent students to enter primary care or locate in rural and underserved areas, but in fact does quite the opposite -- the actual increase in the number of providers would need to be many times higher. Much recent work has demonstrated the decrease in student interest in primary care, and in particular the phenomenal decrease in the percent of internal medicine graduates entering primary care (as opposed to entering subspecialties or hospitalist practice), as documented by Garibaldi[1] and Hauer[2] among others (see A Quality Health System Needs More Primary Care Physicians, Dec 11, 2008). More recent data collected by the American College of Physicians (ACP – the internists’ group) from residents taking required examinations in 2009 indicate that only 21% of these residents are planning careers in general internal medicine (65% subspecialties, 10% hospitalist) and the actual results tend to show that these plans tend to skew even more to the latter two groups when decisions are actually made.

I have pointed to money, specifically the anticipated income related to student debt, as a major determinant of specialty choice, and Dr. Phillips makes this quite graphic by comparing the ratio of primary care and family physician incomes to more highly paid specialties over time. Using Diagnostic Radiology and Orthopedic Surgery as comparators, primary care incomes, which were about 60% in 1979, dropped to barely 35% in 2003, a trend that has not decreased since. Other graphs show that the % of graduate training (residency) positions filled by US medical graduates tracks linearly with specialty income, and that the growth in new residency positions has been almost entirely in those high-income specialties with drops in primary care positions. (This is not only because of student interest; it is also because many of these new positions are funded by hospitals. The same specialists – radiologists, cardiologists, orthopedists, anesthesiologists – that make big incomes for themselves also make big profits for the hospitals, so that hospitals are more interested in increasing their capacity to do these functions by having more trainees, residents and fellows, in these specialties.)

This creates a problem. The Graham Center data support much other research that has been cited in this blog by Starfield and others indicating that a health system that is based on primary care, with 40-50% PCPs, creates the greatest benefit in health and lowers cost. We have currently about 32% PCPs. With an interest in primary care among medical students now at about 22%, the problem is going to grow, not shrink. And, as I have often written, if we are interested in increasing primary care specialty choice, we are largely taking the wrong students into medical schools (e.g., Primary care specialty choice: student characteristics, July 12, 2010). Given that these characteristics are in large part negatively associated with family income, the changes in funding for medical schools are also troubling. Phillips cites an interview with the founding dean of the University of Missouri-Kansas City (UMKC) medical school, E. Grey Dimond MD, in the Kansas City Star (April 25, 2011). Dr. Dimond is asked how UMKC, as the “public” medical school with the least state funding of any in the US, survives, and he answers that they have increased tuition to become the highest tuition school in the country. This, of course, does not bode well for low-income students, urban or rural, becoming physicians: “Farm kids in Missouri from little towns that need doctors can’t pay what we have to have.” And, for those low (and middle, and even upper-middle) income students who graduate with debts often exceeding $250,000, those income differences among specialties loom very large – and this does not bode well for primary care.

Phillips provides evidence that Medicare costs and avoidable hospitalizations and hospital readmissions drop dramatically when there are higher primary care ratios (ratios of 1 FP+NP+PA:1500-2000 people, or 1:1000 if all PCPs considered[3]). He cites a large number of studies demonstrating essentially the same thing.

Is there a bright side? Are there solutions? Well, the contributions of primary care are now being widely acknowledged, and there are lots of calls for increasing primary care physicians. The ACA bill provides some increased funding for primary care (about a 10% increase under Medicare) and major funding increases for the National Health Service Corps (NHSC), which pays for medical education by (some) scholarships or (mostly) loan repayment for physicians who enter primary care (and sometimes general surgery) and practice in an underserved area for a period of years. Unfortunately, these are not sufficient; a 10% increase sounds like a lot, but if it brings the primary care doctor’s income from 33% to 37% of that of a specialist (and this would be if the whole practice were Medicare), it is not going to do the trick. The loan repayment from NHSC is good, but it rarely covers the whole bill.

What would work? Medicare, taking the lead among all payers, needs to increase primary care physicians’ income dramatically. The Council on Graduate Medical Education (COGME) estimates in its very impressive 20^th Report, Advancing Primary Care, that a family physician must be able to anticipate earning 70% of what a subspecialist makes if the goal of having a 40% primary care workforce in 20 years is to happen., the level at which income expectations tend to wash out of the decision on specialty choice. The federal and state governments should learn from successful models and repay all of the loans of medical school graduates who enter primary care over 8-10 years (enough time to ensure they are actually practicing primary care) and do it twice as fast for those who practice in an underserved setting.

This is what it will take to bend the curve of specialty choice, and, as a result, to bend the cost curve of providing health care.

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[1] Garibaldi, RA, Popkave C, Bylsma W, “Career plans for trainees in internal medicine residency programs”, Acad Med 2005 May;80(5):507-12

[2] Hauer KE, Durning SJ, Kernan WN et al., “Factors associated with medical students’ career choices regarding internal medicine”. JAMA 2008;300(10):1154-64

[3] The benefit on cost of hospitalization, avoidable hospitalizations, and readmissions is more difficult to assess for general internists than for family physicians; this would be unsurprising given that their training in almost all in the hospital rather than in the ambulatory setting.

Family Medicine in the era of health reform - 2

This is the second of three parts presenting the content of the 21^st G. Gayle Stephens lecture that I gave at the Primary Care Access Conference. It more specifically addresses the current status of family medicine, and in particular, family medicine training.

What about Family Medicine? There has been something of an uptick of interest in FM among medical students in recent years, which has been reflected in “better” matches: a larger number of US medical graduates (USMGs) entering family medicine residency training and fewer residency slots filled by IMGs; but these are small changes, nowhere near sufficient to meet the nation’s needs for primary care doctors.  In addition, we are not sure of the reason for this yet. We hope that it is a real increase in interest, but it may also be (and continue to be) a result of increases in medical class size and number of medical schools without a concomitant increase in residency positions, leaving more students who cannot match in their more desired specialties and thus “settle” for family medicine.

Common sense, and some recent data (especially regarding loan burdens), suggests that reimbursement is an major issue, and this is something I have addressed on several previous occasions (recently The challenge of expanded Medicaid and the dearth of primary care physicians, Feb 19, 2011). Although money (income and debt) was not found to be a major determinant of specialty choice in the “Arizona studies” several years ago;[1];, debt loads have increased since then, frequently exceeding $250,000 by the time of medical school graduation. More concerning, we are increasingly hearing reports of negative attitudes among medical students toward the real or perceived lifestyle of primary care, as well as persistence of the idea that primary care -- family medicine – is not as interesting or as challenging as practice in other specialties.

A recent article that appeared in the New York Times on Saturday, April 2, More Physicians Say No to Endless Workdays, illustrates many of these issues as it describes the decision of a young female student, Kate Dewar, to enter Emergency Medicine rather than the primary care practice of her father and grandfather. She is the mother of twins and although she says

“Look, I’m as committed to being a doctor as anyone. I went back to work six weeks after my boys were born. I love my job,” she adds “But I was in tears walking out of the house that first day. I’m the mother of twins, and I want to be there to feed them, play games with them or open presents with them on Christmas morning. Or at least I want the option to do those things without fearing I’ll be called back to the hospital.”

Yes, it is possible that her commitment is simply professed, not real; maybe in an objective sense she is not as committed to medicine as her father and grandfather. And if not, if she is more committed to her family, is that a bad thing? Her grandfather, Dr. William Dewar II, is quoted as saying “My son and I had deeper feelings for our patients than I think Kate will ever have… “ and her father, Dr. William Dewar III, adds “I’ve had three generations of [the owner of the café in which they are being interviewed]’s family under my care. Kate will never have that.”

Yes, but she will fewer work hours. The article notes that “…emergency room and critical-care doctors work fewer hours than any other specialty, according to a 2008 report from the federal Department of Health and Human Services.” And she will not get paid less for working those fewer hours; actually she will be paid quite a bit more. Personally, I have seen little indicating that, overall, students are willing to get paid less in exchange for having more time with their families.

What about the other part? The ostensible lack of intellectual, or at least, adrenaline-infused, challenge? The “Marcus Welby” vs “ER” dynamic? Kate Dewar told the Times “…that treating chronic conditions like diabetes and high cholesterol — a huge part of her father’s daily life — was not that interesting. She likened primary care to the movie ‘Groundhog Day,’ in which the same boring problems recur endlessly. Needing constant stimulus — she e-mails while watching TV — she realized she could not practice the medicine of her forebears.”

Constant stimulus aside – everyone emails while watching TV (is there any other way?) --  is she correct in that primary care does not have enough intellectual stimulation? If we look at medical and surgical subspecialties, it is hard to make that argument. They all see a much narrower range of diagnoses than primary care physicians do. For most of them, their top 5 diagnoses account for 80% or more of their visits; for family medicine our top 20 diagnoses account for perhaps 30%. Indeed, this is in part why we enter FM. 

Is the Emergency Department really that different? There are certainly the big, exciting cases, but also a lot of routine. ED docs often complain that they have to do so much primary care – and they do it without gaining the satisfaction that doctors like the older Dewars get from seeing people get better over time. In addition to the primary care, there are the overdoses, and accidents, and the “frequent flyers” that characterize much of ED work. Yes, ED physicians can resuscitate people from the overdose – but they don’t treat the depression or the domestic violence that frequently was the cause. Yes, they stabilize fractures and abdominal trauma so that patients can be admitted to the surgeons (unlike on television’s “ER” where they seem to do major surgery in the ED, not to mention pushing babies back into the uterus of eclamptic women for whom there is “no room” on the labor floor – this would never happen!) – but they can do nothing to prevent the next one walking in. Yes, they admit the person from the nursing home with decompensated congestive heart failure and get them into the ICU – but if the patient lives until they can be discharged, they will be back again soon. Yes, they complain about the lack of primary care services available that make people come in with relatively minor illnesses, or even worse, with advanced stage illnesses that could  have been ameliorated by primary care – but they don’t want to be the ones to do it.

Kate Dewar says “I like it when people get better, but I’d rather it happen right in front of my eyes and not years later… [I] like to fix stuff and then move on.” At its face value this can be seen as an immature statement; while such attitudes can and do persist for an entire career for some people, they become less pervasive as doctors learn both the satisfaction that her father and grandfather demonstrate that comes from following patients over years, as well as the frustration that comes from “fixing” the same stuff over and over again. Of course, if she is an adrenalin junkie, maybe the ED will be a good place for her.

But the adrenalin rush can wear off, or be eroded. I worked for many years at Cook County Hospital, where there is a Department of Trauma. It recruits many skilled young adrenalin-junkies who want to be like Hawkeye Pierce on “M*A*S*H”, seeing people get better right in front of their eyes. Except not always. Often they don’t get better, they die. And then you have to tell their family. Another auto accident, another gang shooting, another alcohol-enhanced beating.  And then you have to tell their family. And then again, and again. And then, after a while, you get tired of it, which is why so many trauma surgeons spend so much of their time out in the community, talking to people, trying to prevent themselves from having more business. They want to decrease, not increase, their business. 

Or maybe Kate Dewar just doesn’t have the interest in working with people over time and developing the relationships with patients that her father and grandfather did, and that all the stories they tell about their great longitudinal relationships with patients are, for her, dissolved in a memory of beepers going off as her dad sat down to dinner, or on Saturday and Sunday morning. Or maybe she is just selfish. I don’t know about her, but I think that all of these possibilities can apply to many different students.

What remains true, however, is that we  -- this nation – needs to change our health care business model, to keep people from getting so sick that they need emergency rooms and high-tech procedures. In Denmark, for example, the number of hospitals dropped from 190 in 1980 to 52 in 2004[2];, not because some have driven their competitors out of business but because they are no longer needed.

Wouldn’t that be a victory?

                                                                                      

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[1] Senf J, Campos-Outcalt D, Kutob R, “Factors Related to the Choice of Family Medicine: A Reassessment and Literature Review”, J American Bd of Family Practice, 2003, 16:502-12.

[2]Kristensen T, et al., “Economies of scale and optimal size of hospitals: Empirical results for Danish public hospitals”, Health Economics papers 2008:11, University of Southern Denmark

Do resident work hours limits create better physicians?

On a few previous occasions (e.g., Student Debt, Resident Hours, and Primary Care Redux, Jan 2, 2009) I have written about the issue of medical residents’ work hours and the implications that it had, good or bad, for patient care. A recent article in the British Medical Journal (BMJ) by Moonesinghe et al, “Impact of reduction in working hours for doctors in training on postgraduate medical education and patient outcomes: systematic review”, provides the most thorough review to date of studies evaluating the impact of work hours reductions for medical residents in the US and the United Kingdom, where they are even more stringent. They looked at studies examining both “training” (how are the residents learning?) and patient quality and safety.

This was not an easy task; true “meta-analysis” (grouping all the studies together as if they were one and re-analyzing the data) was not possible because they were so different in methodology, issues studied, and quality. In fact, the quality of most of the studies was not terribly high, and they often looked at several different outcomes making it hard to understand whether the changes all went one way, or there were some things that were better and some worse and whether the net result could be stronger (or weaker) if we could focus on only one at a time.

The good news for those who have implemented, supported, and argued for the work hours restrictions is that they seem to have improved the private life of residents, and to have not significantly harmed either the quality of training or patient care, at least insofar as these somewhat contradictory studies seem to indicate. Most of the studies were done in the US, and most were of surgical (28 of 41) or “hospital-based” (e.g., anesthesiology, critical care) trainees, rather than primary care.

Here are some of the results:

Training outcomes:

·    2 papers (both of “low methodological quality”, one of medical residents in the UK and one of surgical residents in the US, which “did not report statistical analyses of the results”) reported an improvement in training outcomes.

·   12 studies found a detrimental association; half from the US (all surgical) and half from the UK.

·    27 studies found no change (20 US and 7 UK)

·    There were also mixed results regarding the quality of “training opportunities” (exam scores, caseload)

Patient outcomes:

·    31 of 34 papers were US

·    4 studies showed improved patient outcomes, including the only randomized controlled trial in the group (note: this was in critical care and coronary care units, where shift work may arguably be more effective)

·    2 studies (in trauma and orthopedics) found increased complications

·    28 studies showed no significant difference

Surgeon and NY Times writer Pauline Chen commented on this article in “Is a well-rested doctor a better doctor?”, April 7, 2011. She describes talking with a surgical resident she knows who is very pleased at how much better her life is than she had feared. “’Training has changed a lot…My life is different than yours was — I have a lot of time outside the hospital.’ She described how she loved her work but was able to sleep at home most nights, go out regularly with friends, stay involved with her church and take an improv class.”  Cool. It is good to know that surgical residents are not acting as slaves, and can have some kind of life outside the hospital.

However, her resident friend was less sure about learning and patient care: “’To be honest, I don’t really know if this is better or worse,’ she said, recounting how she felt she was signing over responsibility for her patients more often than she ever imagined she would, missing key events in their hospital course and even getting dismissed during the middle of a patient’s operation in order to stay within the limits on work hours. ‘Sometimes it seems so counterintuitive to just sign out as if we were shift workers, but this is all any of us know right now…We have nothing to compare it to.’”

So, probably, as Dr. Chen observes, the discussion will go on. Those who believe that working longer hours results in tired physicians and therefore bad patient outcomes will continue to push those ideas; those who (largely, it seems, surgeons) believe that artificial limits on work hours compromise resident learning, thus not only having a negative impact on their current care of patients but, more importantly, their care of patients in the future care because they haven’t had sufficient experience in their residencies. One “side” says “Do you want to be operated on by a surgeon who has been up all night?”, while the other says “Do you want to be operated by a surgeon who is not as skilled because they were coddled in their training and didn’t get sufficient experience?”

“The most important test of success of postgraduate training,” say Moonesinghe and colleagues, “is the professional performance of those who reach the end of it.” They go on to make several suggestions, including, most importantly I believe, that “a consensus should be reached by the medical profession on appropriate measures to assess the quality of postgraduate medical training.” They agree with the assertion (from Temple, et al, “Time for training. A review of the impact of the European Working Time Directive on training 2010”) that “training is patient safety for the next 30 years”. Wise regulation must understand the balance, the risk-benefit of any change, and try to reach the greatest benefit with the least risk.

I would like to comment a bit upon the issues as they relate, in particular, to primary care training. Most of the studies that have been done have been on surgical specialties, which can measure surgical complications, deaths or morbidity, or in anesthesiology or critical care, because these are hospital based and more amenable to shift work. While a very few of the studies were in pediatrics, they also examined hospital work; none were looking at the training of primary care or family doctors. One of the other reasons that the surgical specialties have been so studied is that they have long been those with the longest work hours; thus, they are both the greatest target of reformers and the greatest resistance by current surgeons and teachers who fear that work hours restrictions will jeopardize the skill of their future colleagues.

The irony is that, as in so many areas, when laws or rules are being violated by one group, they are tightened on everyone, and those who were not violators of the old rules find their greater restrictions to comply with while, often, those who were violating it before continue to. In the 1970s when I was in training at Cook County Hospital, we had a resident union (yes!) and were limited to every-4^th-day overnight call. But the surgeons were on more often. If family medicine or internal medicine or pediatrics violated the rule, they were penalized, but the surgery residents were afraid to complain. And so, today, the violations of hours rules in some specialties increases the restrictions for all.

The problem with applying these rigid rules to primary care is that it is not shift-based. While residents spend time on inpatient services, the core of family medicine training is the continuity clinic where those doctors-in-training follow their own patients. It is important to be able to do this, to show up for your office hours to see your patients who are expecting to see you, even if you were up much of the night delivering the baby of one of your patients. If that happened every day, it would be a big problem, but it doesn’t. Yet there is a “zero tolerance” for work hour violations by the Accreditation Council for Graduate Medical Education (ACGME), so the program would be cited. Rigid cut-offs, indiscriminately applied, are a bad idea.

Residents should have work hour restrictions; they shouldn’t be on call every third night and up all night. They should get days off, should get time to spend with friends and family or sleeping. But the restrictions need to regulate hours in a more global fashion: hours in a week, days off in a week, average or typical number of hours off between shifts. They should not be counting minutes (and they currently do!), not create automatic violations for each instance in which, say, a resident returns to clinic after only 9 ½  instead of 10 hours off. They also should be specialty-specific, examining the character of the specialty’s practice, not to allow exploitation but to make them appropriate to how the specialty is practiced.

Some fields, like ER and critical care, work well with shifts. Some, like most hospital work that characterizes internal medicine and pediatrics training, generally work pretty well with “night floats” and days off, as long as there is careful attention paid to information transfer at the shift changes (“hand-offs”). Surgery may require longer shifts with more days off. And family medicine needs to allow residents to occasionally deliver their babies at night without canceling all the patients on their schedule the next day, as long as it is not the everyday norm.

We can do this rationally. We can have training that both provides time for the non-work lives of residents and good training for their careers; that ensures quality care of their patients now and in the future.

The challenge of expanded Medicaid and the dearth of primary care physicians

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The shortage – current and future – of primary care physicians in the US has been a recurrent theme on both this blog and many other venues in journals and the blogosphere. In addition, several posts relating to the Affordable Care Act (ACA) have noted the difficulty Massachusetts has had since it implemented an individual mandate, with many more people covered and not enough primary care doctors to see them (Solving Medicare costs and the budget deficit: primary care, cost-effectiveness, and universal health coverage, Jan 5, 2011; PPACA, The New Health Reform Law: How will it affect the public's health and primary care?, Apr 12, 2010). Apparently, there are a lot of states that will be in worse shape than Massachusetts, according to a study by Leighton Ku and colleagues in the New England Journal of Medicine.

In The States' Next Challenge — Securing Primary Care for Expanded Medicaid Populations (NEJM 10Feb2011;364(6):493-5) the authors look at the expansion of Medicaid mandated in ACA, to 133% of poverty for nonelderly adults by 2014, and note that this expansion will be far greater for states that currently have the most restrictive eligibility for Medicaid than those that have the most generous (e.g., Massachusetts). They note that this will require far more primary care doctors, and observe that many of these same states have the greatest deficit in primary care capacity. Using a creative approach, they create a “Medicaid expansion index” to identify how much a state’s Medicaid population will grow as well as a “primary care capacity index”. They standardized them so 100 was the average, and combined them to get a relative assessment of each state’s “challenge”; over 100 is worse than average, under is better. The scores ranged from 212.6 (Oklahoma) to 15.2 (Massachusetts, in fact!). Unsurprisingly, the states that face the greatest challenges are mostly in the South and Midwest, like Oklahoma, while the other states with low scores tend to be in the Northeast. Some of this is, as Ku notes, a primary care physician deficit in those states with high scores, while and much of it is a result of the fact that these high-score states have such limited current eligibility for their current Medicaid programs that they will have the largest number of newly-insured people.

The authors acknowledge that the “Access to care is determined in local service areas, not at the state level. Access problems could be more severe in rural or inner-city areas than in suburban communities, for example.” No doubt they will be; as many posts on this blog (e.g., Primary Care and Rural Areas, Apr 28, 2010) have noted, distribution of providers (not only physicians but nurse practitioners and other “midlevels”) is not even close to adequate, both for primary and subspecialty care. There are too few providers in the inner-city, but in rural areas the situation is worse -- 20% of Americans live in these areas, but well under 10% of doctors practice there. Only family physicians distribute in proportion to the population, but 20% of family physicians is not anywhere near 20% of doctors. Other primary care specialties, such as pediatrics, are very concentrated in urban areas (Primary Care, Pediatrics, and Physician Distribution, May 21, 2009).

Ku, et.al., express some guarded optimism, suggesting that expanded insurance coverage will support more primary care doctors – but note that the expansion also doesn’t begin until 2014. Given the long time frame to create physicians in any specialty, this will at best leave us with several years of shortages. And, at the current rate, “at best” is unlikely. The authors emphasize the need for training more primary care doctors, especially in the most “challenged” states, but really make no suggestions that are likely to have a significant impact, citing such things as expanded scope for “midlevels” (does not address distribution) and expectation that increased funding for Federally-Qualified Health Centers (FQHCs).

In the very next article in the same issue of the NEJM, Stephen R. Smith does make some suggestions for change that would likely produce more primary care doctors. In A Recipe for Medical Schools to Produce Primary Care Physicians[1], he starts with the admissions process, suggesting that admissions be MCAT (Medical College Admissions Test) “blind”, meaning that above a pre-defined minimum score, MCAT scores will not be considered (so that a student with a very high score is considered “more desirable” than one with just a high score). He emphasizes the need to select students “…who express a desire to serve underserved populations, who demonstrate altruism, and who are committed to social responsibility” because “they are more likely to go into primary care”. (However,expressing interest is not the same as actually having interest. See the experience of Pennsylvania’s Commonwealth Medical College. [2]) He suggests that the curriculum be based on a “patient-centered learning approach” with continuity follow-up of actual patients and teaching of “basic science” in the context of these actual patients. He urges that the entire curriculum be built around the competencies needed for a primary care physician, that students be taught in inter-professional teams, and that community-based settings be used for training.

These are all good ideas. They are consonant with recommendations I have made (of course, this makes them good :)!). While they do not look at “output variables” (mainly income/reimbursement), they do address the two areas over which medical schools have the greatest control – the students they admit (“input variables”) and the curriculum (the “process”). The suggestions that Smith makes have all been tried, and they all work to a significant degree to increase the number and percent of primary care doctors. At the University of Kansas, for example, we do have essentially “MCAT-blind” admissions, and look for the characteristics he suggests, among others, believing that such personal characteristics as caring, altruism, and communication skills are not only important for primary care, but for all physicians. The problem is absolutely not that we don’t know what works; we do. The problem is that we have, nationally, lacked the commitment to implement these strategies on a large enough scale to have a sufficient impact on the supply of physicians.

There are two big issues, though. Obviously, the first is that “output variables” – mainly the enormous differential in expected physician income – are not addressed. This is critical. As long as reimbursement policies by Medicare (see “Outing the RUC: Medicare reimbursement and Primary Care”, Feb 2, 2011) and other insurers dramatically favor subspecialists and especially proceduralists, there will not be enough primary care doctors. Indeed, the other “problem” medical students often identify with primary care – less than appealing “lifestyle” (read: “too much work”) is related to this; if you make a lot more per hour, you have to work fewer hours.

The other big issue is that Smith addresses his suggestions to the many new allopathic (“MD”) medical schools being currently created. He notes that these are (mostly, although not all) designed to increase production of primary care physicians (although, as noted in the footnote about the Commonwealth Medical College, even those may have trouble getting students who are actually interested in primary care), and he is correct that adopting his suggestions, among others, is more likely to keep them on that path. However, this is too simple; it forgives existing medical schools from fulfilling this responsibility, and they absolutely should not be so forgiven. This is particularly true for the most “elite” schools, many of them private and in the Northeast and very “selective” (indeed “selectivity” – the percent of applicants that you turn down – is a criterion for high rank by US News and World Report). Such schools are also the ones with the highest amounts of National Institutes of Health (NIH) research support, and pride themselves on producing researchers. Different schools, the refrain goes, have different mission; we produce “physician scientists”, somebody else should produce the primary care doctors (hey, like those “new schools!”).

The problem is twofold. First, these schools produce a lot of physicians, and they need to produce the kind of physicians that the community needs. Second, these schools set the standard for what most other schools want to be like – to be highly ranked by US News and get lots of NIH money. The last big expansion of medical schools, in the early 1970s, was also supposed to produce primary care doctors, but many or most of them immediately abandoned that mission and began trying to be like Harvard or Johns Hopkins. What needs to happen is that Harvard and Johns Hopkins need to look more like the University of Kansas, and produce a much higher percent of community-serving primary care doctors. In fact, so does the Warren Alpert School of Medicine at Brown University, where Dr. Smith works.

So, in case I haven’t been clear, two things need to happen:
1. Current physician reimbursement formulas need to be abandoned, and Medicare needs to adopt a reimbursement scheme that will result in primary care physicians having at least 70% of the income of subspecialists. Where Medicare leads, private insurers will follow.
2. All medical schools must adopt admissions policies that de-emphasize high exam scores and emphasize desirable personal characteristics, and lead to much greater diversity of students by socioeconomic status, geographic origins, and race/ethnicity. They need a curriculum that reinforces these skills, problem solving, independent learning, and communication. The elite private schools should take the lead; where they lead others will follow.

When? What should be the timeline? Immediately. Right now. No delays. Both should have been done yesterday.

[1] Smith SR, “A Recipe for Medical Schools to Produce Primary Care Physicians”, NEJM 10Feb2011;364(6):496-7 (online available only to subscribers)
[2] The Commonwealth Medical College in Scranton, Pennsylvania selected its students based on an expressed interest in primary care, but found that in their first class, on a pre-matriculation survey (before they even started school!) only 23% still said they wanted to be primary care doctors! (Tracy & Smego, “Discordance of Self-reported Career Goals of First-year Medical Students During Admission Interviews and Prematriculation Orientation”, Family Medicine, Jul-Aug 2010.
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