Primary Care Crises – Ideas for President Obama

Primary Care is in a crises. Physicians are leaving primary care for hospital based practices and only a small percentage of Physicians from US Medical Schools are starting Primary Care Residency programs. Shortages are predicted, and I believe are already present. It is going to be increasingly difficult to establish with a Primary Care Physician.


This is occurring because Primary Care services have been undervalued by Medicare and Insurance Companies. Our fees, for all practical purposes, are not negotiable. Medicare fees are set by Congress and the Department of Health and Human Services and by current law are required to be budget neutral. There have been minimal increases over the last seven years, far short of the inflation rate, and a twenty percent cut is schedule for next year. Private plans mirror the changes in Medicare rates with some a little lower and a few a little higher.


Poor reimbursement is affecting the morale of the Primary Care Office. As practice overhead approaches 60% of collections, there are no funds for new equipment or education. Taking a two week vacation cost the Physician one month’s income, because the first two weeks of work just covers overhead. At HMC our medical assistants are intelligent and motivated. Several have continued their education and are now Registered Nurses (RN). We cannot afford to pay them for their efforts and loose them to the Hospitals.


Medical research supports the role of the Primary Care Physician. In the Unite States, Communities with a higher ratio of primary care providers have lower costs with the same quality of care. The new administration has acknowledged the value of preventive care and its possible role in reducing overall health care costs. The concept of a medical home has growing support from several national medical societies. I would be more optimistic, but I am concerned about how it will be implemented.


Current strategies emphasize large complicated solutions to our health care crises. Here are the claims: 1) Electronic medical records will improve communication between providers, 2) Electronic or ePrescribe systems will decrease medication errors, 3) Pay for performance will increase compliance with national standards of care and evidence based medicine, 4) teams consisting of a Physician, mid-levels and office staff are required to increase efficiency, and 5) Hospitalists and Intensivists will provide more efficient care with fewer complications.


The health care planners have a hard time understanding why Physicians are not following these obvious strategies, so they ignore what is happening spontaneously in one part of our Country and use the carrot and stick approach to demand compliance. Recently the Department of Health and Human services implemented a strategy to require the use of the ePrescribe system, a computer based method of writing prescriptions to the pharmacy. On January 1, 2009 it became illegal to fax prescriptions to the pharmacy for Medicare patients. They could be called, written on protected paper, or filled through the ePrescribe system. Medications filled through the ePrescribe system would be passed thorough a clearinghouse, which would then fax the information to the Pharmacy. Interesting. However, controlled medications could not be sent through the ePrescribe system. If you used the ePrescribe system in the majority of your patients, they would increase your visit charge by approximately $ 1.20 a visit, paid in 2010. Providers not using the system would have their rates reduced in the future.


The ePrescribe system requires our staff to re-enter each patient requiring a prescription, because it will not interact with our current system. Of course Allscripts is happy to provide you with a complete EMR system. Our Community Clinic recently started to use a EMR system and there was a 40% decrease in the number of patients they could see each day. In any case, we started to call in our prescriptions only to find out that the rule was canceled in November.


Complicated systems suffer from the “law of unintended consequences”. Lets look at the previous list of claims to understand this concept:


1) EMR’s improve communication? NO. Primary Care offices will receive records from every encounter for every patient in their practice every day. That can be a lot of records to review. Are they obligated to read each one to make sure their patient is receiving correct treatment. And when the patient arrives they will have to skim through multiple pages and reports (RMC’s ER encounters are all 20 pages at a minimum). Everyone knows that computers are not saving trees,

2) ePrescribe decrease medication errors. Unfortunately, it just changes the type of errors. There are a lot of John Smiths and it is easy to search and open the incorrect record,

3) Pay for performance. Uncertain. It does improve awareness of evidence based standards, but it also encourages practices to select for compliant patients. And when the standards are incorrect, the consequences are magnified,

4) Team medical care from primary care offices is not a new concept and is effective, and

5) Hospitalists and Intensivists are efficient and necessary, but the fragmented care model introduces many new places for errors to occur.


We need simple solutions for the primary care crises. All this time I thought the problem was access and time. It is not helpful to wait 6 weeks for a visit that lasts 15 minutes. Recognizing the value of Primary Care with increased reimbursement, not tied to specific goals, will help solve this problem and is an important first step in the right direction.


In the meantime, improve your health by improving your daily health habits, by keeping a paper record of your important medical tests, by establishing a relationship with a single Pharmacist, by finding a Primary Care Provider you trust, and by continuing to learn about your health care conditions.


In the spirit of health care reform, President elect Obama’s transition team at is requesting ideas. The President is going to move quickly, so participate by letting him your concerns.

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