SHOW LOW — The results of a survey showed Summit Healthcare is short 32 physicians, which does not come as much of a surprise to the hospital.

Dr. Jeffrey Northup, the medical director for regional and cultural outreach and medical education, said the survey was completed in July. He added it is a federal requirement.

We do it about every three to five years. They want to make sure we’re doing our due diligence in serving the community.

“Although we’ve had a loss of a lot of physicians, we are actively addressing it.”

Northup said the hospital has lost about 14 physicians in the last 18 months that they have not replaced. He said they have attracted one physician this year, an independent obstetrician/gynecologist, with plans to recruit ten more physicians by September 2011.

The physicians, Northup said, are in internal medicine with a gastroenterology (disorders of the stomach and intestines) background, pediatrics (2), obstetrics (2), family practice, urology and neurology. He said one of the obstetricians and a urologist are scheduled to join the hospital Dec. 1. He said the hospital also has prospects for an internal medicine physician, one pediatrician and a family practice physician. A nephrologist and an anesthesiologist round out the hospital’s recruitment plans.

Northup said Summit has an eight-member physician recruitment/development committee.

Northup said there are three ways physicians work with the hospital: hired, independent and contracted. He said Summit has a request for proposal to bring on a contract cardiology group and has received two responses so far.

In terms of attracting physicians, Northup said, there’s a few different ways they can do that. The first, he said, is a retained search, where they hire someone to search for candidates. Other approaches include word-of-mouth and networking.

But one approach Northup said he has been working on a lot on is medical student rotation. Formally started three years ago, he said students from the medical schools in Arizona (University of Arizona, Midwestern University in Glendale and A.T. Still University in Mesa) will come and work at Summit, gaining experience.

“That gives them exposure up here so they know where Summit is. And some do come back.”

As an example, Northup said half of the staff at Whiteriver’s hospital rotated through as medical students. He said five students joined Summit this month, five will join next month and in January nine medical students will come on board.

“It’s an important way of attracting doctors.”

“They come up as third year medical students, fourth year students and then do more training. This is just part of their clinical training.”

After doing a rotation like this, Northup said most medical students spend one to two more years in medical school and then a residency from three to seven years, depending on the specialty.

The larger challenge, Northup said, is getting physicians to actually practice at Summit. While Summit is the only full-service, non-Indian Health Services hospital in approximately 18,700 square miles, he said it does not change the fact they are still a rural hospital.

“It takes a special doctor to practice in a rural area. Most people are trained in a big hospital and they’re used to having a lot of support around them.”

Another challenge, Northup said, in getting doctors to move to the area is having a partner or spouse willing to move with them. That could be especially difficult, he said, especially if they are coming from an area that has a lot of social and cultural activities. Meanwhile, he said as a comparison, “The social center of the White Mountains is Wal-Mart.”

Another issue is that Summit may have a need for a doctor, but the patient volume may not be high enough to make it feasible. In those situations and those specialties, Northup said they are developing a telemedicine program. While not the same as recruiting, it can still fill a vital need.

“It takes care of our medical need in the community without having the physical doctor here who couldn’t afford to come here.”

Telemedicine is available in some areas around the country in the form of an electronic Intensive Care Unit, or eICU. For Summit, Northup said they are planning to use the technology for their nursery, becoming the first hospital in Arizona to do so.

“We don’t have a neonatologist; what do we do? We put a camera in our nursery and link to a higher level of care.”

In this case, Northup said they will link with neonatologists in Flagstaff and Phoenix. They will be able to see the baby in real-time and talk with doctors, nurses and the family, and all they need is a laptop and a password. He said having a professional on hand, even electronically, will enable them to diagnose problems and perhaps eliminate the need to transport some patients.

With telemedicine, Northup said that is a relatively new way Summit hopes to address the community’s need. In addition, he said Summit is also looking for nurse practitioners and physician assistants to meet some of the need.

A national study of physician wages conducted by UC Davis Health System has found that specialists are paid as much as 52 percent more than primary-care doctors, even though primary-care doctors see far more patients. As efforts to implement health-care reform evolve, the study is important because it quantifies wage disparities and explores the need for wage reform to help assure a strong primary-care workforce.

“Addressing the generalist-specialist income gap is critical to increasing access to cost-effective preventive care,” said J. Paul Leigh, a professor in the UC Davis Center for Healthcare Policy and Research and lead author of the study, which is published in the Oct. 25 issue of the Archives of Internal Medicine. “There is a huge shortage of primary-care physicians, and in years to come many more of them will be needed to meet health-care reform goals.”

The wage differences add up to millions of dollars over a lifetime, according to senior author Richard Kravitz, a professor of internal medicine and investigator with the Center for Healthcare Policy and Research. The result, he said, is a critical shortfall in the number of U.S. medical students entering generalist careers, in part because of the realization that peers in specialties such as radiology and dermatology will be making more money for less work.

“There is this sense that society simply doesn’t value primary care,” he said.

For the nationwide study, the investigators compared wages of more than 6,000 doctors practicing in 41 specialties in 60 communities. The data came from the 2004 to 2005 Community Tracking Study, a periodic evaluation of physician demographic, geographic and market trends.

Unlike previous studies analyzing income disparities, the research team compared hourly wages, factoring in the hours per day physicians reported working and excluding vacation time. The 2005 hourly wages for four broad specialty categories were as follows:

- Primary care, including pediatrics, geriatrics, family practice and internal medicine: $60.48 per hour.

- Internal medicine and pediatric subspecialties, including allergy and immunology, gastrointestinal, cardiovascular, rheumatology, pulmonary, critical care, medical oncology and neonatal: $84.85 per hour.

- Other medical specialties, including radiation oncology, physical medicine and rehabilitation, emergency medicine, psychiatry, neurology, ophthalmology and dermatology: $88.08 per hour.

- Surgery, including neurological, plastic, orthopaedic and obstetrics/gynecologic: $92.10 per hour.

The specialists with the highest wages were neurological surgeons, radiation and medical oncologists, dermatologists, orthopaedic surgeons and ophthalmologists. In general, physicians who earned the most money either performed surgery, deployed sophisticated technologies or administered expensive drugs in office settings. Lower-paid specialties primarily relied on talking with and examining patients.

An over-reliance on highly specialized medicine results in skyrocketing costs as well as poorer overall health, as prevention and primary medical care are de-emphasized, according to Kravitz. The solution, he said, lies in reducing the wage disparities and redesigning the payment structure for care.

“Instead of rewarding the use of expensive and often risky procedures, greater emphasis should be placed on getting the basics right — immunizations, cancer screenings, chronic-disease management and recognition of the ‘red flags’ that signal the need for more intensive diagnostic study,” said Kravitz.

The authors point out that a shortage of primary-care doctors will be especially worrisome as the baby-boom generation ages.

“Given the central role of generalists in caring for older patients with complex, chronic illnesses, these findings could predict future problems with meeting the medical needs of our growing population of elderly patients,” said Leigh.

Additional study outcomes revealed no significant differences in wages by race, indicating that medicine may have achieved wage parity for minorities. Wages for women, however, were $9 less per hour regardless of practice area, indicating that gender parity in physician wages has yet to be achieved.

Oklahoma ranks last when it comes to primary physicians. And now it seems like the Sooner State has to compete with the state of Texas, for doctors.

Last year Texas started a physicians retention program.Newschannel 8′s Kim Jackson says Oklahoma–could soon have one as well.

O. U. Tulsa is trying hard, to hold on to Oklahoma’s doctors. One way they’re doing it, is using private funds to help doctors repay their loans.

Janelle Whitt has always been a community doctor–since her residency.

“I was not making big huge doctor money. Family medicine doesn’t tend to make big huge doctor money,” she explained.

But now, she’s agreed to work in a poorly served area–in exchange for her student loans being repaid.

“I love what I do, so that in itself, lures me to stay here. The loan repayment plan is a bonus. But if you look at statistics, I could go to south Tulsa and definitely make more money,” she said.

O. U. Tulsa has started that program and recruitment to draw in medical students.

“We’re doing a pretty good job. We’ve watched, 75 to 80-percent of residents in our residency program have been staying in Oklahoma over the past several years,” said Dr. Daniel Duffy, dean of O. U Tulsa’s School of Community Medicine.

Now that Texas has been actively recruiting, more doctors are leaving the Sooner State for the Lone Star.

O. U. Tulsa–has seen the effects, including more students applying to become physician assistants–to help fill the void. This class will graduate in December.

“We believe strongly that physician assistants and nurse practioners are going to be a very important part of primary care workforce over the next several years,” said Duffy.

Still the focus is on attracting more doctors, especially ones who love what they do.

“One of my concerns would be are you going to be seeing them for two or three years until

their contracts up and then they go away?” asked Dr. Whit, who says she would do her job for free, as long as her bills were paid.

Doctors are expecting more programs and more federal funding, thanks to the new health care plan.

Lawmakers could have the bill ready, by the first of the year. The plan is to fund the physician’s retention program, by tightening up sales tax on smokeless tobacco.

Organizers will meet for a community forum, in Muskogee, tomorrow.

In response to a myriad of pressures, many hospitals once again have chosen to hire their own physicians. Although not a prime target, hospital medicine, still coming into its own as a medical specialty, has been swept into the current as hospitals add employed physicians in all fields. For this medical specialty, however, we believe that partnering with a proven and established hospitalist group on an outsourced basis provides the hospital a number of benefits and opportunities that are less available when the hospital invests in developing a group internally.

The strategic and philosophical underpinnings demonstrating the value and importance of hospital medicine are strong, with increasing numbers of academic studies to support this claim. Accordingly, there has been unbridled growth in the number of hospitalists over the past 15 years. Rising from non-existence in the early 1990s to over 30,000 providers today, hospital medicine represents the fastest growing specialty in the history of medicine. The current stage of development may be likened to an adolescent whose growth spurt exceeds his maturity; much evolving and seasoning still lies ahead. In this circumstance, a hospital may find itself facing several challenges in keeping up with and incorporating the changing dynamics in the evolving art and science of hospital medicine.

Independent hospitalist practice groups are confronted with many of the same challenges and pressures that face their colleagues employed directly by the hospital. However, the independent group benefits from advantages inherent in their status as an outsourced entity. Following are ten reasons why it continues to make sense for hospitals to consider outsourcing their hospitalist service to an independent practice.

1. Independent practices offer focused expertise. As the field of hospital medicine matures, there is a growing understanding among hospitalists that in order to demonstrate their value and fulfill their potential they need to function as much more than simply internal medicine doctors without an office. This deeper level of understanding is best developed in an environment offering intense and focused experience steeped in the medical specialty. For the physician, a truly focused hospitalist experience is most readily available from within an independent hospitalist practice wholly immersed in hospital medicine and free from competing organizational distractions.

2. Independent groups generate more productivity without sacrificing quality. Hospitalists who work for independent groups have a demonstrated track record of greater productivity than those who work for hospitals. The recently released 2009 hospitalist survey conducted by the Medical Group Management Association shows that a hospitalist not employed by a hospital sees an average of 19 percent more patients than their institutional counterparts who are employed by hospitals. It is also interesting to note that nowhere in the literature is there evidence that the increased productivity diminishes quality of care. Indeed it is reasonable to argue that the synergistic effect of added focus, expertise and training afforded to independent hospitalists is precisely why improved productivity can be achieved with no sacrifice in quality. To be sure, all practices should stringently monitor their providers on quality measures to ensure that quality is maintained in the face of enhanced productivity.

3. An outsourced practice is the low-cost option. The more advanced independent practices have already developed the business and administrative support systems specifically geared to optimizing efficient and effective practice of hospital medicine. This may include including billing, accounting, recruiting, legal services, regulatory compliance, training, quality control, IT and marketing. In most cases an independent practice is capable of delivering this physician support at a lower cost than an institution or other practice groups. This translates into less physician subsidy and less risk for the hospital. The MGMA survey shows that the median financial support for an outsourced hospitalist is $90,000 per FTE, compared with $103,500 per FTE for hospital-employed hospitalists, a significant 15 percent differential.  Equally noteworthy, there are several highly effective and reputable practice groups that provide high quality hospitalist services with little or no financial support from their hospitals.

4. Maintaining relationships with the physicians in the community is the lifeblood of independent hospitalists.For the independent hospitalist practice, nurturing and cultivating strong relations with community physicians is a high priority. This is essential to implementing an effective discharge planning and transition of care program, a key component to eliminating unnecessary readmissions. Outwardly focused by nature, the independent hospitalist survives by performing to the expectations of the primary care physician and specialist who are entrusting their patients to the hospitalist’s care. Sensitive to the need to provide an extra level of “customer service”, the independent practice will often hire a business development manager to coordinate meetings, phone calls and other clinical communications with outpatient physicians in the community.

5. Hospital medicine is best served with its own software solutions. From streamlined charge capture to real-time clinical communications to post-discharge care, hospital medicine performs most efficiently with its own dedicated technology platform. For the most part such technology resides currently outside of most hospital EMRs. To ask hospitalists to work only with the hospital EMR could lead to compromised performance. A better solution adopted by many independent practices is to integrate their software programs with the hospital’s EMR. The combination results in enhanced compliance, better charge capture and improved data quality, thereby setting the stage for an improved transition of care for the patient post-discharge.

6. The recruiting and on-boarding process is unique for hospitalists. Hiring, maintaining and developing a tight-knit practice group require an ongoing commitment by a practice. A unique characteristic of hospital medicine is the extraordinarily high level of interdependence between practice group members. The team-building effort to create the right fit among team members, with built-in processes to reach consensus and resolve conflicts, starts with the recruiting process and never stops. Hospital staff can play an important role in this process, but team-building has to be done by the team members themselves.

7. Independents have mastered the art of fitting in. This is a skill set that may be overlooked and underappreciated by hospitals: a practice group experienced in a variety of hospital cultures stands a better chance of knitting itself into the hospital’s organizational fabric than a group that has done it only once. By fostering a relationship of transparency and accountability between hospitalists and healthcare executives, independent practices can forge a true partnership in which the hospital’s strategic and tactical objectives are achieved in a manner specific to that facility. For example, independent physicians should be expected to be on at least one hospital committee within their first year in order to become integral with the institution’s goals and performance.

8. Independent practices are flexible practices. Responding to new circumstances and changing situations happens faster and easier with an independent practice. This is an inherent advantage for any small business. For example, managing and resolving conflict can be handled more expeditiously in a small group than in an institutional setting. Also, the ability of an independent practice group to clinically integrate with sub-acute facilities in the community, while availing itself of a wide range of referral sources, is an advantage derived from its nimbleness, adaptability and independence that a hospital-based group may not enjoy.

9. Independent practice leadership is accountable leadership. Independent practices cannot lay claim to having a corner on the market for hospitalist leaders. However, it can be fairly said that many of these programs have created a distinct advantage in developing leadership skills that will be required of physician leaders of the future. Most independent practice organizations of size put all of their practice group leaders and medical directors through their own uniquely designed hospitalist leadership programs. Perhaps most significant is that the clinical leaders of independent groups live with the vulnerability of having to perform every day to maintain their position in the hospital, and this drives the clinical leaders to being directly accountable to the goals of the hospital.

10. Aligning hospital goals with an outsourced group is faster and easier. Team-oriented and interdisciplinary by nature, hospitalist groups measure their success by how effectively they meet the goals and objectives of the hospital. Equating alignment with accountability is and should be the expectation for any successful partnership between hospital and practice group regardless of who owns the practice. Most healthcare executives intuitively understand that it is easier to develop alignment with an outsourced practice because physicians in such practices recognize that alignment with their hospital is critical to the success of their practice.

Although the trend toward employment of physicians seems to be returning, it is important to note that in recent months some new developments have emerged. Several major independent practices report an increase in the number of hospitals requesting an evaluation of their employed practices to assess their performance in all aspects including scheduling, quality, utilization, compensation and profitability. A thorough evaluation process should result in an internal discussion that leads to many of the issues we’ve discussed. With increasing frequency these discussions point towards a restructuring of the hospitalist practice into an outsourced program.

Hospital management would be wise to enter this process with an open mind, prepared to entertain the possibility that the employment model may not be in the long-term interest of the hospital. An independent team of hospitalists can provide hospital management an additional measure of input to assess whether or not an outsourced solution is the right answer. For a growing number of hospitals, we think the answer will be yes.

Patrick G. Hays was president and chief executive officer of the Blue Cross Blue Shield Association, the national coordinating body for the nation’s then 49 independent Blue Cross/Blue Shield plans. Mr. Hays was founding CEO of Sutter Health in Sacramento, California in 1980, where he served as its chief executive officer for fifteen years. He is board certified in healthcare management and a Fellow of the American College of Healthcare Executives. He is an immediate past chairman of the board of directors of Trinity Health, a large multi-state faith-based healthcare organization, based in Michigan. He currently serves on the board of directors of IPC The Hospitalist Company, and has had governance experience in both privately held and publicly traded companies. Mr. Hays holds a B.A. from the University of Tulsa and an M.H.A. from the University of Minnesota. He also serves as a clinical professor at University of Southern California’s Graduate Health Services Administration Program.

C. Thomas Smith served for over 11 years as president and chief executive officer of VHA Inc., Prior to VHA Inc., Mr. Smith spent over 30 years managing hospitals, with nearly half of this time as chief executive officer of Yale New Haven Hospital in New Haven, Connecticut. He has held board and leadership positions in several national associations, including chairman of the board of the American Hospital Association. Mr. Smith currently serves on the boards of directors of Kinetic Concepts, Inc., Informatics Corporation of America and Advanced ICU Care in addition to IPC The Hospitalist Company. Over the last two decades, Mr. Smith has served on the boards of six publicly traded and five private equity boards of health care companies. Mr. Smith holds a B.A. from Baylor University and an M.B.A. from the University of Chicago.

The HealthLeaders Media Industry Survey 2010 report is based on seven concurrent surveys sent to healthcare leaders in seven segments across the industry: CEO, finance, technology, physician, health plan, marketing, and quality leaders. In addition, data has been extracted based on community and rural status. The surveys included some common questions for all respondents and some questions directed to leaders in specific segments; some benchmark questions from the 2009 edition are included. A total of 1,210 print and electronic surveys were completed in October 2009. The sample size allows for a 3% margin of error.

http://www.healthleadersmedia.com/industry_survey/

Some key findings include:

• Between now and 2015, the year after health care reforms are scheduled to take effect, the shortage of doctors across all specialties will quadruple. While previous projections showed a baseline shortage of 39,600 doctors in 2015, current estimates bring that number closer to 63,000, with a worsening of shortages through 2025.
• There also will be a substantial shortage of non-primary care specialists. In 2015, the United States will face a shortage of 33,100 physicians in specialties such as cardiology, oncology, and emergency medicine.
• With the U.S. Census Bureau projecting a 36 percent growth in the number of Americans over age 65, and nearly one-third of all physicians expected to retire in the next decade, the need for timely access to high-quality care will be greater than ever.
• The number of medical school students continues to increase, adding 7,000 graduates every year over the next decade. However, unless Congress supports at least a 15 percent increase in residency training slots (adding another 4,000 physicians a year to the pipeline), access to health care will be out of reach for many Americans.

September 39, 2010 news release

1. Primary care. The impending move toward accountable care within the healthcare landscape is a strong reason for hospitals to enlist primary care providers. With ACOs, a core concept is that the ACO shares in savings with Medicare. To qualify to be an ACO, an organization must have 5,000 or more beneficiaries managed by primary care physicians. The primary care physicians will oversee the management of care and direct services. As such, many hospitals looking to develop ACOs are working to build up their primary care provider base.

Additionally, there is a growing general physician shortage, further increasing the demand to snap up physicians. Several national studies have indicated a shortage of 150,000 primary care physicians over the next 10-15 years. As a result, hospitals wishing to attract these physicians will have to offer competitive salaries. The average total annual compensation is $232,553 for a family medicine physician and $265,545 for an internal medicine specialist, according to data from the Delta Companies, a healthcare staffing firm. Given the primary care physician’s direct power of referral, hospitals are increasingly interested in acquiring primary care providers who can then direct patients to the hospital’s facilities.

2. Cardiology. Cardiology is a specialty that can be a big money-maker for the hospital since it is a high revenue specialty. As such, cardiologists are one of the first specialists hospitals are going after, says Chris Regan, a managing director with The Chartis Group. Fortunately for hospitals, cardiologists are increasingly leaving their private practices to join hospitals due to decreasing reimbursements. According to the American College of Cardiology, 30 percent of cardiologists surveyed said they have begun or have already integrated into a hospital. A great deal more are engaged in discussions to do so. These decreases are more easily absorbed by the hospital institution because employed cardiologists and cardiovascular surgeons generate significant revenue for the hospital.

However, hospitals can expect to pay significantly more in salary to a cardiologist compared to other physicians. The average annual compensation for a cardiologist from June 2009 to June 2010 was $583,750, according to data from the Delta Companies.

3. Neurosurgery and orthopedics. Finally, there is a fair amount of demand for neurosurgery and orthopedics in the surgical category.    Orthopedic specialists are also attractive to hospitals because their procedures pay well and will be on the rise as the population continues to age.

Neurosurgeons and orthopedic surgeons won’t be cheap for a hospital to employ. The average annual compensation for neurosurgeons is $571,000, according to 2010 data from Merritt Hawkins, a physician recruitment firm. Orthopedic surgeons employed by a hospital averaged $404,210 in annual compensation, according to the Locum Tenens 2010 Orthopedic Surgery Salary Report. However, a recent study from Merritt Hawkins suggests an employed physician can generate revenue for a hospital in excess of 5 to 10 his or her annual salary.

By: Newt Gingrich and Jeffrey Kao
Monday, September 13 2010

As health care providers prepare to meet meaningful use guidelines defined for EHR adoption, health care consumers seek providers who approach “meaningful use,” from the patient perspective.

Electronic Health Records (EHR) have been in the news a lot lately. With the goal of improving the quality and efficiency of health care, the federal government recently issued guidelines to determine whether health care providers are eligible for financial incentives pending “meaningful use” of this new technology. These guidelines include physician order entry, e-prescribing, reporting of quality standards, and interoperability.

But what about the patient? What kind of technologies does the American health care consumer find meaningful, and won’t it be equally critical to support the adoption of technologies that engage patients in their care?”

According to a new Harris Interactive poll, 175 million adults are now using the Internet to find health-related information. We use technology to search for health care that fits our specific, personal needs. We seek out providers who post lab results on a secure patient portal and utilize electronic prescribing. We select hospitals which have the lowest infection rates or facilities that provide the highest quality care at the lowest price around a specific treatment or disease state. We are a generation of health care consumers who expect our health care team to incorporate technology solutions into their practice, thereby reducing errors and improving convenience for us as a patient.

While the Centers for Medicare and Medicaid Services (CMS) may not reimburse physicians and hospitals at an enhanced level if they directly involve their patients through self-serve or online solutions, many forward-thinking health care providers are implementing technologies that directly engage patients in their own care and treatment.

Even as health care providers prepare to meet the new meaningful use guidelines, patients and their caregivers are beginning to look for providers who incorporate convenience and technology solutions or, in other words, “meaningful use,” from the patient perspective.

Self-service technology has become virtually commonplace throughout our daily lives. From banking, to retail to travel, we expect to be able to conduct an increasing number of interactions online, at a self-service kiosk or on our mobile device. Not surprisingly, patients are now demanding that same convenience of their health care providers. The growing use of patient-facing technologies, including self-service kiosks, patient portals and personal health records, indicates individuals are taking a more active role in managing their health care.

Implementing technology that further engages patients will not only improve the patient experience, it will improve the bottom line. As health care reform takes hold, reducing costs will be a critical barometer of success. Administrative costs currently account for 7 percent of health care expenditures each year, according to the Kaiser Family Foundation. As an estimated 34 million previously uninsured Americans begin to access our health care system, these costs are is likely to grow if technology doesn’t offset the increased volume. Automating routine health care transactions by allowing patients to pre-register, schedule appointments and pay bills how and when it is most convenient for them can significantly reduce administrative costs while streamlining the anticipated increase in patient flow.

Getting patients engaged up front may also help minimize consumer skepticism of adopting electronic health records. According to a recent Harris Interactive survey, only 26 percent of respondents said they want their medical records digitized and 40 percent believe they will result in more efficient care delivery. Giving patients greater access to and control over managing their health information can allay those concerns while supporting the ultimate objectives of an EHR, which are to enhance the efficiency and quality of care, by improving the accuracy of patient data, and creating a truly paperless workflow.

Because of new incentives available to physicians from Medicare or Medicaid, there will continue to be a large migration to patient-focused EHRs.  But as the adoption rate of EHR technology applications increases, physicians, hospitals, clinics and practice administrators can improve the overall success of their EHR program by deploying solutions that are equally meaningful to patients.

About the Authors
Former U.S. House Speaker Newt Gingrich is the Founder of the Center for Health Transformation. Jeff Kao is General Manager for NCR Healthcare. NCR Healthcare is a member of the Center.

Center for Health Transformation

The primary care physician is the gatekeeper of the health care experience, typically serving as a patient’s first and most constant contact with the health care industry. Considering the linchpin nature of the field, one would think its practitioners would occupy something of a venerated status within the American health care industry and be compensated accordingly. Such isn’t always the case, however; and, in America, primary care is a field in crisis. From demographic trends to cheaper competition, educational second-class status to governmental intervention: primary care’s continued health is going to be subject to any number of factors and actors outside the field itself. In the following report, we take a look at primary care: its present state and its possible future.

The Specialty That Gets No Respect

The image issues begin early for primary care. While the breadth of training necessary for practice means that a primary care physician might be able to handle ninety percent of an individual patient’s medical needs in-office,[1] the perception still exists even among some medical educators that primary care is a dead end.[2] It’s not uncommon to hear about medical students being told not to “waste” a medical education by going into primary care; and research grants and consulting opportunities are more commonly biased for other specialties, so primary care physicians have a much tougher road to professor positions and other perks of a career in medicine.[3] As Dr. Lori Heim, the president of the American Academy of Family Physicians, claims, from the classroom to the residency to the billing department, “Primary care hasn’t been properly valued, not relative to the value it provides for patients and society.”[4]

A look at the numbers confirms the dire straits for primary care in medical education: The Government Accountability Office noted in 1995 that there were fewer than 23,800 residents in primary care programs nationwide.[5] That number dropped to 22,100 by 2006. Since 1997, the number of medical students entering primary care has dropped by more than half.[6] In 2007, less than 45 percent of primary care residencies in the U.S. were filled, and growth in the specialty since 1995 has stalled at 1.2 percent annually, far below what is necessary to fill the national need.[7] The past year saw about a nine percent increase in U.S. medical school graduates choosing family medicine,[8] but in comparison to the numbers from 25 years ago, the relative decline of the specialty is striking.[9] According to Heim, herself a family care physician with twenty years in practice, many students begin their medical training with an interest in primary care but lose that interest over time: “If you talk to first year medical students, you’ll see lots of hands when you ask about interest in primary care. Then compare that against what they go on and do. That’s where we lose them: we lose most of them in terms of their original choice of residency.”[10]

While the image and workforce of the specialty are eroded from one end, practicing primary care providers come under economic and professional pressure from the other end. Even though primary care access is strongly correlated with better management of chronic illness, higher patient satisfaction, better health outcomes, lower hospitalization rates, and lower health expenditures,[11] the specialty is undervalued when it comes to the health care payment system. It’s well known that the conventional pricing model disadvantages primary care physicians. Specialists are able to increase the volume of services they provide and increase revenue, but primary care physicians’ principal services are office visits.

Payers use resource-based reimbursement methods, which strongly favor procedure-based services over office visits. Medicare, for instance, may pay about $100 for an office visit in which a patient is evaluated and given preventative advisement, but $450 for a single diagnostic colonoscopy.[12] As a result, primary care physicians are the lowest-paid among physicians, earning $173,000 per year, while their peers in other specialties earn multiples of that: orthopedic surgeons bring home around $481,000,[13] and the average neurosurgeon and cardiovascular surgeon make around $440,000 and $560,000 per year. [14]

The Burden Bearers

These pressures are having an effect on the primary care physician workforce. Burnout is widely reported, and job satisfaction among primary care physicians is plummeting. Primary care doctors regularly report dramatic increases in nonclinical paperwork, which—in two thirds of cases—is causing them to spend less time with patients. “It does take away from the general enjoyment of a day,” says Dr. Chris Lupold, a Pennsylvania family physician in a five-doctor practice. Lupold has been practicing for seven years and notes that “as a general rule, I spend about as much time doing paperwork as I do face to face with patients doing clinical care.”[15]

Some reports estimate nearly half of primary care physicians are considering abandoning practice altogether or at least reducing their patient loads over the next three years. Early retirement is an attractive option for those that can afford it, but reductions in reimbursement put that option out of reach for many practicing physicians.[16] One survey of primary care providers found that one out of every eleven internists originally certified between 1990 and 1995 was no longer working in general internal medicine or a subspecialty thereof. While satisfied with their career choices, internists weren’t satisfied with their careers. That is to say: they love practicing medicine, just not all the other things modern practice entails.[17] Lupold sees a reason for the disconnect: “Most doctors will finish their residencies very well trained clinically” but be unprepared for the business administrative side of practice. “You want to worry about patients,” he says, “not accounts receivable.”[18] Heim concurs: “Documentation, the problems of preauthorization… all of these are unrealistic within the current practice model. We have to work toward administrative simplification.”

Among those not retiring or otherwise leaving medicine, locum tenens has proved an attractive option.[19] A considerable number of physicians are taking up this itinerant physician lifestyle as it is a mode of practice that results in reduced or eliminated administrative load and fewer paperwork headaches, all while getting back to what they love most: the actual practice of medicine.[20]

The Forty-Seven Million

Of course—whether you love seeing patients or currently find yourself overwhelmed by them—the question is: how will you feel with 47 million more of them in the system? This is the issue at hand thanks to the recently passed health insurance overhaul. Such a massive influx of patients runs the risk of overwhelming a primary care system already stretched thin. The recently passed law bears much in common with the law passed in Massachusetts several years ago. Patients in Massachusetts saw average wait times to see a primary care physician spike significantly, while at the same time primary care providers became less likely to take on new patients. Are we destined for a repeat on a national scale? Dr. Heim is optimistic regarding the bill’s impact, claiming that “Health care reform is having generally a positive impact. We think the [increase in primary care residencies] is a result of the highlighting of the specialty in the health care reform discussion. That’s a beginning. It is an excellent start.”[21]

Dr. Lupold is also optimistic, though perhaps a bit more cautiously: “It’s too soon to tell,” he says. “I’m optimistic and excited, and I feel like I need to wait and see how it’s going to progress.”[22]

A key feature of the reform bill is loan forgiveness for primary care providers working in underserved areas. Additionally, the bill provides a new funding stream for teaching health centers—residency programs set in community health centers or other non-hospital centers. The bill also contains additional funding for Title VII Health Professions Programs, which fund family medicine departments in medical schools and residency programs.[23] So there is much within the bill to encourage prospective physicians to choose and stick with primary care. But at the end of the day, it will still be a hard specialty to sell if the price isn’t right. So what does the new bill do about primary care reimbursement?

The federal reform legislation doesn’t simply mandate greater access to primary care; it also mandates a ten percent bonus payment for primary care services for five years, beginning in 2011, as well as components promoting medical practice models that would emphasize the role of primary care such as the patient-centered medical home model. The bill also contains increased funding for the National Health Service Corps and community health centers. There is also a two-year pilot program beginning in 2013 that will ensure equity between Medicaid and Medicare reimbursement rates for primary care services.[24] The legislation isn’t nearly perfect—for example, many of the reimbursement gains for primary care physicians are not permanent—but it does represent an acknowledgment on the part of the federal government—the largest third party payer—of the vital importance of primary care to the nation’s overall health.

Beyond the health reform bill itself, Heim sees other indications from the government that it is serious about the primacy of primary care going forward. “Look at what the administration has signaled outside the legislation,” says Heim. “Look at the CMS 2010 rules… we’re seeing movement from both regulatory and legislative arms in positive directions.”[25]

The Future of Primary Care

And perhaps that’s a good starting point on the road to recovery for an under-respected but indispensable field. There is, really, little that can be done to make operating a primary care practice easier. Primary care physicians will continue to see the most patients, and even more than usual in the coming years, as more enter the system. There are some measures—electronic health records, the medical home model, maintenance of suitable compensation levels for primary care—that can improve the vitality of the specialty, but it really does come back to a certain level of respect for the first point of contact in the health care world. In the face of shifting revenues and increased workloads, primary care physicians find themselves at a crossroads: they are essential in some manner to the functioning of the health system, but it seems apparent that their profession must undergo some sort of change to move forward.

Drs. Lupold and Heim see the potential for a healthier specialty in the future. Reform efforts, Lupold says, mean we’ll likely see “an increase in student interest in going into primary care. It’ll hopefully bring some of the joy back into it.”[26]

Meanwhile, Heim sees this as a moment of opportunity: “We have an opportunity to really integrate more quality and strengthen primary care. It’s an opportunity for us to refine and help lead the way.”[27]

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[1] Carlson, Gail.   <a href=”http://missourifamilies.org/features/healtharticles/health44.htm”>“What Is a Gate Keeper?”</a> MissouriFamilies.org Health.

[2] Chen, Pauline. <a href=”http://www.nytimes.com/2009/11/12/health/12chen.html”>“Primary Care’s Image Problem”</a> The New York Times, November 12, 2009.

[3] Friedman, Emily. <a href=”http://hhnmag.com/hhnmag_app/jsp/articledisplay.jsp?dcrpath=HHNMAG/Article/data/06JUN2008/080603HHN_Online_Friedman&domain=HHNMAG”>“Surf, Turf, and the Future of Primary Care”</a> H&HN Magazine, June 3, 2008.

[4] Telephone interview, Lori Heim, President, American Academy of Family Physicians, August 26, 2010.

[5] ibid

[6] Lloyd, Janice. <a href=”http://www.usatoday.com/news/health/2009-08-17-doctor-gp-shortage_N.htm”>“Doctor Shortage Looms as Primary Care Loses Its Pull”</a> USA Today, August 18, 2009.

[7] Friedman, H&HN Magazine, op cit.

[8] Heim, Telephone interview, August 26, 2010.

[9] Beaulieu, Debra. <a href=”http://www.fiercehealthcare.com/story/increased-primary-care-interest-not-enough-affect-physician-shortage-trend/2010-03-19″>“Increased Primary-Care Interest Not Enough to Affect Physician-Shortage Trend”</a> Fierce Healthcare, March 19, 2010.

[10] Heim, Telephone interview, August 26, 2010.

[11] United States Government Accountability Office, Testimony Before the Committee on Health, Education, Labor, and Pensions, U.S. Senate, February 12, 2008. <a href=”http://www.gao.gov/new.items/d08472t.pdf”>http://www.gao.gov/new.items/d08472t.pdf</a>

[12] ibid

[13] Wechsler, Pat. <a href=”http://www.businessweek.com/news/2010-02-23/doctors-hours-fall-for-a-decade-adding-to-a-u-s-shortage.html”>“Doctors’ Hours Fall for a Decade, Adding to a U.S. Shortage”</a> Bloomberg Businessweek, February 23, 2010.

[14] ibid

[15] Telephone interview, Dr. Chris Lupold, August 27, 2010.

[16] Stouffer, Rick. <a href=”http://www.pittsburghlive.com/x/pittsburghtrib/business/s_679113.html”>“Medical Experts Foresee Critical Shortage in Primary Care Soon”</a> Pittsburgh Tribune-Review, May 2, 2010.

[17] American College of Physicians, <a href=”http://www.acponline.org/pressroom/int_survey.htm”>“ACP and ABIM Survey Finds General Internists Leave Practice Sooner, Less Satisfied with Career than Subspecialists.”</a>

[18] Lupold, Telephone interview, August 27, 2010.

[19] Samuels, Jennifer. <a href=”http://locumlife.modernmedicine.com/locumlife/Modern+Medicine+Now/Locum-tenens-can-solve-shortage-of-primary-care-phy/ArticleStandard/Article/detail/662972″>“Locum Tenens Can Solve Shortage of Primary Care Physicians”</a> LocumLife, March 15, 2010.

[20] Butterfield, Stacey. <a href=”http://www.acpinternist.org/archives/2009/05/locum.htm”>“Practice Hassles Have More Docs Going Locum”</a> ACPInternist.org.

[21] Heim, Telephone interview, August 26, 2010.

[22] Lupold, Telephone interview, August 27, 2010.

[23] White, Brandi. <a href=”http://www.aafp.org/online/en/home/publications/journals/fpm/preprint/reform.html”>“How Health Care Reform Will Affect Family Physicians”</a> Family Practice Management, April 13, 2010.

[24] American Academy of Family Physicians, <a href=”http://www.aafp.org/online/en/home/policy/federal/hcrleg2010/payment.html”>“How Will Health Care Reform Legislation Impact Payment to Physicians?”</a>

[25] Heim, Telephone interview, August 26, 2010.

[26] Lupold, Telephone interview, August 27, 2010.

[27] Heim, Telephone interview, August 26, 2010.