Leaders of three national organizations representing nearly a third of a million physicians recently visited Capitol Hill offices to express their continued concern for America's patients who do not have access to primary care physicians. The American Academy of Family Physicians (AAFP), the American College of Physicians (ACP) and the American Osteopathic Association (AOA) represent the majority of physicians who care for Medicare patients. The leaders noted that only 17 percent of U.S. medical school graduates in 2008 expressed a preference for a primary care specialty - an all-time low - at a time when demand for primary care is rapidly increasing.

"Unless Congress takes action very soon to stop this precipitous drain on the numbers of primary care physicians in the United States, health care costs will continue to skyrocket while the quality of overall care will decrease," said Ted Epperly, MD, president of the AAFP. "While sub-specialist care is certainly important to achieving a healthy public, such fragmented care cannot take the place of a primary care physician who can diagnose and treat the vast majority of patients in the office."

The AAFP, ACP and AOA urge Congress to take advantage of this historic opportunity for change and enact health care reforms that:

* invest in training more primary care doctors;
* implement new payment models to support patient-centered primary care; and
* reform and enhance Medicare payments to recruit more physicians into primary care and support those already in practice.

The organizations believe that increased funding for competitive grants for training programs in medical schools and in residency programs extend far beyond the medical schools that receive them. The United States lags behind other countries in its focus on primary care. However, the evidence shows that countries with primary care-based health systems have population health outcomes that are better than those of the United States, and at lower costs. The organizations specifically called for increased funding for the National Health Services Corps and primary care training programs funded out of Title VII, and creating additional scholarships and loan repayment programs for physicians who choose primary care careers. In addition, they called for creation of a national commission on workforce to recommend goals for the numbers and distribution of physicians, including primary care physicians.

"Healthcare, at its core, is the interaction between a patient and a physician. Almost all health care services originate as a result of the patient-physician interaction, thus making this the most important element of any effort to reform the health care system," said Larry Wickless, DO, president-elect of the AOA. "Congress must make a concerted effort to restore the patient-physician relationship and take this unprecedented opportunity to make fundamental shifts in how health care is delivered by moving from the current episodic-based payment system towards payment models that promote the patient-physician relationship."

The current health care payment model in the United States is based on the quantity of care a physician provides as opposed to quality of care a patient receives. A more effective, predictable payment method should encourage doctors to provide evidence-based care that is effective. It should be based on a patient-centered medical home where patients and physicians work together to coordinate the patients' care in the context of their overall physical, mental and emotional health. A more effective payment model should include incentives for physicians to coordinate the tests, procedures and patient health care in general, including preventive and health-maintenance services.

The results of such a payment system would ensure that the physician-patient relationship is preserved, resulting in better patient care and lower health care costs.

Medicare has a history of making disproportionately low payments to primary care physicians, largely because its payment formula is based on a reimbursement scheme that rewards procedural volume and fails to foster the comprehensive, coordinated management of patients that is the hallmark of primary care and effective health systems throughout the industrialized world. More broadly, the prospect of steep annual cuts in payment resulting from the flawed sustainable growth rate (SGR) formula is discouraging for all physicians and health care providers. Under the SGR, physicians face steadily declining payments into the foreseeable future - 21 percent next year and about 5 percent a year for several years thereafter - even while their practice costs continue to increase.

The organizations called on Congress to enact a five-part plan to reform physician payments:

1. Provide a substantial increase in Medicare payments to primary care physicians, beginning in 2010. Such an increase should be large enough to send a powerful signal to medical students and established physicians that Congress is serious about making primary care a more attractive career option, and to recognize the demonstrated value of primary care in improving outcomes and lowering costs. This initial increase should become a permanent part of the Medicare payment structure, they said.

2. Eliminate the Medicare SGR and replace it with a system that provides predictable and stable updates to all physicians with positive and higher updates for services provided by primary care physicians. The accumulated SGR deficit should be eliminated and reflected in the Medicare baseline.

3. Improve the accuracy of relative values for services paid under the Medicare physician fee schedule.

4. Expand the Patient-Centered Medical Home nationwide, supported by a new payment system that reimburses qualified PCMHs for the value of prevention and care coordination.

5. Pilot test other new payment models to align incentives with the value of services provided by primary care physicians.

"We believe that a comprehensive and multi-faceted approach is needed to encourage students to pursue career choices in primary care medicine, and to help established primary care physicians stay in practice," noted Joseph W. Stubbs, MD, FACP, president of ACP. "We are highly encouraged that President Obama and members of Congress from both parties have endorsed the need for more primary care physicians, but the question now is whether they will follow through with steps that are big enough to address the crisis - starting with payment reforms that will once again make primary care medicine an attractive and viable career choice for young physicians."

As Congress seriously considers health care reform in the coming weeks, the AAFP, ACP and AOA urge the House and Senate to take advantage of the climate of change in Washington and address the issues causing the expensive fragmentation of America's health care system. We remain concerned that the continuation of the current physician training system and the flawed physician payment system is a steep pathway to decreased access to and growing cost of health care for all Americans.

Source:
David Kinsman
American College of Physicians