Primary care physicians (PCP) have been identified as a critical part of the future health care value chain. Yet, we know we have far too few of them. We also know that independent providers are struggling financially. As a result, a large number of primary care docs, perhaps a majority, have chosen to become employees of larger health systems. Most physicians label ‘salary’ as the top reason for becoming an employed clinician rather than trying to compete as an independent practitioner. But, with a CPT driven foundation for reimbursement, can this marriage between primary care and large health system be a healthy one?
When a PCP joins a health system and begins to receive a regular salary, the payments are often above that physician’s prior experiences in private practice, perhaps higher than could be reasonably calculated from the their daily productivity. CFO’s are willing to accept the scenario of primary care salaries exceeding productivity, because they are keenly aware that the primary care physician acts as a feeder for the more lucrative profit centers at the hospital. Specialists and their ancillary staff perform most of the profit generating procedures, imaging studies, pathology examinations. These high priced resources need patients (and their insurance cards) to generate the margin-rich revenue for the financial viability of the health system.
This ‘trickle down economics’ philosophy, has given rationale for supplemented incomes for primary care physicians for many years. Private practice physicians, in an ‘eat what you kill’ private office, simply cannot compete because they have no such entity to supplement their low margin CPT codes- the preeminent method by which they generate the bulk of their cash flow. The RUC has continuously biased the relative value of specialty care (procedural value) over primary care (cognitive value) to the point where this trickle-down phenomenon has become the norm in our industry.
No matter the methods for how relative value (RVU) is distributed among them, CPT codes will always place value on the side of driving utilization and consumption of the highest margin health resources. Perhaps the RUC failed to embed value in pure cognitive work because it is inherently abstract, difficult to quantify among individual patients, and even harder to value objectively for financial remuneration. Perhaps the RUC, with its specialist domination among the membership, was simply looking out for the interest of their constituencies, Either way, the primary care physician has perennially struggled to get a foothold in higher margin coding opportunities and thus have found themselves in need of joining the larger institutions to survive. They, in essence, are vicariously tapping into the higher margin CPT codes via a business association with specialists while employed at the larger health system.
Yet, does this vicarious relationship incur an inherent conflict of professional interest between the primary care doc and his new boss? The core foundation of a primary physician’s training is around minimizing disease and preventing complications. That is, the training is geared to minimize the generation of higher value CPTs. For most family physicians, pediatricians and general internists, clinical success and professional satisfaction is measured by keeping patients healthy and out of the hospital. Success means fewer complicated hospital procedures, lower rates of preventable cancer cases, and fewer cerebrovascular accidents. In other words, fewer high margin CPTs.
Primary care physicians will always need specialists, complex imaging, and procedures in their care. Illness, injury, and chronic disease are inevitable. The association of primary care and specialty care is a healthy, necessary requirement for excellence in disease management. But does one have to exist at the financial dependency of the other?
If we ask a health system CFO if he would prefer for his growing investment in a primary care workforce to result in true ‘clinical success,’ he would be torn. On a personal level, he would say, “of course, that’s better for our patients!” But on a professional level, he would be slightly concerned about his balance sheet. He knows clinical success for his PCP’s means fewer inpatient procedures, less frequent use of complex imaging modalities, and lower utilization of ancillary therapy services. So, in some ways, the investment by health systems in high performance primary care may provide clinical benefits that are contrary to the larger system’s financial goals.
Until the conflicts between primary care’s clinical goals and the system’s financial goals are aligned and harmonized, the primary care physician will struggle to achieve a prominent leadership role in the health system value chain. The Centers for Medicare and Medicaid and our governmental leaders working on health reform clearly understand this problem and are actively looking at ways to implement wellness and outcomes oriented reimbursement schemas that resolve the conflict between clinical and financial performance drivers. But they are not going far enough. Current methods are likely destined to fail.
ACO’s, bundled payments, medical homes, and patient-centered care are all worthy attempts. However, these innovations continue to rely heavily upon the inherently flawed CPT foundation for defining value. The new Bundled Payment Initiative is simply an extension of the Diagnostic Related Groups (DRG) concept that combines CPTs from formerly unassociated billable events from providers and hospitals. Medical homes merely add monthly payments that supplement the existing CPT system, and that augment the payments to primary care for care coordination. Accountable Care Organizations are perhaps the most advanced concept, but they too continue to rely on a “CPT plus bonus” type model. It remains unclear whether the ACO incentive curve has, in fact, shifted from pro-utilization CPT drivers and towards pro-clinical-value drivers. The ambiguity is making the heavy investments needed to fully enable care that promotes value, outcomes and wellness measures questionable at best. Many institutions have decided to take a wait and see approach for this reason.
Until system-wide financial value is placed squarely on a level of professional and clinical success that promotes prevention, clinical outcomes, and wellness, we will not see true innovation in cost containment, care delivery methodology, wellness care and holistic medicine. Until that happens, hospitals will continue to look for ways to drive top line revenue by leveraging the most lucrative procedures and diagnostics among their specialty providers. That is what they know how to do.
The pro-utilization and pro-procedure CPT code needs to be fully exchanged for an alternative methodology for defining value. Only then will primary care physicians advance from being a second-class citizen in the health care food chain, to the champions for value creation within a health system. Financially rewarding family practitioners, pediatricians, and internists for successfully living up to the highest standards of their holistic training will go a long way to encouraging our medical students to choose primary care.
Our country needs more primary care physicians. They are the foundation of any future health system. But the foundation of any structure, even a health care system, should never be dependent on the elements that are built on top of it. Such a system is not built on solid footing and will not stand the test of time.
Tom Schwieterman, MD is a family physician in Ohio and the fourth generation of his family to practice primary care in the same small midwestern town.