Paying for Primary Care

Posted by

Bradley Flansbaum

Posted 3/5/12 on the Hospitalist Leader

I recently gave grand rounds at my hospital, and spoke on specialty over primary care dominance in the U.S. system.  I focused on the difficulties of care coordination, i.e., “the stress” of ambulatory practice, and touched the third rail of reimbursement and salary.  Surprisingly, on the latter point, I received little venom or push back from the specialists.  I was shocked–literally, and staved off my own electrocution.  Maybe we are accruing more evidence to support non-specialty practice and reality is setting in?

Despite that, at the annual AMA House of Delegates meeting, no other subject generates more sizzle than physician pay (putting the ACA aside).  However, given the national budget, no new money will enter the system, and solving the primary care provider crisis will entail multiple fixes:

  • Loan Forgiveness
  • Stipends and financial support
  • GME incentives, including lifting training caps
  • Restructuring office practice to improve quality of life
  • Utilization of midlevels and other venues of care to offload low acuity patient volume
  • A National Health Care Workforce Commission (currently without appropriations)

Given congressional gridlock, I am not sanguine we will solve the primary care challenge in the next decade, and the likeliest revamp scenario is yearly hole patching.  When there is a catastrophic crisis, perhaps the system will change course, but only then will we have receptivity to an overhaul.

Along those lines, I came across an interesting paper that clarified physician positions on how we as a profession might handle self-financing.  The authors surveyed specialists (and primary care docs) and their willingness to adjust personal salaries 3% downward (or endorse strategies to adjust salaries) to buttress primary care pay.  The response rate was excellent at >60%:

Here, note the breakdown for or against:

The survey is typical of AMA sentiment.  Specialists wish to strengthen primary care, but naturally, they don’t want it to come from their hide: two-thirds of primary care docs favor cross subsidization, but only one-third of specialists feel similarly.

I mocked up the following chart to express the “fairness” dilemma that often unfolds from surveys like above.  As always, “the dollar signs” fall out on whichever side of the fence you are sitting.

Kin Hubbard though, says it more succinctly than I ever could:

–When a fellow says, “It ain’t the money but the principle of the thing,” it’s the money.

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