Primary
care physicians (PCPs) have been marginalized by Medicare for decades with low
reimbursement rates for routine office visits which has led to the 15-20 minute
office visit with 10-12 minutes of actual “face time” and a panel of patients
that well exceeds 2000.
Is
there a good solution to the Medicare cost and quality issues? Setting aside
either the Democrats’ approach to basically enact price controls
by ratcheting down reimbursements or the Republican’s plan to re-structure Medicare to a
defined contribution plan, albeit not for ten years, are there approaches that
could be instituted now that would have an immediate impact on improving
quality of care and thereby reducing costs? There are, but in this Part 6 of my
Medicare series, we first need to understand one of the major issues facing
Medicare today – the crisis in primary care.
A
10-12 minute interaction means no time for the PCP to truly listen, no time to
prevent, no time to coordinate and no time to just think. This has in turn
meant that whenever a patient has a slightly more complex issue, one that is
not easily recognized in a short time frame, then the PCP is quick to refer to
a specialist. It is this very act that dramatically drives up expenditures with
added tests, imaging and procedures along with the specialist’s fees. Medicare
has been exceptionally short sighted in this regard and as a result is the
prime culprit in the rapidly rising costs of care.
Further,
this lack of time being reimbursed means that two critical quality care needs
area left largely unattended. The first is offering extensive preventive care
and the second is coordinating the care of the patient with chronic illness.
Recall that 85% of Medicare enrollees have at least one chronic illness and 50%
have three or more. These are mostly the result of years of adverse behavior
patterns but it is never too late to begin preventive care so time spent here
is valuable for better health quality and ultimately reduced costs. And those
with a chronic illness need to have their team of caregivers coordinated –
every team needs a quarterback and the PCP is the obvious choice. But Medicare
does not reimburse for this critical function which when done correctly means
less reliance on specialists, tests, procedures and prescriptions. The result
of this low reimbursement for routine visits and lack of reimbursement for either
extensive preventive care or chronic care coordination over the years is a PCP
shortage, many current PCPs no longer accepting Medicare, and the remaining
PCPs trying to see 24 to 25 patients or more per day, each for 15 minutes
despite the patient’s complex problem list. And this means less than stellar
patient care in many instances.
The
result is a real problem facing Medicare right now - the rapid loss of primary care physicians (PCPs) who will no longer accept
Medicare. In 2009 there were 3700 physicians that opted out of Medicare; the
number rose to 9500 in 2012 according to CMS in a Wall Street Journal article; this on top of the shortage of
PCPs across the country, with no end in sight. The ACA does include an extra
10% increase to primary care providers but this will probably be too little,
too late. And if the mandated 27% across the board physician cut in
reimbursement is ever implemented by Congress (it probably never will be but
Congress refuses to clarify itself) then it is reasonable to expect that there
will be a mass exodus from accepting Medicare reimbursements by all physicians,
not just PCPs.
What
is the fix? As long as fee for service predominates in the payment system,
Medicare needs to increase its reimbursement of PCPs in a manner that ensures
that they will offer the patient more time per visit. Time to listen, to
prevent, to coordinate and to think. And in a capitated system, Medicare (or
its agent) needs to pay enough per patient per month/year to insure that each
PCP does not have more than a maximum of 1000 patients (even fewer if the
practice is largely geriatric) so that there can be adequate time per patient
encounter.
The
next post will highlight some specific recommendations for Medicare to enact
that would improve quality and reduce costs.
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Our current reforms' seem to be getting rid of the old Elton Mayo management techniques. What was considered rather harsh industrial management at the turn of the 20th century, is now being wiped out of medicine as too inefficient.
Mayo's rules for talking to employees in a managerial situation:
-> 1. Give your full attention to the person interviewed, and make it evident that you are doing so.
-> 2. Listen - don't talk.
-> 3. Never argue; never give advice.
-> 4. Listen to: what he wants to say; what he does not want to say; what he can not say without help.
-> 5. As you listen, plot out tentatively and for subsequent correction the pattern that is being set before you. To test, summarize what has been said and present for comment. Always do this with caution - that is, clarify but don't add or twist.
Now, that's a good training exercise for empathic patient interviewing. But now, we're too busy for that.
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