How Many Patients Should A Primary Care Physician Care For?

The answer is probably about 1000 or less. But most primary care physicians (PCPs) have a panel of perhaps 2,500 patients and often more.  Why the dichotomy?

As insurers have held the line on physician reimbursement in the current fee-for-service system, PCPs have found that they must increase the number of visits per day in order to meet overheads yet still maintain their personal income of about $175,000 per year.  In order to see more patients, usually 24-25 per day or more, they must no longer visit inpatients in the hospital nor see their patients in the emergency room.  And they have shortened most visits to about 15-20 minutes which means 8-12 minutes of “face time.”  Too little time for someone with multiple chronic illnesses on 5-7 prescription medications and possibly impaired by age with reduced vision, hearing and memory.

Further, there has been a major shift over the years form mostly seeing acute illnesses to a much larger proportion of patient with chronic illness, often complex and often with multiple chronic diseases. These diseases are difficult to manage, last a lifetime (some cancers excepted) and are inherently expensive to treat. These patients often need to be seen, over time, by many specialists. Someone, preferably the PCP, needs to coordinate this team of caregivers to assure quality, safety and in so doing keep expenses down..

Baron published an article on how a primary care physician spends his or her time. He is part of a Philadelphia area internal medicine group practice with an active caseload of 8840 patients divided across the equivalent of four full-time physicians each working 50-60 hours per week. The office has 3.5 full time support staff per physician. Each physician handled 24 telephone calls, 17 emails, reviewed 20 laboratory tests reports, 11 imaging reports and 14 consultation notes and processed 12 prescription refills each day in addition to seeing patients. It is clear from this report that the PCP spends a lot of time in clinically relevant work not directly associated with a patient visit – which is the only activity that generates an insurance reimbursement. Not noted was the very substantial time spent in non-clinical requirements such as insurance forms.

So what is an appropriate number of patients under care or number of visits per day?  The answer, of course, is that “it depends.”  It depends on the type of patient, their reason for the visit, their impairments and their personal needs, to name but a few. 

I have completed multiple in-depth interviews with many PCPs.  Most were in private practice; some were in an academic setting.  Most accepted fee-for-service insurance; some were retainer-based PCPs.  Some had been in practice for decades, others for a few years.  About three-quarters were men, the remainder women.  Of the 21 questions, one asked the ideal size of the PCPs patient panel. Their responses varied but here are some generalizations.  PCPs, they said, should have no more than about 1,000 patients under care, perhaps less if the majority are geriatric with complex chronic illnesses and perhaps up to 1500 if most were basically healthy.  But, in order to meet overheads, most of these same PCPs had closer to the 2,500 panel size.  The exceptions were retainer-based PCPs with about 500 and a salaried PCP in a retirement community with 400 patients in his panel.  These physicians felt they were able to give much better care to these smaller sized panels of patients. The retirement community PCP had strong data to support his contention, e.g., reduced hospitalizations and markedly reduced unplanned 30 day readmissions to the hospital. One of the retainer-based physicians participated with MDVIP, an organization which has developed similar data on substantially reduced admissions.

I asked the same question on a LinkedIn group.  Many responded as did the PCP interviewees.  Here are some specific comments: “Patients are not products on an assembly line that must all fit into specified compartments as business models dictate.”  “Time is what affords the physician the ability to utilize all of his or her experience and medical expertise in the most efficient manner to benefit the patient.”  “Time is the one component necessary to be effective.”  Another response was that PCPs who decline insurance and have the patient pay directly can actually charge less because their overhead declines so dramatically, perhaps by about $58 per patient visit.  A third stated that PCPs need to develop and properly manage an office team and delegate responsibility and authority accordingly.  Data collection and data entry for example can be done by non-clinicians and much preventive care can be handled by nurses and nurse practitioners, thereby freeing up substantial time for the PCP to interact with patients – time to listen and time to think. 

An article in the Annals of Family Medicine by Altshuler and others sought to estimate a reasonable sized patient panel for a PCP with team-based task delegation consistent with the patient centered medical home model.  Using published estimates of the time needed by a PCP to provide preventive, chronic and acute care they modeled how panel sizes would change if some portion of the work in each of the three categories was delegated to team members.  If there was no delegation of work, as has been typical in PCP practices for decades, the data suggest that a patient panel size of about 983 is the maximum, not too far from my own estimate of 1,000 based on the various interviews.  They then assumed varying levels of delegation to the team.  Their model panels with team-based delegation ranged from 1,387 to 1,947 patients.  This analysis suggests that a primary care physician can care for more than 1,000 patients provided he or she practices as part of a well-oiled team-based medical home practice.  It does not address the question of whether the team can practice true “population health” meaning that the PCP and his or her office team reach out proactively to all members of the patient panel to address high quality preventative care rather always being reactive by waiting for the patient to arrive at the office with a problem. 

PCPs (and all doctors) need time with the patient if they are to be effective and to be trusted.

Something needs to change if PCPs are to get back to providing the level of humane, comprehensive care that patients want and doctors wish to offer. The current reimbursement system short changes the patient and frustrates the physician. Insurers should look to new approaches that pay the PCP to actually spend time with the patient – time to listen, time to prevent, time to treat, time to coordinate chronic care, time to think and time to interact with their colleagues, especially regarding more difficult situations. This can be with fee for service, capitation, bundling, etc. or by the PCP no longer accepting insurance and expecting the patient to pay directly by the visit, the month or the year. In whatever manner, the new paradigm must create time for the physician to spend with the patient so as to listen and think about both the patient and his or her condition.

Small Businesses And The Not So Affordable Care Act

The Affordable Care Act is not so affordable if you own or if you are an employee of a small business. Here is why.

Consider the owner of a small service business with one or multiple outlets (e.g., a large restaurant or a small chain of sit down restaurants, a chain of barber shops, a taxi company.)  The owner has more than 50 employees but the business is still “small” with less than 1000.  It is a service business where the usual wage is about $10 per hour or about $20,000 per year plus significant tips. Many of the staff have been with the company for decades and some prefer to work fewer hours for family reasons.  Let’s also imagine that the company has always offered a quality health insurance plan to those who work full time (greater than 32 hours per week).  The owner selected a plan that has a modest deductible of $200 per year, good catastrophic coverage and a maximum out of pocket expense for each employee of $1,000.  Company policy has always been for staff to pay approximately 50% of the premium.

At the company whose owner I talked with, both the company and a single individual are paying about $2,000 per year in premiums.  Most   of the full time employees are not enrolled.  Some have coverage through a spouse’s employer.  Others are young invincibles and choose to use their wages for other purposes. But the owner encourages all to participate who wish to or to sign a waiver that they chose not to do so. The health care policy is (and has been) consistent with the ACA/Obamacare guidelines for the various essential services that must be covered; it has never been a “substandard” policy. 

In 2014 all of the full time staff must, per the ACA, have insurance or pay a penalty tax.  That means the young invincibles will be required to sign up somewhere.  If they enroll in the company plan and pay their share of the premium, they will have less take home pay – perhaps a hardship.  But every time one more employee enrolls, the business will also have to pay its 50% share of that premium as well.  The owner is pleased that the employee is now covered but this is a new and substantial expense for the company. 

But that is not all.  Beginning in 2015, an employee cannot be required to contribute more than 9 ½% of wages for their insurance.  Since the full timers tend to earn about $20,000 per year, less for someone working say 32 hours per week, a $2,000 per year share of the premium exceeds the 9 1/2 % limit.  To avoid a significant penalty, the business will need to lower the employee contribution amount, adding further substantial expense to the company. 

So what’s the import?  Does it really matter? 

There is general agreement that it is good for everyone to have insurance.  But this company’s prices will have to go up to cover the new expenses.  And a price hike may make the business less competitive because other companies in this business may have less than 50 employees and hence are not affected by the ACA requirements.  What the owner will likely decide to do is preferentially hire part-timers even though having fewer employees who work longer hours each is otherwise preferable. 

So, in the end, all fulltime employees will have insurance; some employees forced to buy insurance will now have a lower take home pay with its consequences; the person who wants to work more hours will be pushed toward less hours with yet lower take home pay; and the customer will pay a higher price for the service. Is this affordable health care or is it is the law of unintended consequences? 

Cheap Drugs From Canada– Good Idea?

The price of drugs comes from a perverse system and what you as a patient pay is equally perverse. Let’s consider a few examples.

Older people often develop actinic keratosis on their scalp as a result of years of ultraviolet rays from the sun. They can progress to skin cancer so it is good to treat them. A dermatologist can remove them with liquid nitrogen or the individual can apply a prescription drug that kills the cells in the AKs. The drug most commonly used for decades is an anticancer drug – 5-flurouracil or 5-FU. Applied topically it can be very effective. 5-FU was developed before I went to medical school which is now 50 years ago. It is obviously off patent and not difficult to manufacture. But the branded topical called Efudex costs about $300 retail. Wow! There is a generic but it is also expensive, albeit at half the price of about $150. It is a large tube and will last a long time but it is a lot of money none the less. It is not a high volume drug and there are only two manufacturers so the competition is minimal enough to keep the price high. And even with the generic, there is a large middleman profit between what the manufacturer sells it for and what the pharmacy ultimately charges you (or your insurer.)

Staying with dermatoligic issues, rosacea can be cosmetically bothersome with redness, papules, acne-like pustules on the face and coarsening of the nose (rhinophyma.) Its cause is unknown and there is no really good treatment. One approach has been to use an antibiotic called doxycycline taken orally in the usual “antibiotic” dose of 100mg. It seems to have an anti-inflammatory effect rather than an antibiotic effect in the skin and often can clear the face. It is a very inexpensive capsule at about 30 cents each. But it can also have an adverse effect on the bacteria in the gut and possibly lead to overgrowth of yeasts. A new approach is a 40mg capsule branded as Oracea which is both regular doxycycline and a sustained release form so that the blood level stays low and relatively constant over the day; perhaps it will have less likelihood of adverse problems. It has been tested and found to be reasonably effective for rosacea and hence approved for market by the FDA. But it is on patent and costs about $10 per dose or $300 per month– a drug that the patient will probably have to take forever to keep their face clear. That adds up – fast. Instead one might consider using the standard 100mg doxycycline but only for a few days whenever a flare-up begins. Low cost and limited side effects, if any.

Steroid creams are commonly used for rashes. I was once given a prescription for betamethasone for a small rash. Why betamethasone rather than over the counter hydrocortisone? “It is stronger and will work faster,” said my doctor. But, since I had a high deductible insurance policy, I had to pay the entire bill which proved to be a remarkable $67. An over the counter tube of hydrocortisone at the same pharmacy, enough to last a whole family for years and years, costs only $1.98. Sometimes it pays to accept a slower cure.

Let’s say you need an acid suppressor for reflux esophagitis [acid reflux or GERD.] There are multiple drugs called proton pump inhibitors on the market, some off patent and now over the counter and others still on patent and only available by prescription. They are all effective. The differences among them are minimal. Your doctor could tell you to go to the grocery store and pickup Prilosec for about $30 for a month’s supply. Or, he or she could give you a prescription for Nexium. It would cost about $150 for a two week supply. But your insurance will pay for it except for your co-pay of, say, $15. So your doctor will probably suggest Nexium since it will cost you less. But the overall system is paying out a huge amount more than necessary. What a perverse system. 

If you are the one paying for the drug because you have a high deductible plan or no plan at all then you start to ask questions. Sometimes you can find a generic equivalent like the fluorouracil example but sometimes the generic is still expensive. That is you might start to look elsewhere. 

What about buying drugs from Canada? Same drug but at a better price. I checked PharmacyChecker.com and found the topical fluorouracil branded Efudex for $75 including $10 for shipping. That is a lot better than the generic price here of about $150 and way better than Efudex at about $300. For the doxycycline, using the same web checker, I found a 50mg dosage (albeit not sustained release) that costs about $17 per month. Oracea 40 mg capsules can be found in Canada for about $2.00 each if you buy more than 50 at a time. Both are quite a difference from $3600 for a year’s supply. Nexium can be found for about $1.00 a pill, way less than in the United States but it is just as easy to go to the local grocery store and buy Prilosec for much less still. As for betamethasone, it is $25 with a $10 shipping fee. A lot less but over the counter hydrocortisone is still only $1.98! 

But buyer beware. We have a very carefully monitored market in the United States through the FDA. We benefit greatly from its regulations and its careful scrutiny of each new drug before it can be marketed. IN the United States, the drug can be traced from the manufacturer to the distributor to the pharmacy to you so you can be certain it is the real thing. And companies that manufacture overseas must follow the same stringent requirements as in the USA in order to sell here. The FDA's concern is not to protect the drug companies profit from competition but to protect us (you and me) from the unscrupulous. The concern is that the drug bought from Canada (or elsewhere) may not actually be the drug it is said to be. Witness the highly expensive drug Avastin used to treat certain cancers. A counterfeit was somehow entered onto distribution in the USA from somewhere else- except that it was not Avastin. It was not a drug at all. A lot of unsuspecting doctors and patients were duped. So it behooves us to carefully balance the pros and the cons.  

Why does it cost less in Canada or other countries for the same drug? Because the other countries tell the drug company that it can only sell the drug at a set upper price limit. If that limit is still within the pharmaceutical manufacturer’s marginal cost per unit of drug, then they will agree and sell at that level. In America, we are effectively paying for the entire R&D cost of bringing a new medication to market along with the company’s marketing cost and still giving it a huge profit potential. Rather than import the drug from Canada, we should just expect the company to sell here for the same price as there. But they do not have to and so they do not. Right now, Americans effectively pay for the R&D costs of new drugs while others get a discount because their governments insist. So should ours. It would bring the price down and negate the need to look to Canada or elsewhere.

How to do that without imposing price controls or getting the government into further regulatory policies. I wrote in the Future of Health Care Delivery that the federal government should simply say that it (through it drug purchases via Medicare, Medicaid, the military and Veterans Administration) will only buy medications from drug companies that sell it for the same price here as overseas. The drug company still can sets whatever price it wants but since the government buys at least half of the drugs sold in the USA, it should have an impact and quickly.

 

Nanomedicine - A Key Component to the Future of Medicine

Nanotechnology is making fast advances in medicine. I have written about it before here and in "The Future of Medicine - Megatrends in Healthcare." A nanometer is one billionth of a meter. New science and technology based on the nanometer refers to the ability to manipulate individual atoms and molecules to build machines on a scale of nanometers or to create materials and structures from the bottom up with novel properties.Nanotechnology, according to the National Science Foundation, could change the way almost everything is designed and made, from automobile tires to vaccines to objects not yet imagined. The concept is to prepare "smart objects" that can invade small spaces and target specific parts of the body. Some researchers expect nanoscience to have a profound impact on the way medicine is practiced.
Here is a an infogram that gives a nice overview, compliments of  its originator, Marcela De Vivo and her sponsor Associates Degree in Nursing.

 

Have You Had Your Colonoscopy Yet? –A Ludicrous Colonoscopy Rule and the ACA

“An ounce of prevention” we all know is good medicine. An example is colonoscopy. It was time for mine so after some lengthy procrastination I called and set up an appointment which I soon found a perfectly good reason to postpone for a few weeks. A common occurrence. The government wants me (and you) to not procrastinate, at least not because of the cost. The Affordable Care Act (ACA or Obamacare) makes an effort to get more people to get preventive care screening by requiring that there be no deductibles or co-pays for defined screening and prevention services. Sounds good. But,  in this Part 8 of my Medicare series, there may be a catch, as I soon learned.

The concept and purpose of colonoscopy is to find a polyp and remove it before it turns into cancer. Colon cancers arise from polyps. Polyps are common but only a minority of polyps progress to cancer. But if removed they obviously cannot become colon cancer. Colon cancer is the third most common cancer in men and women in the USA with about 150,000 new cases per year, behind only lung, breast and prostate cancers. And it causes about 50,000 deaths per year. Prevention obviously makes sense.

On my appointed day I arrived at 8:25am having had clear liquids for 24 hours and the effects of a very strong purgative. I was pleased that part was now over. The receptionist seemed like she already had a long day but was nevertheless efficient. By 8:35 I was in a cubicle getting into my procedure gown. Thelma – a wonderful nurse and nurse administrator who had come out of retirement for the intellectual stimulation of working with people – reviewed my pre-completed history and kept up a patter while another nurse deftly inserted an IV. The senior anesthesiologist came by and then the gastroenterologist, Dr Kester Crosse. I was whisked off to the procedure room, slipped off to sleep and awoke back in the cubicle. Dr Crosse came by to say that the procedure went smoothly, that he found a polyp which looked benign and that he had removed it. The pathology report would be back in few days. Another cheery nurse chatted with me and my wife for about fifteen minutes; her medical purpose was to be sure I did not aspirate before fully regaining alertness. When she was satisfied that I was really awake and alert she let me get up and get dressed. We walked out at 9:32am. Most everyone at Digestive Diseases Associates had been friendly, all had been competent and all had done their job effectively. Very efficient and satisfying to me.

The Medicare and Medigap statement came in a few weeks. Dr Crosse had billed $964. Medicare reduced this to $327.61 as per its formula. In other words, Medicare says a colonoscopy is worth about $328 and it paid its portion of that amount or $262. The doctor is not allowed to “balance bill” me for the rest of what he had originally charged. In order to participate with Medicare he, by contract, has to accept the price Medicare determines. Since Medicare generally pays about 75% of covered services, the bill next went to my Medigap provider (Carefirst Blue Cross/BlueShield in my case.) They did not pay the remainder stating correctly that I have a high deductible policy. So the doctor’s office sent me a bill for the $65.57. I paid it. But what about the new Medicare rule in the ACA/Obamacare that there are to be no co-pays or deductibles for such preventive services?

A check of the www.healthfinder.gov  web site stated that colonoscopy was covered by the ACA and that   “If your doctor finds polyps inside your colon during testing, these growths can be removed before they become cancer.”

I decided to call the doctor’s billing office to check. After the clerk talked to her supervisor she called back to say that I was correct that there was to be no deductible if it was a simple “screening” colonoscopy. But since the doctor had found and removed a polyp it became a therapeutic procedure. Medicare and Medigap (and apparently commercial insurers as well for those under 65) do not recognize this as a preventive screening procedure under the ACA guidelines. Hence I was on the hook for the remaining $65.52. By chance I was at a breakfast shortly after with a senior person at Blue Cross who confirmed that, yes, this was the rule. I also received a facility charge (nurses, procedure room, equipment, cleaning, etc.) of $695; Medicare reduced that to $391. This left a Medigap portion of $78.15 but again it was my responsibility to pay. Finally were the anesthesiologist s’ bills totaling $975. Medicare reduced that to $150, paid $65 leaving me with a bill of $66. So altogether it cost me just under $250 to have the colonoscopy and the peace of mind that all is in order. Not a bad value.

Admittedly $250 was not a huge amount of money but it strikes me as strange, to say the least, for Medicare rules to say that, since Dr Crosse removed a polyp while doing the colonoscopy, then it was no longer a preventive/screening procedure.

As an aside, I happen to be a big believer in high deductibles. I think that Medicare should be totally changed so that everyone (except the financially challenged) should be required to have a high deductible. That would engage patients into more dialogue with their physicians and lead to better quality at lower cost. I have posted and written an op-ed in the Washington Times about this concept.

But that is not what Congress set into law in the ACA, i.e., Medicare recipients would not pay deductibles for specified preventive screening, including colonoscopy. The whole point and purpose of the colonoscopy is to look for polyps and to remove them if found. It makes little common sense to claim that polyp removal changes the procedure from screening to therapy and therefore not eligible for the no deductible rule. Admittedly, my argument can be challenged. For example, a screening test for cholesterol would have no deductible but the drug treatment for high cholesterol would of course be another matter. Similarly, if a mammography detects probable breast cancer, the subsequent treatment would not be covered with no deductible. But in the colonoscopy example, the procedure is underway, the doctor finds a polyp and, as part of the process, removes it. Maybe there should be a separate bill just for the polyp removal part and a deductible for that portion. The facility charge would be the same except for sending the specimen off to pathology and I doubt the anesthesia was any longer or more complicated as a result of the polyp removal.  So most of the deductibles would be eliminated as per Congressional intent.

I wonder what our elected representatives really intended – or maybe they never really thought about the details.

 

A “Grand Bargain” To Improve Quality and Decrease Medicare Costs

There are just a few key reasons why Medicare has become inordinately expensive. There is no end in sight for cost escalation. But there are some obvious solutions and they all begin with chronic illnesses.

Chronic illness – diabetes, heart failure, cancer, chronic lung disease, etc. – are increasing at exponential rates; are caused largely by lifestyle behaviors; and consume 70-85% of all claims paid. Medicare enrollees tend to have chronic illnesses; 85% have at least one and 50% have three or more and many are taking 5-7 prescription medications. Any attempt to control costs must begin with chronic illnesses. 

Is there a good solution to the Medicare cost rise issue? Are there approaches that could be instituted now that would have an immediate impact on improving quality of care and thereby reduce costs? There are and could be the basis of a “grand bargain.” Here are five workable suggestions. 

1) The first recommendation is to recognize that one is never too old to benefit from sound preventive measures. Most chronic illnesses are related to excess calorie consumption, lack of exercise, chronic stress and tobacco. And aging leads to impaired mobility, vision, hearing, dentition and cognition. So Medicare should strengthen the wellness, health and preventive programs with specific funding to PCPs to engage in detailed, in depth preventive care. The new annual preventative care session built into the Affordable Care Act (ACA/Obamacare) is a good start in this direction but it must be augmented since a single yearly session is not sufficient to deal with the serious lifestyle issues leading to and exacerbating these chronic illnesses. This will improve health now and substantially bring down costs in the longer term.

2) The second recommendation is to recognize that older individuals with multiple chronic illnesses on multiple prescription medications who may have visual, hearing, mobility and cognitive impairments cannot be effectively diagnosed and treated in short time periods. There must be time – to listen, think, prevent and treat. This means adequate reimbursement per visit to spend the time required. And it means Medicare must pay the PCP sufficiently and specifically to provide chronic illness care coordination. This must be done in a way that is a quid pro quo – higher reimbursements but only in return for the care the patient needs and deserves. This will markedly improve quality, substantially reduce costs and do so immediately. It means the PCP must substantially reduce his or her case load from today’s 2000 plus to no more than 1000 (and preferably substantially less) so as to have the time required for each patient. (Many believe that it best to convert from a fee for service to a fixed reimbursement system, capitation system or a salaried approach. That is probably a good idea but only if the system grants the PCP the critical needed time per patient, i.e., assignment of a limited number of patients or a large enough payment per year per patient so as to keep the total number of patients under care low enough to give the time needed.)

3) The third recommendation is that Medicare should reconsider its approach to hospital care alternatives. For example, today a patient becomes eligible for nursing home care only if he has been hospitalized for three or more days. Costs could be dramatically reduced if a patient could be sent directly to a well-qualified nursing home by his PCP who certifies in writing as to appropriateness. Similar consideration should be given to home antibiotic administration and other home care alternatives which mean better quality and lesser costs. 

4) The fourth recommendation, somewhat of an alternative of the second, begins with the realization that primary care is generally not expensive. Indeed when Medicare originated, it was the patient’s responsibility to pay for primary care and should be again. Medicare should institute high deductibles with the opportunity for a health savings account (HSA) to pay for primary care with tax advantaged dollars. Patients begin to ask questions and challenge recommendations when they are paying for primary care directly. They can request more time per visit and pay for it through their HSA. Both have the result that the care quality goes up and the overall cost to Medicare goes way down because the patient gets the time needed by the PCP to give good care, avoid excess testing and avoid the reflex to refer to the specialist unless really appropriate. The patient-doctor relationship is corrected to being a direct contractual relationship leading to better care at much lower cost. Most studies suggest that the deductible needs to be high enough to be meaningful, often about $1000 or more. This could be reduced for those of lesser means. Given the importance of preventive care, that might be excluded and continued to be paid for by Medicare. High deductibles will be politically difficult. But high deductibles are available thought the private plans for Medigap and for the Part D prescription drug policies so the precedent is there. This would lead to a much more responsible use of the entire system with better care and much reduced costs.  

Meanwhile, many PCPs are switching to a direct pay system where they no longer accept Medicare and either expect to be paid per visit by the patient or be paid a flat annual amount (retainer). Medicare is losing these physicians now who are providing better care but at a cost to the patient. Better that Medicare reexamines its policies and adapts now. 

5) The fifth recommendation relates to end of life care. Americans believe in individualism and the right to whatever care is available, damn the expenses. And physicians are trained to treat death as an obstacle to be surmounted rather than to be accepted as ultimately inevitable. This plays out eventually towards the end of life where “one last” drug, procedure, etc. is proposed or requested or both. Generally this occurs because the physician has not engaged in a constructive, honest and empathetic conversation with the patient well ahead of time and ongoing. This is fundamentally irresponsible use of the medical care system by both patient and doctor. Much better is reasoned, empathetic discussion between patient (and family) and the doctor followed by humane, compassionate active support and emotional care – in other words, death with dignity. End of life discussions are not only logical but humane. And it must be stressed that this recommendation has nothing to do with so called “death panels” or some nefarious means of rationing care. 

Each of these recommendations incorporates a balancing of rights and responsibilities. The first offers the enrollee added wellness and preventive services but it must come with the responsibility to use them effectively. The second grants the PCP added revenue per patient but only for the commitment to take the needed time with patients and of offering extensive preventive services and chronic illness care coordination. This of course means limiting the total number of patients under care per PCP. The third grants a new approach to paying for alternative care but only provided that it is certified as appropriate. The fourth places the responsibility for first dollar coverage on the patient/enrollee but with it must come a right to a better doctor-patient contractual relationship – one that the patient can void if the response is not adequate for the dollars expended. And the fifth recommendation places a responsibility on patient and doctor alike to have in depth and rational discussions regarding end of life options and needs while expecting Medicare to pay not only for the discussion time but also for the option selected. 

These five recommendations could have a major impact on Medicare expenditures, beginning immediately. The real benefit of course is that these recommendations will improve health care quality while leading to more satisfaction by patient and doctor alike. It would be a valuable “Grand Bargain.”

 

 

Medicare and the Continuing Loss of Primary Care Physicians

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.