Monday, January 30, 2006

Primary Care About To Collapse?

The headline may be a bit overdramatized, but it raises a valid and pressing issue: primary care physicians/practitioners (PCPs) are undercompensated, and the problem is getting worse.  
Primary care about to collapse, physicians warn
By Maggie Fox, Health and Science Correspondent
Mon Jan 30, 1:44 PM ET

WASHINGTON (Reuters) - Primary care -- the basic medical care that people get when they visit their doctors for routine physicals and minor problems -- could fall apart in the United States without immediate reforms, the American College of Physicians said on Monday.
"Primary care is on the verge of collapse," said the organization, a professional group which certifies internists, in a statement. "Very few young physicians are going into primary care and those already in practice are under such stress that they are looking for an exit strategy."

Dropping incomes coupled with difficulties in juggling patients, soaring bills and policies from insurers that encourage rushed office visits all mean that more primary care doctors are retiring than are graduating from medical school, the ACP said in its report. [...]
The article goes on to mention that fewer medical school graduates are choosing primary care fields.  They authors of the original article propose a variety of solutions, none of which seems very likely to solve the problem.  What they want the most is for Medicare to increase reimbursement rates for primary care practitioners.  That obviously would work, but it does not seem likely to actually happen.

They also want PCPs to have a more central role in coordinating health care for a given patient.  That is a good idea, everyone knows it is a good idea, but nobody wants to pay for it.  Coordinating care means spending a lot of time on the telephone, a lot of time requesting, reading, and organizing records, a lot of time writing and sending notes to other physicians, and a fair amount of time just sitting and thinking.  In some cases, it means spending time on the Internet or in a library, checking up on things.  No insurance company pays for any of that.  

To be honest, I think the reason nobody pays for it is that insurance companies are distrustful.  They worry that doctors will pad their bills, either by billing for things they did not actaully do, or by billing for unnecessary paperwork and phone calls...as if there are doctors around who actually want to do more paperwork and phone calls.

I can envision two possible solutions.  One would be to put all doctors on a salary.  That could cause other problems, and it would not be popular with doctors or with the government.  The other would be to have a standardized, comprehensive medical office software package that doctors would use for all pertinent activities.  The computer would make, record, and bill for all phone calls.  It would keep track of time spent dictating or typing notes.  It would keep track of time spent with patients.  It would keep track of all prescriptions that are written, faxed, or called in.  It would keep track of recommendations for nonmedical interventions, such as counseling for smoking cessation, recommendations for OTC products, and recommendations for alternative medical interventions.  

Such comprehensive software would be highly intrusive, and would invariably introduce security problems.  Doctors might resent letting anyone have such a comprehensive view of what they do with their time.  On the other hand, having such complete information might be valuable to policy researchers and others who are trying to get the system to be more cost-effective.

Another good thing about such a system would be that doctors would get paid for taking the time to explain things to patients, and to help patients feel comfortable as recipients of health care.  Of course, there still would be pressure to cut out all of that stuff that seems like a nice -- but nonessential -- extra touch.