THE JOURNAL OF FAMILY PRACTICE

Brian Yoshio Laing, MD, and Thomas Bodenheimer, Primary care’s eroding earnings: MD, MPH, Department of Family and Community Is Congress concerned? Medicine, University of California, San Francisco [email protected] Barely. Our study suggests that our best hope for change

Robert L. Phillips, Jr, is to work with lawmakers who want to reform Medicare’s MD, MSPH, and Andrew Bazemore, MD, Sustainable Growth Rate MPH The Robert Graham Center, Washington, DC Practice recommendation Government Accountability Offi ce. Department of Family Medicine, • Write your senator and congressional Results: Interviewees revealed Georgetown University, representative about the need for that issues in primary care are not Washington, DC Medicare payment reform that high on the congressional agenda, Department of Family Medicine, ® Dowden Health Media Virginia Commonwealth addresses the primary care/specialist and that Medicare’s Sustainable University, Richmond payment gap. Let them know, too, if you Growth Rate (SGR) is the physician- areCopyright no longerFor able topersonal accept Medicare use paymentonly issue on the minds of patients due to reduced payments. congressional staff members. Conclusion: Attempts to solve primary care’s reimbursement diffi culties IN THIS ARTICLE should be tied to SGR reform. ❚ 6 questions Abstract Purpose: Despite increasing data he viability of primary care in the we asked demonstrating the positive impact United States is in question, attrib- congressional primary care has on quality of care and T utable in large part to declining staffers costs, our specialty faces uncertainty. provider payments in the face of rising Its popularity among medical students medical school debt and fee-for-service Page 580 is declining, and the income gap is pressures to increase patient volume.1–3 ❚ Medical Home growing between primary care and other Congress—which has authority over specialties. Congress has the power Medicare and its price-setting function for concept gains to intervene in this impending crisis. provider reimbursement overall—is seem- recognition If we want to infl uence lawmakers’ ingly unaware of the problems facing pri- Page 582 actions, we need to know how they mary care, including barriers to payment are thinking about these issues. reform. The future of our specialty may Methods: Using a set of questions hinge on our ability to persuade Congress covering several physician payment that these problems are dire. A growing topics, we interviewed 14 congressional body of evidence supports the essential staff aides (5 aides on Medicare- and integrative function primary care oversight committees, 9 general staff plays in health systems, and its positive aides) and one representative from impact on quality of care and costs.4–6 each of 3 governmental agencies: the Medicare Payment Advisory Commission, The confused order of things now Congressional Budget Offi ce, and Advantages of primary care are proven.

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578_JFP0908 578 8/19/08 12:42:26 PM Regions with higher ratios of primary care row the payment gap and help open the physicians relative to specialists have low- primary care pipeline: the Sustainable er rates of hospitalizations, lower Medi- Growth Rate (SGR) and the Resource- care costs, and higher quality of care.7,8 Based Relative Value Scale (RBRVS) People with a primary care physician are process. more satisfi ed with their care and more The SGR formula sets a target for Medi- likely to receive preventive services and care physician expenditures each year. Re- better chronic disease management.9–11 cently, physician expenditure growth has Most countries that have built their health exceeded the target and, by law, the dif- care systems on a strong foundation of ference is subtracted from the fees paid to primary care demonstrate better health all physicians. According to the Medicare outcomes, fewer health care disparities, Payment Advisory Commission (Med- and lower costs.4,6 Thus the waning of pri- PAC), much of the excess spending has mary care presents risks to both personal come from rapidly increasing volumes and population health. of procedures used by specialists.19 The Still, society undervalues primary care. SGR system therefore disproportionately Despite evidence of the benefi ts just cited, penalizes primary care physicians because the income disparity between primary payments to all physicians are cut regard- care physicians and specialists continues less of which specialties are responsible to grow, discouraging medical students for excess spending. from entering primary care careers.12 RBRVS is the system of relative values The Medical Group Management As- applied to every procedure and offi ce vis- sociation shows that between 2000 and it. The Relative Value Units (RVUs) for 2004, the median income for a family each procedure or offi ce visit are multi- physician increased 7.5% to $156,000; plied by a conversion factor determined for invasive cardiologists, 16.9% to by the SGR formula. RVUs are largely $428,000; and for diagnostic radiolo- governed by the Relative Value Scale Up- gists, 36.2% to $407,000. Adjusted for date Committee (RUC), which advises infl ation, primary care income fell 10% the Centers for Medicare and Medicaid FAST TRACK from 1995 to 2004.13 Services (CMS) on revisions to physician When adjusted No wonder students shy away from reimbursement. primary care. Though there is little pub- The RUC reviews the relative val- for infl ation, lic sympathy for the fi nancial woes of ue scale at least every 5 years. Though primary care primary care doctors, lower incomes primary care physicians provide about income fell 10% are contributing to a drying of the pri- half of Medicare physician visits, they from 1995 to 2004 mary care pipeline.14,15 The number of US represent just 15% of the RUC’s voting medical school graduates choosing fam- members.12 ily medicine residencies dropped by 50% The committee’s reevaluation process between 1997 and 2005.16 From 1998 to tends to raise some RVUs without suf- 2004, the number of internal medicine fi ciently defl ating others.20 The resulting residents choosing careers in primary overall infl ation of fees forces CMS to re- care plummeted from 54% to 25%.17,18 duce payments equally to all physicians, This waning interest in primary care co- meaning primary care is again dispro- incides, unfortunately, with the aging of portionately penalized. Moreover, both the US baby boomers and an increasing Medicare and private insurance compa- prevalence of chronic disease. nies follow the RUC’s recommendations. Infl uencing Congress: Where to begin? How Congress could help As Congress escalates its deliberations on fi x the disparity Medicare physician spending, we investi- Medicare reimbursement has 2 compo- gated how key legislators perceive issues nents that Congress could amend to nar- in primary care and physician payment. CONTINUED

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TABLE including views on the state of primary 6 Questions we asked care and physician payment (TABLE). the congressional staffers Three researchers separately reviewed the interview notes to identify and com- 1. What are your views on the current state of primary care in the pile themes. United States? 2. When considering legislation to improve health care in the United States, how—if at all—does primary care factor into your vision? ❚ Results 3. If there is legislative movement to change the Sustainable Growth Rate Of the 14 congressional staffers, 8 were and Resource-Based Relative Value Scale systems in the next year, what should the goal be? Republican and 6 were Democrat; 5 were committee staff and 9 were general staff. 4. What is your sense of other health legislative assistants’ understanding Committee representation was fairly of primary care? even among staffers: Senate Finance (4), 5. Who are you hearing from on issues of primary care? House Ways and Means (5), and House Who are you not hearing from? Energy and Commerce (5). Range of ex- 6. What are the best sources to learn about these issues? perience on Capitol Hill was 3 months to 9 years. Some staffers are empathetic, others ❚ Methods unaware. Most respondents expressed To better understand perspectives of con- concern about the decreasing number of gressional committees with jurisdiction students entering primary care careers over health care spending, we conducted and the potential impact on patient ac- semistructured key informant interviews cess to care. One staffer acknowledged, in March 2007 with 14 health staff aides “the way our reimbursement system to members of Congress who have juris- works, primary care is not an option for diction over Medicare. Interviews were students…reimbursement is so low…the done face to face and lasted 30 to 60 number of primary care physicians is go- minutes. ing down relative to other specialties.” FAST TRACK The congressional committees with Another participant added that Staffers from rural jurisdiction over Medicare physician pay- most staffers “recognize a role for pri- ment are Senate Finance, House Ways mary care. It’s also tough because of how districts noted that and Means, and House Energy and Com- strong the specialty community is.” One constituents are merce. Each committee has 1 majority and staffer advised, “The Alliance of Specialty having diffi culty 1 minority staffer specializing in Medicare Medicine goes along with the AMA, try- fi nding primary part B, which includes physician payment. ing to represent a coordinated front…I Of these 6 specialized staffers, 5 agreed to don’t see this much coordination around care doctors who participate in semistructured interviews. primary care.” take Medicare Other staffers were contacted by using a A few staffers did not understand purposeful sampling technique known as the defi nition of primary care or did not “snowballing” or chain-referral, whereby know which physician groups represent participants with whom contact has been primary care. made refer the researcher to other poten- Legislation to improve US health care— tial interviewees. This process yielded an- and primary care. Participants varied in other 9 interviewees to total 14. their input on this subject. One staffer The aides identifi ed several other in- stated that primary care is “important formation sources, and we interviewed 1 but rarely singled out…usually the goal staff member each from 3 of these sourc- is broader reform so [primary care] is still es: MedPAC, the Congressional Budget a goal, but unstated.” Offi ce (CBO), and the Government Ac- Some committee staff described the countability Offi ce (GAO). need to incentivize greater use of pri- Interviews covered several topics, mary care and increase coordination

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of care. A few proposed reevaluating cian payment that are more directed and RBRVS to help primary care, and they “convincing.” spontaneously raised the Medical Home Some expressed a need for “hands-on concept as a way to encourage growth models and demonstration projects.” Al- of primary care. The Medical Home in- though these staffers have heard of mod- volves pairing each Medicare benefi cia- els that would split the SGR by specialty ry with a patient-centered practice that or geography, they remain skeptical about meets certain criteria including continu- such proposals without evidence of effi - ity with a personal physician, care co- cacy. Staffers were also wary of splitting ordination, quality assurance, increased the SGR by specialty, believing it would access, and specifi c payment.21 A pilot cause infi ghting among physicians. project in North Carolina that incor- Staffers know far less about RBRVS porates the Medical Home is saving the than they do about the SGR. One staffer state about $162 million annually.22,23 admitted, “I won’t pay attention until One staffer championed primary care, something is at a crisis point or we have but pointed out that a critical barrier a hearing or a vote.” A few staffers assert- preventing Congress from investing in ed that there should be a more rigorous it is the CBO, which is not convinced RUC review to examine what services are that primary care can save money over over- and undervalued. the long term. Government agencies are not asked to address primary care. At the time of The SGR dominates discussions interview (March 2007), staff from on physician payment MedPAC, GAO, and CBO said that Con- All respondents had a functional under- gress had not asked them to study issues standing of the SGR and desired reform, in primary care. One CBO analyst as- but few understood how the SGR con- serted that “nobody’s been able to dem- tributes to the payment gap. Many staff- onstrate signifi cant changes in volume ers would like to do away with the SGR, or outcome [as a result of investing in but CBO estimates show that this would primary care]…we need empirical data.” FAST TRACK be cost-prohibitive.24 The analyst also mentioned CMS dem- According to one A few staffers believed that SGR re- onstration projects as a way to gather form may not happen until 2009, after data. According to a Capitol Hill veter- Capitol Hill the next president takes offi ce. Some par- an, the CBO believes that even if primary veteran, the CBO ticipants also predicted that SGR reform care extends a person’s life, this may not believes that even will not happen until more physicians necessarily save money. if primary care refuse to see Medicare patients. To date, MedPAC has reported each year that extends a person’s there is no Medicare access crisis. Staff- ❚ Discussion life, this may not ers from rural districts, however, affi rmed Although most of the interviewed con- necessarily that constituents are having diffi culty gressional staffers recognize the payment fi nding primary care doctors who take gap and understand that the number of save money Medicare. physicians entering primary care is de- Staffers uniformly agreed that no- creasing, Congress has not taken action body has the answer to fi x the SGR. to address these issues. Several factors Several staffers commented on the com- explain this. plexity of the problem, pointing out that SGR is the 800-pound gorilla. When MedPAC’s March 2007 SGR report did discussing physician payment, congres- not achieve a consensus on how to re- sional staffers appear far more concerned structure the rate. Many participants with reforming the SGR than address- were disappointed with the MedPAC ing problems in primary care. This per- report and want solutions to fi x physi- ception is supported by the fact that

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Congress has asked MedPAC and CBO Care Act of 2006, Congress mandated to investigate the SGR, but has not asked a 3-year Medical Home demonstration them to examine issues in primary care. to be conducted across multiple demo- For Congress, the dilemma is to hold graphic communities in up to 8 states. down physician spending while keep- The concept encompasses “large or small ing physicians in the Medicare market. medical practices where a physician pro- Staffers are dissatisfi ed with SGR reform vides comprehensive and coordinated proposals from MedPAC and are eager patient centered medical care and acts as to learn about new possible solutions. the ‘personal physician’ to the patient.”25 No one perceives a crisis in access to (The Medical Home is also a focus of Medicare providers. According to annual The Patient-Centered Primary Care Col- MedPAC reports, the number of primary laborative [http://www.pcpcc.net/], a co- care doctors accepting Medicare patients alition of medical societies, employers, is suffi cient. Staff for members of Congress insurers, consumer groups, and others from rural areas, however, contend that that is exploring the concept as a way to some constituents cannot fi nd a primary contain health care costs and also achieve care provider who accepts Medicare. fair remuneration for physicians.) Congress is not convinced that pri- The demonstration must be carefully mary care saves money. Although some crafted to test the concept fairly. Even be- staffers believe that primary care can fore the demonstration begins, Congress reduce costs, the CBO argues that this could ask the CBO and GAO to investi- is not necessarily true. It is indeed diffi - gate existing evidence of primary care’s cult to prove cost savings from investing cost-effectiveness. Support from the CBO in preventive services because there is is essential for Congress to invest in pri- greater upfront cost, and extending peo- mary care. ple’s lives could incur higher future costs. Other experiments are underway. As Research, however, shows that primary of this publication, several major insur- care-oriented systems reduce prevent- ers are beginning regional experiments FAST TRACK able hospitalizations, which decreases in raising fees for primary care visits in Research shows costs.4,5,7,8 It seems that either the exist- an effort to avoid greater costs down the ing evidence is insuffi cient to convince road.23 that primary the CBO or the evidence has not been Access issue needs further study. Our care-oriented communicated effectively. interviews revealed that while MedPAC systems reduce asserts there is no primary care access preventable Strategic leverage moving forward issue, staffers from rural districts dis- The time is ripe for SGR reform because agree. In fact, had Congress not over- hospitalizations, most staffers conveyed a desire for solu- ridden President Bush’s recent veto of which decreases tions. Because the SGR appears to take a Medicare bill to increase physicians’ costs priority over primary care issues, it must fees, doctors in urban areas would also be dealt with fi rst. It is possible, however, have stopped accepting new Medicare for policy makers to address the SGR and patients.26 Additional physician work- RBRVS reforms while simultaneously in- force studies are necessary to fully vesting in primary care. The SGR and understand the current primary care RBRVS reforms could hold specialties ac- physician supply. Also useful would be countable for their own volume growth studies by Medicaid and Medicare that and protect specialties with minimal vol- investigate thresholds at which physi- ume growth. cians stop seeing patients with low- The Medical Home is a concept gain- paying coverage. ing recognition among congressional staff Advocacy is needed, too. Congressio- and could involve restructured physician nal staffers appear to understand some of payment. In its Tax Relief and Health the diffi culties in primary care, but give

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priority to broader SGR reform. Fur- care-specialty income gap: why it matters. Ann In- ther research and advocacy on the value tern Med. 2007;146:301-306. of primary care and payment reform 13. Tu HT, Ginsburg PB. Losing ground: physician in- come, 1995-2003. Tracking Rep. June 2006;15:1-8. solutions will be necessary to establish 14. Rosenblatt RA, Andrilla HA. The impact of US med- primary care as a means to cost-effec- ical students’ debt on their choice of primary care tive, high-quality care in the United careers. Acad Med. 2005;80:815-819. States. ■ 15. Newton DA, Grayson MS, Thompson LF. The vari- able infl uence of lifestyle and income on medical students’ career specialty choices. Acad Med. Correspondence 2005;80:809-814. Brian Yoshio Laing, MD, San Francisco General Hos- 16. Pugno PA, Schmittling GT, Fetter GT, et al. Results pital, 995 Potrero Avenue, Building 80, Ward 83, San of the 2005 national resident matching program: Francisco, CA 94110; [email protected]. family medicine. Fam Med. 2005;37:555-564. 17. Garibaldi RA, Popkave C, Bylsma W. Career plans Acknowledgment for trainees in internal medicine residency pro- grams. Acad Med. 2005;80:507-512. Part of the content in this article was presented as a poster at the North American Primary Care Research 18. West CP, Popkave C, Schultz HJ, et al. Changes in Group Conference in Vancouver, British Columbia, Oc- career decisions of internal medicine residents dur- tober 2007. ing training. Ann Intern Med. 2006;145:774-779. 19. Medicare Payment Advisory Commission. Report to the Congress: Medicare Payment Policy. March Disclosure 2006. Available at: http://www.medpac.gov/pub- The authors reported no potential confl ict of interest rel- lications/congressional_reports/Mar06_EntireRe- evant to this article. port.pdf. Accessed April 25, 2007. 20. 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