Will the Primary Care Physician Story Have a Happy Ending?

I have been publishing articles and speaking on diverse topics in healthcare for many years. Three of them ignite a passion and anger in me and they are all interrelated:

• The diminishing role of the primary care physician (PCP)
• The plight of residents in rural America from both a health and quality of life perspective.
• Payers (CMS and commercial) continued reliance on the fee-for-service payment methodologies that incents over-utilization, undervalues the primary care physician, and further entrenches us in our sick-care system.

This is the first of a series of blogs that will focus on the importance of addressing the decreasing number of primary care physicians (PCPs) and their diminishing role in our communities.

The Important Role of the Primary Care Physician (PCP)

• Ideally, the PCP should be a trusted patient advisor and advocate for their patients. Not having the PCP as their advisor/advocate will place patients in a fragmented healthcare maze without any real independent clinical and emotional guidance.
• As a trusted patient advisor and advocate, the primary care physician can play a key role in engaging patients in their own health. Given this ideally long-term and trusted relationship, there is a greater likelihood that patients under the guidance of the PCP and their team will play an enhanced role in their own health.
• PCPs play a key role in transitioning our healthcare system to be value-based. The overall role of the PCP and their team is to keep their patients healthy, which is the nucleus of a value-based healthcare system as well as overall population health.
• As we are evolving to reimbursement methodologies that are more risk-based and rely on patient compliance, the role of the PCP needs to be enhanced. The key to financial success for hospitals and physicians in a risk/value-based world is keeping members healthy, which is the primary role of the PCP.
• The PCP plays an important role in positively impacting social determinants of health. An effective PCP practice will leverage community stakeholders on an as-needed basis to proactively address social determinants of health, impacting their patients.
• The PCP responsibility is to address the overall clinical and mental health and quality of life of their patients. No other physician specialty focuses on the whole person.

A Historical Review of the Role of PCPs in Our Society

I grew up during the height of the role of primary care physicians in our society in the 1960s and ‘70s. Through the wonders of TV, we also saw firsthand the important roles of family medicine physicians such as Dr. Kildare and Dr. Marcus Welby in caring for their patients and being a long-term trusted advisor.

I also experienced firsthand, in the 1970s, being cared for by residents in a freestanding family medicine center associated with a hospital. Patients from all demographics were being seen by the family medicine residents, and I especially appreciated their proactive advice that focused on keeping me not only healthy today but also for the long term.?

Family medicine continued to flourish in the 1980s, but starting in the 1990s with the increased role of emergency medicine, hospitalist medicine, urgent care and changing physician lifestyle, the PCP scope of practice has gradually narrowed.

Sadly, as noted in this article in KFF Health News , “American physicians have been abandoning traditional primary care practice — internal and family medicine — in large numbers. Those who remain are working fewer hours. And fewer medical students are choosing a field that once attracted some of the best and brightest because of its diagnostic challenges and the emotional gratification of deep relationships with patients.”

The U.S. Investment in Primary Care Pales to That of Our International Counterparts

Per a recent report , “Relative to its international counterparts, the United States underinvests in primary care, as reflected in spending by both public and private payers. On average, the United States spends 5%-7% on primary care as a percentage of total health care spending. By comparison, Organization for Economic Co-operation, and Development (OECD) countries average 14% spending on primary?care.

In the United States, approximately 30% of physicians are in primary care , which stands in stark contrast to other high-income countries, where the ratio of primary care providers to specialists is generally 70:30. Also, four in 10 family physicians are over age 55, and nearing retirement age while a growing proportion of primary care residents choose to subspecialize or become hospitalists.”

Why have Primary Care Physicians’ been undervalued in the marketplace which, in turn, has had a negative impact on medical students selecting this honored profession?

The following are the key factors that have negatively impacted the PCPs’ value in the marketplace and, consequently, medical students selecting this honored profession:

1.??? Primary Care Physicians’ Public Enemy Number One Are the Payers, and It Starts With Medicare:

Healthcare payers’ (government/commercial) payment policies and methodologies along with the misallocation of their payment dollars between the respective healthcare stakeholders, are major factors in creating the “sick care” system that exists today, which devalues primary care.

The historical reliance on a fee-for-service payment methodology (“the more you do, the more you make”) primarily benefited physician specialists and was the growth engine for hospitals, all to the detriment of primary care physicians.

The primary care physician was further penalized when Medicare developed the Resource Based Relative Value Scale (RBRVS) as a basis for calculating reimbursement for physicians.?This coding system does not adequately account for the work performed by primary care physicians in that it rewards procedural work over cognitive work.

Commercial insurance companies also played “follow the leader” in cloning?the Medicare RBRVS fee schedule?as their own base for determining payment levels for physicians and the related services.?This, again, was done to the detriment of the primary care physicians.

As I have noted in many of my publications, Medicare, as the largest payer, is the 800lb. Gorilla that sets the tone for both governmental and commercial payers.

In recent years, the Centers for Medicare & Medicaid Services (CMS), which administers the Medicare program, has made changes to address some of the payment imbalances between primary care and specialist services. The agency has expanded the office visit services for which providers can bill to manage their patients, including adding non-procedural billing codes for providing transitional care, chronic care management, and advance care planning, but the financial impact to the PCP is minimal.

Also, under federal law, changes to Medicare physician payments must preserve budget neutrality, a zero-sum arrangement in which payment increases for primary care providers mean payment decreases elsewhere.

The budget-neutrality mandate means CMS cannot improve payment in any area of the fee schedule without cutting it somewhere else. Ideally, primary care increases should be carved out of the budget-neutrality mandate. You cannot pay too much for value-based care provided by a primary care physician.

These same financial incentives that are embedded in the fee-for-service payment methodologies have also played a major role in the devaluation of employed primary care physicians by hospital systems.? Employed primary care physicians in most hospital systems are often utilized as a gateway to specialists and procedures, which are the money-makers in a fee-for-service world.

Consequently, the combination of financial disparities between the earning power of primary care physicians relative to specialists and their devalued role in this fee-for-service world is a major factor in medical students' decision not to select primary care as their specialty.

2.??? The Residency Slot Game Negatively Impacts Both Primary Care and Healthcare Disparity:

As noted in the Society of Teachers of Family Medicine Journal ,

“Because graduate medical education (GME) is largely publicly funded, it should be judged on how well it addresses the public’s health needs. However, the current system distributes GME resources inequitably by specialty and geography and neglects to focus on training physicians adequately in the care of populations while reducing health disparities. Instead, GME continues to concentrate training in hospital-based academic centers and in subspecialties, which often exacerbates disparities in health outcomes and access to care. GME can be more socially accountable by shifting incentive structures to support primary care, creating a more equitable distribution of residency slots and funding, and promoting training programs that focus on social and structural determinants of health.

Funding the most needed specialties, especially primary care, in the most medically underserved areas has not been a priority.

Medicare GME payments continue to be hospital-centric, formula-based, and not tied to local or national community needs.”

3.??? Primary Care Physician Burnout:

• Burdensome Electronic Health Records (EHRs) are a leading contributing factor in PCP burnout. Per interviews and data provided by primary care physicians, their EHRs are not user-friendly for their practice, and the time consumed in reviewing them for pertinent information relating to the patients is both burdensome and takes away from their “face to face” time with their patient.
• Administrative burdens, with little real value, imposed by governmental agencies and commercial insurers also contribute to PCP burnout and added costs to their practices.

Short-Term Fixes Do Not Address the Most Important Role of the Primary Care Physician – The Long-Term Relationship Between the Doctor and the Patient:

There are many initiatives in today’s society that are focusing on filling the primary care gap.

• The utilization of nurse practitioners and physician assistants might help relieve some of the strain relating to the shortage of primary care physicians, but they still do not have the training and experience of a primary care physician.
• Urgent care clinics and retail clinics are increasingly more common as they play a role in addressing the need for immediate, routine care of the recipient.
• Telehealth visits also play an expanding role in healthcare, which can be especially beneficial if part of the overall array of services provided by a primary care physician practice.

The challenge with all of these “fixes” is that they still do not fill the role of the well-trained primary care physician who has had a long-term, trusted relationship with the patient.

If we identify the utilization of NPs/PAs and the growth of urgent care/retail clinics as well as virtual office visits as the answer to this primary care physician shortage, then we are downgrading the potential value that primary care physicians can bring to the table, and further entrenching society into our “sick-care” system.

Primary Care Physician Long-Term Fixes

There is no silver bullet answer to the primary care physician shortage and the need to move primary care physicians to center stage, but here are a few recommendations:

Changing How We Pay Primary Care Physicians:

1. A major conclusion of The National Academies of Sciences, Engineering, and Medicine (NASEM) Report on High-Quality Primary Care was the need to shift towards paying for primary care teams to holistically care for people rather than paying doctors to deliver individual services. The report recommends a shift to hybrid primary care payment models that combine per-member per-month capitation payments with fee-for-service to provide added flexibility for interprofessional care teams to deliver coordinated, whole-person primary care. This more stable model encourages investment in practice and payment for care that is of value to the patient but may not otherwise be billable because it does not generate a specific service or billable code.
2. In 2016, the Urban Institute published a thoughtful study that focused on primary care capitation.?That report stated the following: “The theoretical virtue of primary care capitation is that it permits primary care physicians themselves to decide what mix of activities best serves each patient, rather than rely on third-party payers to approve payment codes and payment levels to influence how clinicians spend their time.”
3. As further stated in the Urban Institute report, “A hybrid of primary care capitation and fee schedule payment, as well as incremental payments such as Shared Savings and Pay for Performance , are all compatible—and in some contexts, probably desirable.”
4. If we recognize the value of the enhanced role of primary care physicians and their teams, then we need to support these efforts by paying for their services in a more holistic fashion.?In the ideal world, this would be in some form of per-member?capitation and, as it relates to health systems/ACOs, global capitation .
5. Medicare Advantage plans are increasingly contracting with large independent primary care practices utilizing global capitation. A future blog will provide the reader with specific examples of this contracting relationship which has benefited all parties, especially the patients.
6. The Center for Medicare and Medicaid Innovation’s (CMMI) legislative mandate is to develop innovative payment models. CMMI (which has been around since 2010) needs to expedite the transition from fee-for-service to some form of a hybrid payment model for primary care physician practices. Such models developed by CMMI cannot be cumbersome for practices to administer, and they need to provide the appropriate financial incentives to support a primary care physician practice team. The major message to CMMI needs to be, “You cannot pay too much for value-based primary care, so do not create a payment model that provides an administrative burden on these practices.”
7. Hospital-based primary care practices need to be viewed differently than independent primary care physician practices. As noted earlier in this blog, many hospital systems have devalued primary care and perceive it as a gateway to their hospital-based specialists. Any payment models for these hospital-based primary care physician practices need to include requirements that place the PCP in a role equivalent to that of an independent practice. Obviously, there are challenges in implementing such a model, but the goal should be to move the primary care physician to center stage, even in the hospital environment.
8. Finally, at the national and state level, there should be a deliberate strategy to engage governmental and commercial payers, as well as employer coalitions, to focus on strategies to enhance the role of the PCP and develop models and levels of payment that align with the value provided by primary care practices. These “payer councils” also need to identify ways to reduce the administrative burden on PCP practices.

Addressing PCP Burnout Because of Burdensome Administrative Requirement by Payers:

1. There should be fewer and more uniform measures relating to the provision of value-based care by primary care practices.
2. Measures should focus on outcomes that matter most to patients and that have the greatest overall impact on better health of the population, better health care, and lower costs.

Changing the Recruiting Process for Medical Students Along With the PCP Development Process in Medical Schools

1. To increase the number of students in medical schools who want to be PCPs, we need to increasingly focus on rural and financially disadvantaged students who can understand the health and quality of life needs of residents in their communities and want to play a role in addressing these challenges.
2. We also need to develop special tracks, pipelines, and educational awareness for those who would be more likely to pick primary care. There are examples of these primary care tracks and pipelines in many states. Check out one of my past blog posts on this subject for examples.

Expand Osteopathic Medical Schools That Stress Primary Care Career Paths

1. Osteopathic medical schools have historically had a strong focus on developing family medicine physicians. We need to create more Osteopathic medical schools throughout the country that primarily focus on developing family medicine physicians. These “new” medical schools also need to have a collaborative relationship with community stakeholders who play a role in addressing social determinants of health and with family medicine residency programs located in rural America.
2. A critical focus in family medicine student training needs to be the development of problem-solving and critical thinking skills, which have suffered in recent years. The primary care physician of the future cannot be limited to “checking the boxes” based on only evidence-based protocols. These physicians need to have developed the appropriate diagnostic skills that complement their knowledge of evidence-based medicine.

Restructuring the Graduate Medical Education and Residency Programs to Prioritize Primary Care and Health Disparities

1. As noted in the Society of Teachers of Family Medicine Journal , “Congress should direct CMS to build a new GME financial infrastructure with focus on these recommendations: Congress must direct CMS to reform the current Medicare-GME funding system to produce physicians trained to meet community needs. This new system must be data-driven and transparent.?The Residency Review Committee for Family Medicine should further prepare graduates to address health equity concerns by requiring residency programs to increase their health equity training in community settings, involving experts such as social scientists and community health workers. There should be an expansion of family medicine residency programs, especially in rural areas.
2. Hospitals should not be allowed to reallocate family medicine residency slots to specialty slots. If large hospital systems do not want residency slots for family medicine, they should lose those slots and be directed to rural areas.
3. States also have an important role in addressing both the primary care physician shortage and health disparities, especially in rural areas. The State of Indiana in 2015 created a Medical Education Board and Fund to develop a strategic approach to residency slots. The Board’s priority is primary care residency slots, especially in rural and underserved areas of the state. States and the federal government need to develop a strategic focus to best allocate residency slots, especially regarding primary care in rural areas. Continued investment in the state’s physician pipeline is critical to meeting increasing primary care physician demand, especially in rural and underserved areas, thereby increasing positive outcomes and increasing the quality of life of all residents of the state.

Conclusion

As noted previously, it is important that, both in medical school and in residency programs, family medicine physicians/PCPs develop extensive problem-solving and diagnostic skills that allow them to provide enhanced value to their patients in the inpatient and outpatient settings.

The enhancement of the role of the primary care physician, along with increased income (and less financial educational debt because of focused loan forgiveness programs), will attract more medical students to this needed specialty.

Another advantage for medical students in selecting primary care as their area of specialty is the increase in career options that will be available to them in this risk/value-based world ahead.

As discussed in my blog titled “Physicians, Your Future is in Your Hands ,” physicians have options, and they can control their own future.?This is especially true for primary care physicians.

A future blog in this series will identify primary care practice models that allow the physician to exercise their clinical and patient advocacy skills to the fullest.

As always, I appreciate feedback from the readers on this topic, especially from both primary care physicians and specialists. ?

Tom Campanella is the Healthcare Executive in Residence at Baldwin Wallace University. Backed by more than 35 years of experience in the industry—particularly the health insurance, physician and hospital sectors—he’s focused on strategic advising and community outreach.?Follow Tom’s articles on LinkedIn for his latest weekly coverage of the healthcare industry.

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