Residency Match Results Bad for Primary Care (Again)

Once again, though not trumpeted as much as in previous years, reports of this year's residency match results are in, and some media outlets are claiming this to be good news for primary care.
The LA Times claimed Match Day 2013 results are good for future internal-medicine patients, stating "America’s future doctors are increasingly interested in become primary-care physicians -- good news for America’s future patients."  OBGYN News' claim was my favorite: Primary care spots are hot in largest-ever Match Day.

They are basing this on a few things. First, the actual numbers of US medical student graduates going into primary care fields such as internal medicine have in fact increase. For example, 3,135 students will be going into internal medicine, which is a 19% increase from 2009 and 6.6% increase from last year.
However, the main source of positive news is coming from the NRMP (the folks who do the match) themselves. According to their press release:

Match results can be an indicator of career interests among U.S. medical school seniors. Among the notable
trends this year:
• 3,135 U.S. seniors matched to internal medicine, an increase of 194 over last year.
• 1,837 U.S. seniors matched to pediatrics, an increase of 105 over last year.

• Family medicine matched 1,355 U.S. seniors, 33 more than last year. More than 95

percent of family medicine positions were filled.

Based on these numbers it would seem that more students are choosing careers in primary care. However, this is not the case, and in some instances things are actually worse.

You have to look at the total number of slots as well as the percent that our US students are choosing primary care fields.
Below is a table that has the match results for the last three years. It is important to note that there was almost 1000 more US seniors graduating, which according to the NRMP they attribute to the rising number of U.S. students to three new medical schools graduating their first classes as well as enrollment expansions in existing medical schools.

Despite having almost 1000 new graduating medical students, the addition of these students to the primary care fields are limited.  The real way to see what are students are choosing it to look at the percent of graduating students choosing a specific field (% US grads matching in my table).  The results are pretty bleak. 




There is virtually no change in student choosing internal medicine from 2011 to 2013 (18.9% to 19.1%). Family medicine, which looked to have a slight bump last year is actually down from 2011 to 2013 (8.35% to 8.26%). Peds is up from last year, but still down from 2011 (11.34% to 11.2%).  One also needs to look at how many of the positions that were offered (a major increase from prior years) were filled by graduating US seniors.  Internal medicine, which was filled by 57% of US seniors dropped significantly to just below half!. Family dipped from 48% in 2011 to 44.6% in 2013. Peds dropped by 1%. 

In other words....

• More residency slots were offered across the board in primary care specialties, but more of these new slots were being filled by non-US graduates, than use graduates
• Despite having three new medical schools worth of graduates, the pool of newly minted primary care physicians isn't really expanding that much
• Our US seniors ARE NOT choosing primary care as a career, and if anything, are choosing primary care slightly less than previously, and certainly not more.

While internal medicine hasn't really changed, it is important to note that of those going into internal medicine, only 2% of seniors plan to go into primary care.

I blogged about this in 2011, when the media seemed to decry a boom for primary care. What I said two years ago is even more true today. This is a crisis. Many of the few primary care docs we have are retiring, leaving practice, or going cash only or retainer. If something is not done to increase the value, reimbursement, and job satisfaction of our primary care doctors; we will have no one left to care for our sick and aging population. (And before you post a comment about NP's and PA's filling this gap, those students aren't going into primary care either. A surgical PA makes more money than a primary care MD).

Choose Wisely when Choosing Wisely

Yesterday, the media was a buzz with the latest recommendations from lead medical organizations about overused tests and treatments.

Maggie Fox from NBC news states, "You don’t need an MRI for lower back pain. You don’t need antibiotics for a sinus infection. And you don’t need to be screened for osteoporosis, either, if you’re under 65. " The Washington Post's headline reads "Group releases list of 90 medical ‘don’ts.’"  The New York Times similarly describes this report as a list of "don'ts."

All this stems from the Choosing Wisely initiative from the non-profit American Board of Internal Medicine foundation in conjunction with Consumer Reports. The group ask most of the major physician specialty societies to come up with al list of the most common unnecessary things done in medicine. Each group came up with the top 5, to comprise a list of 90 commonly overused tests and treatments.  A few examples include:
•A feeding tube in patients with advanced dementia. (American Academy of Hospice and Palliative Medicine and American Geriatrics Society)
•A routine annual Pap test if you’re 30 or older, or under 21. (American College of Obstetricians and Gynecologists).
•DEXA (dual-energy X-ray absorptiometry) screening for osteoporosis in women under 65 or men under 70, unless there’s a suspicion of bone loss.
•A CT scan for a child with a minor head injury. (American Academy of Pediatrics)

This work is important as due to our fee for service system that reimburses for ordering tests and treatments whether or not they are effective or worthwhile, has proven to be costly and inefficient. Thus, cutting unnecessary testing or treatment in medicine will both save money and potentially reduce harm.  For example, in many ER's across the country, almost all children that come in after a head injury get a CT scan. Not only has this not been proven to be effective, but radiating a child's head can increase the risk for cancer.

However, a word of caution.....
Based on the headlines, one might think that these tests or treatments should never be done.  Two major media outlets call these a list of "don'ts."  However, this is not what the experts were saying.  These are commonly overused tests and treatments, not useless.  There might be very good reasons to get a CT scan after a head injury in a child that outweigh the very small potential increase risk for cancer.  It is very important to understand this because it is possible that insurances and/or the government will use these recommendations to determine reimbursement. While it is correct that physicians and patients should question the routine use of these tests or treatments, patients and doctors shouldn't have to fight with insurance companies to use these tests and treatments when they feel it is necessary.  Finally, if as a patient you question your physician about a test or treatment they recommend (which is the entire purpose of the Choosing Wisely campaign), be prepared to sign something that states you won't sue them should your refusal of their recommendation turn out to be wrong. While the Choosing Wisely campaign starts to address the problems with our fee for service reimbursement system, it fails to address the other major driver of health care costs- malpractice.  Many physicians would likely gladly give up these over-used tests and treatments, but will not for fear of being sued.

The Future of Health Care is Now Clear

As a physician who is involved in educating medical students, I am often asked for career advice. Medical students are by nature smart and ask very good questions. "Will I be able to pay of my student loans if I choose primary care?" "Will I have a balanced lifestyle if I decide to go into primary care?"
I try to be both encouraging and realistic.  However, far too often I have found myself telling students that the future of medicine, primary care in particular is not clear.
That is no longer true.
The future of health care, and particularly primary care is now very clear.
Several recent events along with trends that have been in place for the last few years have clarified the future of health care over the next few years. The passage of the Affordable Care Act (ACA), the decision of the Supreme Court to uphold the constitutionality of the individual mandate, the re-election of President Obama, and the fiscal cliff/sequester have all set into motion changes to our health care system that are likely irreversible and clarify the future of health care. Essentially, there are two paths:
1. Health Care in Large Integrated Systems.  Health care costs are skyrocketing. The major fixes to the problem that are accepted on both sides of the aisle are an end to fee for service, bundled payments, and incentives for improving quality at lower costs. Accountable Care Organizations (ACO's) are one model being tested.  However, even if the ACO turns out to be HMO 2.0, and ultimately fails; health care will be delivered in large integrated systems. This trend is already occurring with hospitals, academic medical centers and other health care systems gobbling up (through incorporation or outright purchase) smaller private practices.  Because payment will be linked to performance, and performance must be measured and reported; the only way physicians will be able to make money is to not only have a large, robust electronic medical records, but also a staff that can help collect, process and report the important data. Even large private practices don't have the economies of scale to make this happen. Thus, private practice as we know it will cease to exist.  This trend is already happening. According to a report by Accenture, over the past decade, the number of independent U.S. physicians has dropped dramatically, from 57 percent in 2000 to 39 percent in 2012.
The move to large, integrated is not necessarily a bad thing. Integrated systems allow for quality improvement. Large integrated systems like Mayo, Kaiser, and the VA have some of the best outcomes for health care in our country, usually at significantly lower costs. For physicians, being a salaried employee also has its benefits which include a guaranteed paycheck, reasonable hours, good benefits and no worries about running a practice. The current generation of medical students tend to value work life balance over the potential opportunities seen in private practice.  
The down side of large integrated systems is less personalized attention. Rather than seeing your doctor when you are sick, a patient will likely wind up seeing a member of the doctor's care team.Other modalities such as group appointments might be employed.

2. Health Care Outside the System. Some doctors (likely the ones currently in practice) will refuse to join these large integrated groups.  Some patients may decide that access to their own personal physician has some value. These patients are tired of waiting forever to get an appointment or a call back from their doctor, and want to see their doctor when they are sick, not a team member. They are even willing to pay beyond what their insurance premiums cover. These patients and providers will go outside the system.  Growth of retainer (often called concierge) practices, cash-only practice, or direct primary care demonstrate that going outside the system is already happening. This will likely be limited to primary care, as one might be able to pay cash for a doctor's appointment, but not a colonoscopy or cardiac catheterization.

Health care delivery is already occurring in large integrated systems as well as outside the system. The aforementioned changes will cause these trends to continue, squeezing out the current physicians who are still in an insurance based private practice. These changes are certain.  What is unclear is the proportion of health care that will be delivered in either model. Will large integrated systems become so effective, that only the very wealthy will deem it worthwhile to get their care outside the system?  Or, will large integrated systems become so impersonal and inconvenient that only those with modest incomes will be forced to get their care in these systems? The truth is likely somewhere in between, i.e. 70/30, 50/50 or 30/70.

Regardless, medical students and residents who are trying to determine a career path should now have a clearer vision of the future health care. Patients who are currently receiving their care by a private practice physician who accepts their insurance should also realize that their current situation will likely not exist in the next few years.

No Medicare "Doc Fix" Could Result in Over 50% Salary Cut to Primary Care Physicians

With the Fiscal Cliff looming, I have re-posted this entry from November 2011, the last time Congress was against a deadline, and what got us into the mess we are in today.  Hopefully, Congress will come together and in addition to putting together a package that will spare most Americans tax increases, will eliminate the 27% cuts in payments to physicians that are set to go into effect on Jan 1, 2013.

From November, 2011:

Fortunately, the 27% reduction in Medicare payments to physicians that is set to take place in a matter of weeks unless congress acts is getting some press.  Fox News published this piece yesterday, as did the Washington Post. Writer Merrill Goozner breaks things down nicely in his article, "Is There a Doctor Fix in the House...and Senate?"

However, one thing that seems to be getting confused in all the media reports is the difference between physician payments and physician salary. A doctor's income is what he takes in (payments) minus expenses or overhead. Physician overhead (staff, office space, electricity, malpractice, equipment,etc.) is very expensive. One of the reasons, but not the only reason, a doctor's overhead is so high is because we need to hire extra staff just to deal with the insurance bureaucracy.  (See "Your 10 minute office visit needs 8 people and 45 minutes of work" via KevinMD.) While payments from Medicare to physicians have not really increased over time, overhead has gone up dramatically.

Physicians, patients, and policy makers need to understand that a 27% cut in physician payment will have a far greater impact on physician salary because of this overhead. 

An article from the AMA News discussing the issue of the "doc fix" has an interesting table with current payments and proposed payments.  Let's say a family physician sees 25 Medicare patients a day, 5 days a week for 50 weeks out of the year. At the current rate of  $68.97 per visit, this generates $431,062 in revenue. At 60% overhead of $258,637, this family physician's income would be $172,425 per year. Now any doctor reading this will tell you that 1) no physician would see exclusively Medicare patients because they just don't pay enough (at current rates) to sustain a practice and 2) you can't see 25 Medicare patients in a day because patients 65 and up have multiple medical problems and you simple couldn't see them all in 15-20 minute visits. However, the income is very close to$168,550 which is the average salary for a family physician. Thus, the numbers are good for the purpose of discussing the impact of Medicare cuts on not just payments but salary.

Now, if the 27% Medicare costs go into effect, Medicare will only pay $51.07 for that same visit.  Using the same numbers, the revenue generated is only $319,187 (26% decrease in Medicare payments), but the $258,687 in overhead stays the same.  This leaves the primary care physicians with a $60,550 annual income. That's a 65% cut in physician salary.  Even if my numbers are off, its clearly more than a 27% cut to salary, and much greater than 50%.  The bottom line is that if these cuts take place, primary care physicians will certainly stop seeing new Medicare patients, and many will stop taking Medicare patients altogether.Many already have!!!

Now, most pundits seem to think that since seniors vote, and Medicare is a big issue for them, and that the election is less than a year away; Congress will find a way (like they have for the past few years) to find the money to cover the cuts for at least another year.  However, I wouldn't be so sure.  I would advise anyone who is on Medicare, has a loved on on Medicare, or who plans on having Medicare in the future to call their representatives and ask them to ensure that these payment cuts not go into affect.

Why Primary Care is the Future of Health Care

Primary Care Progress is a non-profit organization of doctors, students, advocates, etc who have a vision for revitalizing the primary care workforce pipeline through strategic local advocacy that promotes primary care and transforms care delivery and training in academic settings.  This October 8-12, Primary Care Progress is co-sponsoring National Primary Care Week with the American Medical Student Association (AMSA).  In preparation for this they have asked some of their contributors, myself included, to answer the question "Why is primary care the future of health care?"
Here is my attempt to answer this very important question.

First, I am glad the question was not "What it the future or primary care?" as this is a much harder question to answer. The American Academy of Family Physicians just today put out their vision for the future of primary care. In their Primary Care for the 21st Century,  a personal physician coordinates with other health care providers within a Patient Centered Medical Home model of care, where quality and safety are hallmarks, and patients and their families actively participate in decision making. They envision enhanced access to care through open and same-day scheduling, expanded clinical hours, and new options for communication. This sounds like a lovely vision, but whether or not this or other models, such as Accountable Care Organizations, will save Primary Care is unclear.
However, the to the question of whether Primary Care is the future of health care is crystal clear. Our health care system and the health care of our country can not survive without Primary Care.  Here are three reasons why, in my opinion, Primary Care is the future of health care.

1. Primary Care is High Value Care. Health care spending is out of control. We are spending about 18% of the GDP on health care. We are essentially at the tipping point of health care spending in that if the percent of GDP spent on health care grows any higher, we are going to have make substantial cuts to spending in other places that are deemed essential to the functioning of our country such as social security, education and defense. It would be like if the amount you were spending on your electricity bill was starting to equal the amount you were spending on your monthly mortgage. When that happens, you can't live in that house much longer.  Yet, despite spending so much money on health care, we are not getting a great value. A large segment of our country is currently uninsured or under-insured, and health indicators which are used to compare health across countries (mortality,access,safety) show that the US underperforms compared to others. So, our current spending is crushing our economy but at the same time we are not getting a good return on our investment. Thus, the future of health care is going to have to be about value.  We need to get much more for the precious health care dollars we spent.  And there is no better health care dollar value than Primary Care. There are many studies that demonstrate a strong primary care sector is associated with lower costs in improved quality.  Countries that have a more robust primary care infrastructure have healthier citizens at lower costs. Therefore, the future of health care has to be Primary Care, because we need better value in our health care system if our country is to survive.

2. Primary Care is Critical in Reducing Waste. The Institute of Medicine just released a report that shows we waste $750 billion in health care. This is more than what we spend on defense! There are many sources of waste.

• $210 billion on overuse and unnecessary care.
• $130 billion in inefficiency, including mistakes and harm.
• $190 billion in excess administrative costs.

The reasons behind all this waste are complicated, and there is no "magic bullet" solution.  Yet, one likely reason behind some of the waste is that there are"too many cooks in the kitchen." Medicine has gotten incredibly complex. Because of this sub-specialization in medicine is rampant. Instead of just going to a specialist (cardiologist for example), patients need to go to a sub-specialist (interventional cardiologist vs. an electrophysiology cardiologist). A 2007 student in the New England Journal looking at practice patterns about a decade ago noted that int the course of two years, Medicare patients saw a median of two primary care physicians and five specialists working in four different practices.  My guess is that today these numbers would likely be much worse. In addition, as more care is being delivered in the outpatient setting, there is an increase in other health care providers (home care, rehabilitation, physical therapy, etc.) involved in a single patient's care.  The more health care professionals that care for an individual patient, the more likely for errors in communication, duplication, and administration. Having a Primary Care physician as the leader of the health care team is therefore critical in terms of reducing the number of potential errors. It is not that we don't need so many players on the team.  We actually do as, advances in health care have made things more complex.  However, we need better coordination in care to prevent potential waste.  Primary Care is perfectly positioned to do this, which is why it is the future of heath care.


3. Increasing Technology and Access to Information Requires Navigation and Experience. We live in a DIY world. Cable TV shows about remodelling your own house or preparing a gourmet meal on your own are numerous.  One can find a "how to" YouTube video on virtually any subject. (I have personally used You Tube to help me cook a Thanksgiving Turkey and fix a toilet.) There are even legal web sites that allow you to create your own will or incorporate your own business.  With so much health information now available on the web, you would think that the DIY mindset would translate to health care, but it has not. Even though the latest study published in major medical journals is now on the web and a sound byte on the morning news well before I have even had a chance to read it, patients who have access to this information still want their personal physician's interpretation.  The reason for this is that, in most cases, the more we learn (research) the more complicated decisions become. For example, prostate cancer screening has been in the news lately. More evidence suggests that screening for prostate cancer may not only be unnecessary but also potentially harmful.  The current US government guidelines now recommend against this practice.  What should you do?  Though most of this data is fully accessible to the public, how to interpret the data and apply it to an individual patient requires expertise.  Not only does one need expertise to interpret and apply data, but experience in practicing medicine.  DIY projects gone wrong might lead to a burnt dinner or having to call the plumber anyway.  However, DIY health, in many cases, is a life and death decision that most people don't want to make on their own. Health care in the future promises not only more innovations in diagnostics and therapies, but also more difficulty in how to apply these tests and treatments to individual patients. Advances in technology, even with unprecedented access to this information, requires a skilled navigator and interpreter.  Because of their breath of knowledge, holistic approach and familiarity with patients they have known for some time, no other health care professional is better suited for this role than the Primary Care physician.

A Health Care System to be Proud Of

I was not able to watch the 2012 Olympic opening ceremonies until last night. Though we are only half way through the spectacle on our DVR, I was remarkably surprised to find that featured among some of  the UK's proud traditions (the Queen, James Bond, Sir Paul McCartney, etc.) was a significant tribute to their national health service or NHS. According to the media guide, “The NHS is the institution which more than any other unites our nation."  Founded after World War II, the NHS offers universal health care to all of the UK's citizens.
This is not meant to be a post that necessarily supports a government run, single payer system or even the Affordable Care Act.  Rather, this is simply a musing on "what if" the US had a health care system that we could truly be so proud of that we too thought it worthy of such a national mention. Once can imagine that an opening ceremony in the US would likely feature similar historical events and sources of national pride such as our farmlands, Hollywood, "mountains and prairies," jazz music and maybe even Elvis; but probably not Medicare and Medicaid. Yet, our we really that far off?
We have some of the best trained doctors, skilled health care workers and the most technologically advanced hospitals in the entire world.  People travel from all over just to received their health care in the US. Yet, despite the many marvels of the US health care system; not all of our citizens have access to it, many that do can not afford it, and the escalating costs of care will likely cause our country to go bankrupt if something is not done done.
Part of the problem, in my opinion, is that we aren't seeing this as a national problem to be solved.  Our health care crisis has become so politicized, that nothing seems to be getting done (despite the ACA's passage). Not only have Republicans blocked Democratic health reform initiatives at every step of the way, but also remember that it was in-fighting among Democrats the lead to the failure of passing health care reform with a Democratic controlled House, Senate and Oval Office.  In addition, all stakeholders including doctors, hospitals, insurance companies, pharmaceutical manufactures, patient groups, etc. seem so entrenched in their positions; that no one is willing to budge and nothing appears to be getting any better.
But what if we saw our country's health care crisis as a national priority? What if politicians, stakeholders, and citizens all came together and decided that we as a country needed a solution now and, like "The Manhattan Project" got the greatest minds working together to create a uniquely American solution to health care? Surely that would be worthy of an opening ceremony mention.
I recognize that this vision is likely very unrealistic.  However, the way in which the NHS was featured during the Olympic opening ceremonies in London certainly gave me pause, even if just for a moment, to wonder "what if."

What if IVIG really worked for Alzheimer's?

ABC News and other media outlets are reporting the results of a small, but very important study regarding a new treatment for Alzheimer's Disease.  Most Americans are familiar with Alzheimer's because it is so common (President Reagan had it), so devastating, and without a cure.  This new study gives hope to people who have or are at risk for the disease.

This week at the Alzheimer's Association International Conference 2012 in Vancouver, researchers presented the positive results of a study using intravenous immunoglobulin, or IVIG, to successfully keep Alzheimer's disease at bay.  Controversy exists because the study was very small (16 patients total), of which 11 patients took IVIG for three years and showed improvement thinking, memory, daily functions and mood.

Immunoglobulins are part of the human immune system.  They are made naturally and help ward of a variety of infections and disease. IVIG has been used to treat a variety of auto-immune disease. Though no one is 100% sure how IVIG works, it is though to have antibodies against amyloid.  Amyloid is a protein which accumulates in the brains of patients who who have Alzheimer's.


Though most experts caution current use in the general public and are clear that more research is needed, many believe this is a very good sign indeed.

However, let's assume that the research is proven correct, and that IVIG actually does work well for most patients to treat Alzheimer's disease.  One of the problems is that IVIG is not cheap.  Since it is a blood product it is expensive- you need to get it from human donors, you need a nurse to administer it, and it must be given in a doctor's office or hospital. It is given once every two weeks, with an estimated to cost a patient $2,000 to $5,000.

According to data from Alzheimer’s Association, there are 5.4 millions American’s with Alzheimer’s. If we take the low estimate of $2000 every other week, it would cost $280 billion each year to treat patients with Alzheimer's. In 2012, the direct costs of caring for those with Alzheimer’s to American society will total an estimated $200 billion, including $140 billion in costs to Medicare and Medicaid.  Essentially what this means is that it would cost nearly $100 billion dollars more each year to treat patients with IVIG and prevent Alzheimer's progression, than to simply treat this very expensive disease.

Though in some instances, like vaccines, an ounce of prevention is worth a pound of cure.  However, in many examples, medical treatment is very expensive and keeping people alive and well cost more in the long run. It is our skyrocketing health care costs that plague our health care system and if we don't fix the problem soon, it could bankrupt our country.  Resources are not limitless.  Since much of our health care is funded with taxpayer dollars, we as a society are going to have to make some very important decisions. If we decide that we think it is worth paying for everyone who has Alzheimer's to get IVIG for example, we are going to need to decide what we are not going to pay for to keep costs down.  These are difficult decisions.  The problem is that these types of conversations or not really happening today because the health care debate has become more about who will be the next President than actually solving our country's problems.