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).

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.

Prior Authorizations Suck

"Suck" is a word I seldom use. It's a word I ask my children not to use.  However, in this case the word is appropriate. If as a patient, you have ever had a delay in getting a medication or a test your doctor ordered, it was probably due to a prior authorization.  A prior authorization is a bureaucratic hurdle (sometimes a phone call, sometimes a fax, sometimes a letter) that is required by your physician to get you the test or treatment he or she believes is right for you. A prior authorization is essentially a mechanism that insurance companies put in place to make ordering more expensive tests or medications more difficult for you to get. The decision maker on the insurance company's end who decides whether your doctor (regardless of specialty or years in practice) is justified in requesting the medication or test that your insurance company is obligated to provide for you is often a 20-something college grad with no clinical experience.  Prior authorizations are probably one of the most frustrating things about being a primary care physician. 


I am far from alone in this opinion.  My medical society, The Medical Society of the District of Columbia or MSDC actually did a survey of their members examining the impact of health insurance prior authorization protocols on patient care in Washington, D.C. The study reveals widespread concern among area physicians, with over 93% of respondents saying that insurance company requirements are having a negative impact on their ability to treat patients.

In their press release,  Dr. James Cobey, President of MSDC stated that “Doctors, not insurance companies, know best how to care for their patients, yet prior authorization and other insurer protocols are dictating how physicians provide treatment. Prior authorization requirements put D.C. patients at risk by causing unnecessary and potentially dangerous delays for medications and care while preventing doctors from providing the most appropriate forms of treatment.”


Specific findings of the MSDC survey include:  

• 93.1%  of D.C. physicians surveyed said that insurance company requirements such as prior authorization, pre-certification, therapeutic switching, and step therapy are having a negative impact on their ability to treat patients;

• Nearly 90% of those surveyed said that they have been forced to change the way they treated a patient, including changing prescription medications, due to restrictions imposed by an insurance company;

• Over 76% of physicians also reported that they have switched treatments in order to avoid dealing with prior authorization requirements;

• 94.8% of physicians surveyed said that insurance companies have delayed or denied treatments for their patients, such as prescription medications, diagnostic testing, or other services;

• 84.6% of physicians said that is it difficult to determine which prescription drugs or medical procedures require prior authorization;

• About half (47.2%) of MSDC members surveyed said that on average, prior authorization requests take several days or more to be resolved;

• 89.7% of respondents confirmed that completing and clarifying insurance requirements imposes “hidden” costs—such as extra staff time for the additional paperwork and phone calls—that have a negative impact on their medical practice.

Folks at the MSDC are trying to get laws passed to implement a standardized system across the District, with uniform requirements for filing and processing prior authorization requests which would expedite this onerous process and allow doctors to finally focus on what really matters—treating patients. Every medical society should follow their lead. 

How the Government Plans to Lower Cost by Eliminating Doctors and Shifting Costs to Patients

In our world of 24/7 media, where we seem to hear about the next big cure, important dietary change or very dangerous drug virtually every day, it is hard to believe that the news people, tweeters and bloggers could miss anything that is going on in health care today.  However, it appears most everyone missed a big one. This might be one of the most important stories in health care today, that no one seems to have picked up on.  No mention in the Times, Wall Street Journal, Washington Post, etc. Only US News mentioned this by re purposing material from Health Day.  It's how the government, through the FDA, plans cut health care costs by eliminating the need to see a doctor and shift the costs of medications to the patient.

And you should be afraid....very afraid!!!

What I am referring to is a public hearing that was held on March 22 and 23rd; the notice was placed online only a few weeks before on 2/28.  The meeting was entitled:


 Using Innovative Technologies and Other Conditions of Safe Use To Expand Which Drug Products Can Be Considered Nonprescription
 
What was the purpose of such a meeting? According to the briefing document:
"The U.S. Food and Drug Administration (FDA or the Agency) is announcing a public hearing to obtain input on a new paradigm we are considering. Under this paradigm, the Agency would approve certain drugs that would otherwise require a prescription for nonprescription use (also known as over-the-counter or OTC) under conditions of safe use. These conditions of safe use would be specific to the drug product
and might require sale in certain pre-defined health care settings, such as a pharmacy."

You have to read between the lines here, but essentially what this is saying is that the FDA is thinking about a completely new way to approve or classify drugs, so that some drugs if dispensed in a pharmacy would be allowed to be purchased over the counter/without a prescription.

Their rationale which I have extracted (the bolding and underlining are mine):
" Undertreatment of many common diseases..is a well recognized public health problem..... The requirement to obtain a prescription ... may contribute to undertreatment of ...hyperlipidemia (high cholesterol), hypertension (high blood pressure), migraine headaches, and asthma. For instance, some consumers do not
seek necessary medical care...because of the cost and time required to visit a health care practitioner for an initial diagnosis and an initial prescription. Some patients who obtain an initial prescription do not continue on
necessary medication because they would need to make additional visits....Some prescription medications require routine monitoring through the prescribing practitioner such as blood tests..... FDA believes that some of these visits could be eliminated by making certain prescription medications available without a prescription but with certain other conditions of safe use that would ensure they could be used safely and effectively without the initial involvement of a health care practitioner... In addition to improved health outcomes .... Eliminating or reducing the number of routine visits could free up prescribers to spend time with more seriously ill patients, reduce the burdens on the already overburdened health care system, and reduce health care costs.
 
Now, on the surface, this might sound like a good thing.  Wouldn't it be great if we could find easier ways for patients to get their needed medicines?  After all, as our nation gets older (and more overweight), chronic diseases are going to be main issue in health care. It all about improving health, right?
 
Unfortunately,  the bottom line here is that instead of finding a real solution to improving access to primary care physicians or finding real ways of reducing health care costs, the government (through the FDA) has come up with a simple plan: take the doc out of the picture and shift costs to the patients.
 
The fact of the matter is that though medications are expensive, they only represent about 10 cents of every dollar spent.  The two biggest costs are doctors and hospitals. Thus, if we are trying to cut costs, the most economical solution would be to eliminate or at least curtail a visit to the doctor. Since prescription medications require a prescription which requires a doctors visit (or at least phone call); the FDA can just make certain medications available over the counter and we no longer need those annoying, inconvenient, and expensive visits to your primary care provider.
 
Now there are already lots of medications available over the counter.  These medications are considered safe enough to use, and a medical degree is not required to figure out that you take cold medicines for your cold and heartburn medicines for your heartburn. However, what the FDA is talking about are medications to treat chronic diseases like asthma, high blood pressure, high cholesterol and though not mentioned, probably diabetes.
 
It was only back in 2005 when the FDA rejected Merk's bid to make their cholesterol medicine Zocor (simvastatin) OTC. At that time, they knew that even drugs that seemed relatively safe and could benefit many people required expertise to properly diagnose and treat high cholesterol safely and effectively. More recently, Pfizer also tried to get their patent expiring Lipitor to be sold over the counter (see my post Why OTC Lipitor is a Bad Idea).
 
How can medicines that were only a few years ago considered too dangerous to be taken over the counter, would now be considered safe?  According to the briefing document:
 
"The conditions of use could include requiring pharmacist intervention to ensure appropriate nonprescription use. Additionally, conditions of safe use could involve the use of innovative technologies, such as diagnostics
approved or cleared by FDA for use in the pharmacy or other setting."

 
In other words, for certain (particularly expensive) chronic diseases such as asthma, high blood pressure and high cholesterol; the FDA would consider these medications safe by allowing the pharmacist, not the doctor, to determine which medication is right for you. And if you needed any blood work, the FDA might clear the way for this to be done in the pharmacy as well.
 
But my favorite part is about the kiosks:

"For example, kiosks or other technological aids in pharmacies or on the Internet could lead consumers through an algorithm for a particular drug product."

 

Can you just imagine patients going up to an ATM-like machine, entering their conditions, allergies, blood levels, etc. and having the computer spit out exactly what dose of what medicine that they should be taking for their high blood pressure or high cholesterol?  Would there be a soda-like machine right beside it that could dispense the appropriate medication?

 
When it comes to prescribing, physician is best
I have nothing against pharmacists.  I value pharmacists as part of the health care team.  In addition, I feel their role is substantially  underutilized. Part of the problem with chronic disease is adherence to medication, a large part which has to do with education.  Pharmacists are experts when it comes to informing patients about their medications, how to take them properly and why taking them is necessary.  They can monitor adherence to medication and can also serve on the front lines to alert physicians if their patients aren't doing well and need closer attention.
 
However, when it comes to making a diagnosis and determining which therapy is best, pharmacists do not have the depth and breadth of training that physicians receive.  As a primary care physician, I can tell you that even the most common conditions like asthma or sinusitis is not always that easy to diagnose, and even determining treatments for these conditions do not do well with cook book like algorithms.  
 
Another concern I have with pharmacist essentially prescribing medications is that they are employed by the pharmacy that dispenses these medications, and thus have a potential direct conflict of interest. Now, I am sure skeptical readers will say that drug reps have been given physicians gifts and samples for years, and this is conflict as well.  Though this may be true, a pen or a slice of pizza is a whole different level of conflict then direct money in your paycheck. Also realize that the pharmacy makes a bigger profit on generics, thus the pharmacist may be consciously or unconsciously biased to give you a generic when it may not be the best choice.
 
Patients Will Pay More
Usually when a drug goes OTC, it usually means the patient has to pay more.  This is because most insurances do not cover over the counter medications. Ask any patient who suffers from seasonal allergies.  OTC non-sedating antihistamines like Claritin, Zyrtec, and Allegra cost a lot more out of pocket, even when using the store brand, then when they were available by prescription.  This is because the out of pocket cost for co-pay for a preferred drug (even when branded) is often less then the out of pocket cost for and entire supply of over the counter medication, even when generic/store brand. The same is true for acid blocking medicines such as Prilosec. Generic OTC Prilosec (Omeprazole) is just over 50 cents a pill, which means a patient requiring a daily dose will pay over $15 for a 30 day supply. This is generally much more than patients pay for a generic prescription of omeprazole, some paying as little as a $5 co-pay. (Some insurers have actually made the co-pays for the generic omeprazole more expensive then the acid blocking medicines that are not yet over the counter, like Nexium, to steer patients to buying the over the counter medication (full out of pocket cost), rather then request a prescription!) 
 
 
Where is the Outcry?
What's most shocking to me is the lack of dialogue on this topic.  My guess is that this may be due to lack of awareness, since the FDA seemed to slip this past the media.  Physician representation at the March hearing was pretty poor. Few groups such as The America College of Physicians seem to be interested (or aware). The AMA did testify at the hearing, and according to their website:


"While the increased availability of certain prescription-based antidotes, such as Epi-Pens, appear to have few if any safety concerns, the FDA has not offered evidence that patients with hypertension, hyperlipidemia, asthma, or migraine headaches can self-diagnose and manage these serious chronic medical conditions safely on their own. This sort of self-diagnosis and treatment conflicts with the kind of care coordination and disease management that both the administration and private sector are trying to achieve through the new health care payment and delivery models."


To me the "conflicts with.....new health care payment and delivery models," is very interesting. This suggest to me that the government is trying to hedge their bets. In other words, if the new plans for health care reforms don't work, we can still lower cost and increase access simply by making many chronic disease drugs over the counter.

Most commentary that can be found on this issue seems to be coming from the pharmacist groups, who are not surprisingly supportive.  However, there is at least one pharmacist that remains skeptical. Pharmacist blogger Eric Durbin at his blog Eric, Pharmacist states:
"I've never known our government or any of its agencies to move quickly on issues, especially when it comes to our profession. But for this issue, the notification for the hearing was filed on February 27, published in the Federal Register on February 28, with a deadline to present oral comments & presentations of March 9. That's less than two weeks. With the hearing being held less than two weeks after the deadline. 3-1/2 weeks from the notice of hearing in the Federal Register until the hearings begin seems to be moving rather quick to me. Which makes me skeptical"
 

Bottom Line: Though this may seem like an initiative that could improve patient access and chronic disease outcomes, allowing chronic disease medications to be over the counter is a way the government can cut health care costs by eliminating expensive doctor's visits and shift medication costs to patients.

What can you do?
Though the hearing was over weeks ago, the website still allows visitors to submit comments (due May 7, 2012) online (CLICK HERE- also note the 20 minute lock out, so you may want to type in Word first and then copy/paste).  You can also use the address below for regular mail:

Division of Dockets Management
(HFA–305), Food and Drug
Administration, 5630 Fishers Lane, rm. 1061
Rockville, MD 20852

In addition, you can send this post to those who know who might care about this issue and/or write your own post. You can Tweet, post to Facebook, etc. Social media has done wonders recently in getting the word out and making changes.  However, time is of the essence.

Paying For Your Time

There has been a lot of Internet/Twitter buzz regarding a recent CNN article "Would your doctor pay for wasted time?" by Elizabeth Cohen.  The premise of the article is that a patient's time is valuable, and if the doctor keeps a patient waiting for longer than anticipated, it should be the doctor that pays the patient, since the patient's time is valuable too.  She describes the story of patient Elaine Farstad waited over two hours to see her physician.

"I decided to bill the doctor," she says. "If you waste my time, you've bought my time."

Farstad mailed an invoice to her doctor based on her own hourly wage, and eventually received a $100 check in the mail.

As mentioned, this story has received considerable attention. Over at the blog Survivor: Pediatrics , Brandon Betancourt humorously counters "Why not bill everybody that wastes our time?" including the movie theaters that make us sit through commercials and previews before the movie we came to see, or even Disney for waiting in those long lines. 

However, the issue of why patients have to wait is an important one. Most patients recognize that emergencies do come up in medicine, which often causes doctors to run behind schedule.  However, medical emergencies are not the main reason why patients spend long waits in doctor's waiting rooms.  The answer can be found in a study published last year and discussed in the New York Times "Study Shows ‘Invisible’ Burden of Family Doctors."  Primary care physicians do a lot more during their day than just see patients.  However, they only get paid for seeing patients.  The actual study, published in the New England Journal of Medicine measured exactly what a group of family physicians did in a given day.

Family doctors are paid mainly for each visit by patients to their offices, typically about $70 a visit. In the practice in Philadelphia covered by the study, each full-time doctor had an average of 18 patient visits a day.


But each doctor also made 24 telephone calls a day to patients, specialists and others. And every day, each doctor wrote 12 drug prescriptions, read 20 laboratory reports, examined 14 consultation reports from specialists, reviewed 11 X-ray and other imaging reports, and wrote and sent 17 e-mail messages interpreting test results, consulting with other doctors or advising patients.

All of this unpaid work takes an incredible amount of time.  Also, assuming that the doctors were collecting 100% of their $70 per visit, at 18 visits a day, with 60% overhead  (often more for doctors), the doctor only takes home about $120,000 a year in salary.  Now that seems like a pretty good salary, and is certainly much more than most Americans make.  However, it is far lower than many other professionals with equal or less training (lawyers, accountants, dentists, college professors, etc.) and also doesn't take into account the enormous debt that medical students accumulate (in some cases close to $200,000 at graduation, adding up to  well over $1 million if paid over the course of a typical loan).   This is why our medical students are not going into primary care.

All this work can't be done in a given day, and the doctor can't see fewer patients to squeeze in this work because it will lower her salary even further. Another way to put this is that the doctor's time is valuable too, but she isn't get paid for her time. The doctor is getting less than what's it worth from the insurance companies for actually seeing patients and getting nothing from insurance for anything that's not face to face.

Thus, the doctor who is trying to see too many patients in too little time while simultaneously trying to get all the phone calls, lab results, etc. is going to run late. In my practice, with the exception of the first patient of a morning or afternoon session, I start each patient conversation with, "I am so sorry to keep you waiting."  There is only so much that can be accomplished in 15 minutes.   Primary care physicians who need to manage multiple complex medical issues have a choice: be good or be on time.  I choose to do the best job I can, which causes most of my patients to wait much longer than any of them should.

One solution to the problem is to have insurers properly reimburse primary care physicians for all the work that they do.  Unfortunately, regardless of who gets elected in 2012, this seems unlikely to happen.  Another solution is to get the insurance companies out of the mix all together.  This alternative solution is already starting to happen.  Retainer or concierge practices, which charge an annual fee (on average $1500/year) allowing doctors to have a very small number of patients who have instant access and no wait times, are gaining in popularity. Some have suggested that this is one solution for the primary care crisis.

However, many patients can not afford high retainer fees nor necessarily need this level or service.  For these patients, another solution is direct access primary care. Direct access primary care works more like a gym membership, where you pay a monthly fee for all of your basic primary care needs.  You can use your direct access primary care provider as little or as much as needed.  Qliance in Seattle, charges about $75/month.

There are a variety of other models that improve patient and physician satisfaction, and likely the actual quality of care.  However, the key ingredient in all of these models is cutting out the insurance companies to save money, hassle and overhead costs; and collecting money directly from patients to enhance revenue. This combination allows primary care physicians to spend more time with patients, have increased access, and subsequently low to no waiting for patients.

Bottom Line: The current insurance based system keeps primary care physicians on a treadmill, usually forcing them to choose quality of care over patient convenience. Though all patients deserve high quality, patient centered care that is convenient as well, the solution of higher reimbursements and decreased hassles for primary care physicians does not appear to be happening any time soon. Thus, as a patient, you have a choice. If your time is valuable, then you are going to have to pay extra for primary care services. If you choose to (or are only able to) rely on health insurance premiums and co-pays to cover the cost of your care, you should expect to wait. Expect to wait to get a timely appointment with your doctor. Expect to wait for the phone call with results of your recent tests. And, of course, expect to wait in your doctor's waiting room.

2011 Residency Match NOT Good News for Primary Care

The there are currently few reports of this in the mainstream press, the AMA news announced "Residency Match sees continued growth in primary care." The American College of Physicians reports on their web site states "Residency Match Results Encouraging for Adults Needing Primary Care." Kevin Pho of KevinMD appropriately wonders whether this increase is enough to save primary care in his post "Match Day 2011: Family medicine grows, but enough to save primary care?" based on the assumption that this year's match meant good news for primary care.

Don't believe the hype.

This was not a good match for primary care or our health care system in general. These positive reports are based on the press release from the National Resident Matching Program or NRMP which is the group that runs the match. They stated that


"The number of U.S. seniors matched to family medicine positions rose by 11 percent over 2010 . Among primary care specialties, family medicine programs continued to experience the strongest growth in the number of positions filled by U.S. seniors. In this year’s Match, U.S. seniors filled nearly half of the 2,708 family medicine residency slots. Family medicine also offered 100 more positions this year.

The two other primary care specialties that increased in popularity among U.S. seniors were pediatrics and internal medicine. U.S. seniors matched to 1,768 of the 2,482 pediatric positions offered, a 3 percent increase over 2010. In internal medicine, U.S. seniors filled 2, 940 of 5,121 positions, an 8 percent increase over last year."

At first glance, this seems like good news for primary care. However, their use of statistics is misleading. They are not taking into account that there were almost 500 more US medical students in the match this year. This is equivalent to a drug company telling you that their medication reduces hearts attacks by 30% (from 50 to 35), but forgets to tell you that there were 1000 patients in each group, so that the real reduction in heart attacks is only 1.5%.
What you need to look at is the percent of US medical students that matched into that speciality and whether or not it changed from last year to this year. If you go to the NRMP web site, you can get the actual raw numbers. For Pediatrics, though more US seniors matched into Pediatric residencies (remember there was about 500 more students this year than last), the percent of US seniors matching into Pediatrics was unchanged. For Family Medicine, there was a slight bump, but compared to last year, only about 1/2 of a percent more of US seniors chose to go into Family Medicine (far less impressive than the relative increase of 11%). The real big bump was in Internal Medicine, where almost 1% more US seniors matched into Internal Medicine. However, we know from previous studies, that only 2% of seniors that choose Internal Medicine plan to go into primary care. (See here for previous post).


What is also in the NRMP press release (that some are paying less attention to)

"Dermatology, orthopaedic surgery, otolaryngology, plastic surgery, radiation oncology, thoracic surgery, and vascular surgery were the most competitive fields for applicants. At least 90 percent of those positions were filled by U.S. medical school seniors.

The number of U.S. medical school seniors in emergency medicine increased by 7 percent and grew for the sixth year in a row, as they filled 1,268 of the 1,607 first-year positions available. Anesthesiology offered 44 more positions and matched 45 more U.S. seniors who filled 671 positions of the 841 offered "

Essentially, though there are more medical students this year than last, and thus more doctors available to society when they are done with their residencies, the same low numbers of students are choosing residencies that will lead to careers in primary care. This small increase will not make up for the many patients in the US who lack a primary care physicians and certainly won't even begin to fill the gap when many of our now close to 50 million uninsured patients suddenly gain insurance under health care reform. Rather, despite the clear need for more primary care physicians, our students continue to choose the more lucrative subspecialties.

America, this is a crisis. Many of the few primary care docs we have are retiring, leaving practice, or going cash only or retainer. Our students see this and continue to choose other specialties. 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).

Don't Call Me for A Prescription for Your Aspirin

As reported by MSNBC, the federal government will no longer allow flexible spending accounts (FSA's) to be used for over the counter medications, without a prescription. FSA's, which are offered by many employers, allow you to use tax free dollars for medical expenses that aren't covered by your insurance. FSA's are a great idea and can be used for things like eye glasses, dentistry, or even nicotine patches for smoking cessation.

The people most likely affected by this rule are those that take over the counter medications on a regular basis. Examples of such medications include pills for allergies, heartburn , aspirin for heart attack prevention, and smoking cessation aids. Medical supplies like insulin syringes and crutches, though sold over the counter, are exempted.

Now, you might think, "no big deal, I will just call my doctor and ask her to call in a prescription for a baby aspirin a day." This would certainly solve your problem, but it adds to your physician's problem and is a perfect example of the problems with the reimbursement system for health care, particularly for primary care.

If you are not aware by now, procedures get reimbursed much more than just talking to patients, which is why cardiologists make so much more than primary care physicians. However, anything that doesn't happen in an office visit is generally not reimbursed at all. Primary care physicians can be great managers of your health care, done in a way that it convenient for you, and at a low cost- phone calls, emails, forms, etc. Problem is that the few minutes spent on you add up and take a whole lot of time. None of which is reimbursed by health care insurances under the current system. One doctor started adding these things up, and of the 50-60 hours each week the doctor put in, each day they:

Handled 23.7 phone calls.
Answered 16.8 e-mails, mostly dealing with test result interpretations.
Dealt with 19.5 lab reports, 11.1 imaging reports and 13.9 consult reports.
Issued 12.1 prescription refills, excluding those issued during patient visits

None of these are reimbursed.

Now, here's the real kicker about asking your doctor for an aspirin prescription. Not only are you compounding this problem, but you are also doing it not for better care (or any care for that matter), but so you can save money!
Finally, consider this:
Even though you can easily go to CVS and get aspirin on your own, if your doctor writes you a prescription for aspirin, legally speaking it is a whole different ball of wax. By writing a prescription, even if only for an aspirin, your doctor is rendering medical care. He is required by law to accurately document this. He is also liable for this care. If you had an adverse reaction to the aspirin prescribed, you could certainly sue.
Thus, by asking for a prescription for an aspirin, you are asking for the doctor to deliver care which he is liable for, which he will not get paid for, which (when added up for each patient) will take time away from true patient care and for the sole purpose of you saving yourself a few bucks.

Now, one of the reasons that primary care physicians have gotten into the mess that we are in is because we generally want to do what's best for the patient and have been delivering this kind of free care for a long time. We actually were glad to do it, and only started complaining recently when what we got paid for actual care kept declining while our specialist colleagues kept getting more money, and our paper work started to increase. Many of us (probably including myself) will likely grant these requests without a complaint.

The point of this post was not to prevent your from requesting an OTC prescription from your physician for tax purposes. After all, the economy is still horrible and many patients truly need daily medications for allergies and heartburn that are quite expensive. The point is that are entire health care reimbursement system must change, and must change very soon. A few requests for OTC prescriptions for FSA's on top of a 23% Medicare cut might be all it takes for a primary care physician to stop practicing medicine altogether.

Having health insurance doesn't ensure it will be easy to find a doctor

An excellent article appears in today's Washington Post entitled "Having health insurance doesn't ensure it will be easy to find a doctor," where a young, otherwise healthy and insured woman discusses her extreme difficulty in finding a doctor in Washington, DC who will see her.

"I was just 23, basically healthy and, most important, insured. So I pulled out my computer, looked up the UnitedHealthcare list of pre-approved doctors and started calling. And I got rejected. Again. And again. (Usually after being put on hold for three or four minutes.) "

Next to Massachusetts, D.C. has the largest number of physicians per patients. (The article briefly mentions the lessons Massachusetts has learned about providing health care for everyone without addressing whether there are enough primary care physicians to see them). D.C.'s doctor excess, like Mass., is somewhat exaggerated given that there are several teaching hospitals with more than a few resident physicians. However, there are more than enough docs in D.C. to see patients. The problem is that in addition to not having enough primary care physicians, more and more primary care physicians are not accepting new patients. The article suggests that this is a supply and demand issue, which is true. However, another major factor that the article neglects to mention is that there are many primary care physicians in D.C. gladly accepting new patients. However, they will not take your insurance.

I practice in a large, academic teaching center in D.C. and we stopped taking new patients several years ago. This happened because many of the physicians in D.C. stopped taking insurance, and many of their former patients who were not willing to pay out of pocket to see their former doctor came to our practice (we take virtually every insurance). The problem is that we now have so many patients, they have a very difficult time getting to see us for an appointment.

The article suggests several solutions to increase the number of primary care physicians including recruiting more primary care oriented students into medical school and funding more residency spots for graduates going into primary care. These are good ideas but will not solve the problem. In a survey we did, we found that only 2% of students going into internal medicine were going into primary care internal medicine. The main reason that they chose not to do primary care was lifestyle. Students perceived primary care physicians as too busy, doing too much paperwork, and undervalued by society. Until this problem is fixed, the primary care crisis will remain. ( See Factors Associated with Medical Students' Career Choice Regarding Internal Medicine: Pay is Not Really One of Them! )

I have previously discussed that the same issue happened with psychiatrists years ago, and this is why we have a two types of psychiatry in the US. The psychiatry that you see on the TV and in the movies only occurs for those patients willing to pay out of pocket for their care. Those who pay for mental health with insurance might see a psychiatrist once a year for a few minutes, but any counselling is done by someone else. Getting an appointment with a mental health professional that accepts your insurance is similarly challenging. (See a piece I wrote for KevinMD called "As psychiatry goes, so will primary care," and How can a psychiatrist write 100,000 prescriptions a year, and why this matters to Primary Care? )

Though I believe it is important to support health care reform, it will do nothing to fix the lack of primary care physicians nor does it address the root cause of the problem (see Why you must support health care reform, even though it won't fix our health care system. ). If you are frustrated by the system, one thing to think about is paying out of pocket to see your primary care physician. Though many doctors who see "cash paying" patients run more of boutique or concierge practice, more and more primary care physicians are seeing patients at more reasonable prices, and just desire to get the insurance middle man out of the picture ( see Insurance Free Medicine )

Update: A related post byDr. Toni Brayer was just posted on KevinMd. Primary care needs to be valued first before it can be saved . I think a lot of us are all saying the same thing.

Insurance Free Medicine

I never thought I would be in academic medicine for so long. When I was hired about 12 year ago, I figured I would stay in academics for a few years and then join a private practice Internal Medicine group. Now, I can't even fathom that idea. One of the reasons I have stayed at my institution for so long is that I love teaching and the academic environment. However, a second reason is that the "real world" for primary care medicine is a scary one. As a salaried employee in a large practice, I am somewhat sheltered from the harsh realities of running a business in the current health care environment. Yet, I hear horror stories from my colleagues in the community that are struggling to survive. With reimbursement rates from insurances so low, and administrative burdens so high, many older physicians have retired and younger physicians have adopted new models of delivering care. These have various names such as "concierge medicine" or "boutique practices".

Though I have no intention of leaving any time soon, I know that (assuming there are not major changes via health care reform) the current model of a small group of primary care physicians who accept insurance is simply not sustainable. Yet, I have a hard time imagining myself practicing in one of these new models, or even attracting patients to my practice. Retainer medicine is one model, where primary care physicians are able to see a much smaller panel size (and thus increase access) by charging patients an annual fee, which ranges from hundreds to thousands of dollars. Though the model makes financial sense, the word "retainer" sounds too legalese for me and likely not easily understood by the lay public. I would prefer something like "membership fee" similar to something would pay to join a club. However, "membership medicine" or "club medicine" just doesn't seem to have a good ring.

"Boutique" practices often use a retainer model, but boutique can also refer to primary care physicians who charge for extra services such as laser hair removal or botox injections. There are many primary care physicians who still take insurance that have started using these kind of practices or have found other ways to meet their bottom line, such as selling nutritional supplements. Though there is no question that the public has a demand for these services, providing them for a fee as a primary care physician seems to carry some conflict of interest, since none of these services show any benefit in overall health. "Concierge medicine" is another term used with retainer models and boutique practices. This implies some sort of preferential treatment, but also usually is associated with "executive physicals" and a battery of unnecessary testing and high technology that again provides little in the way of proven health benefits.

Some physicians have continued to practice normally, but simply do not accept insurance. They have figured out that they can sustain a primary care practice if they simply refuse to accept the substantially reduced rates that insurance companies give them. These are often referred to as cash only practices. Yet, the term "cash only" seems to imply (at least to me) something shady or under the table. In addition, most patients who see cash only physicians, pay for these services using a credit card, making the name somewhat illogical.

However, the reason that all these new models of medicine exist boils down to one single reason: health insurance. Rates from insurance companies are so low, that the only way a primary care physician can make ends meet is to increase volume to the point that both access and care delivery suffer substantially. In addition, the administrative headaches which include fighting to get tests/medicines covered and arguing over claims once submitted, make the practice of medicine less than enjoyable. The often quoted study (that I co-authored) showing that only 2% of medical students are interested in primary care internal medicine, is often used to support the argument that primary care physicians need to be paid more. While the need to substantially reduce the growing income discrepancy between primary care physicians and specialists is critically important, the study actually showed that educational experience, nature of patient care and lifestyle were the primary factors influencing career choice, not income. This was regardless of students' medical school debt. In other words, it was more about the hassles of primary care medicine and less about the how much money they would make, that led students away from careers in primary care.

Thus, I think a term that I would like to propose for use in further discussions of newer ways of practicing primary care (in blogs, media, etc.) is "insurance free medicine." In my opinion, the term "insurance free medicine" captures the essence of the newer models of primary care. Patients have certainly seen their premiums and deductibles increase and can probably relate quite well to reasons why a doctor would not accept insurance. Insurance free primary care practices could certainly adopt retainer membership fees and promote improved access, but eliminating terms like "boutique," "concierge," and "cash only" might help eliminate the notion that primary medical care without insurance is somehow tainted or only for the super-wealthy. In a previous post on KevinMD, I discussed that without substantial changes, primary care will soon go the way of psychiatry in that patients who use their insurance to see a psychiatrist get one kind of care (very brief visits, mostly management by a non-physician) and those who pay their psychiatrist out-of-pocket get the kind of care that we see in TV and the movies. With a more frequent use of the term "insurance free medicine," patients might start realizing that if they continue to pay their primary physician using their health care insurance, they should expect even briefer visits, longer waits to get in, seeing non-physicians, and greater delays getting a return phone call or results back.

Though I have no immediate plans to leave the world of academia any time soon, I could certainly see starting an insurance-free practice if I ever did.

How can a psychiatrist write 100,000 prescriptions a year, and why this matters to Primary Care?

The Miami Herald is reporting an investigation of a psychiatrist who wrote almost 100, 000 prescriptions a year. Sen. Grassley and the feds have halted payment to this Miami psychiatrist who stated that "he prescribes only what is medically necessary" and "works long hours, seeing patients for 10 minutes at a time and many of his patients need four or five medications."

I have no personal knowledge, interaction, acquaintance with psychiatrist Dr. Mendez-Villamil. However, though this sounds fraudulent (which is why the fed likely pulled payment), how could this doctor personally benefit from all of these scripts? Doctors do not get paid by how many prescriptions they write (unless you count docs like oncologists who collect fees for administering chemotherapy). Drug companies are now forbidden to wine and dine doctors, so it is highly unlikely that some pharmaceutical rep is incentivizing this psychiatrist. Besides, these patients areMedicare and Medicaid, so they are likely getting generics in the first place.

So if there is no wrong doing or even an incentive to write all those scripts, is this even possible and why does it happen? If the good doctor is seeing patients every 10 minutes, and each patient needs 4-5 prescriptions (assuming an 8 hour day); that's 46 patients a day needing about 3 prescriptions on average to yield the 150 prescriptions a day that Dr. Mendez Villamil is "accused" of writing. Though this may not be good medicine, with that volume of patients, the numbers sound pretty reasonable, espescially since many chronic psychiatric patients are on multiple medicines. So it it possible that one psychiatrist sees almost 50 Medicare and Medicaid patients a day in 10 minute visits? If the psychiatrist accepts Medicare and Medicaid, then this is actually quite likely the case (and probably not the exception but the rule).

In a piece I wrote for KevinMd a year an a half ago, I described how there are two kinds of mental health care in the US: care for those who pay with insurance and care for those who pay out of pocket. The kind of care that you see in TV and movies where a patient talks to a psychiatrist and possible gets medication; that kind of care happens, but only if you are willing to pay out of pocket. In many cases fees for a regular sessions run over $200. For those paying with insurance, the experience is quite different. If a patient sees a psychiatrist, it is usually only for medication management and usually only in short (10 minute) visits. Any "talk therapy" is relegated to a psychologist or psychiatric social worker. I mean no disrespect to some of the excellent and well qualified non-physician therapist we have in the US. I am not even stating that having a short visit with a psychiatrist for medication management and counseling done by non-MD's is bad medicine. However, the public must be aware that this is how psychiatry is practiced in the US.

In the case of Dr. Mendez-Villamil, he probably is one of only a handful of psychiatrists in Miami that accepts Medicare and Medicaid. Patients probably wait months to see him. The Miami Herald makes him look like a criminal. However, think about the majority of his colleagues who only see patients who can pay $200 or more out of pocket per visit? Dr. Mendez-Villamil is probably a hero, and if he writes 100,000 prescriptions per year this should be seen not as a crime, but a sign of a broken system.

The piece I wrote for KevindMD was entitled, "As psychiatry goes, so will primary care." The reason why so many psychiatrist stopped taking insurance and the reason why those psychiatrist who accept insurance cram patients into 10 minute visits is because the reimbursement rate from insurers is ridiculously low. Many psychiatrist realized that accepting insurance just didn't make sense. The same thing is happening right now in primary care. More an more primary care physicians have stopped taking new Medicare or Medicaid patients, or any insurance altogether. Some have even gone beyond cash only, and started "concierge" practices which charge patients a retainer fee (sometimes well over the usual $1500 a year) in exchange for easy access to their primary care doctor.

Health care reform has focused on how to cover the uninsured and how to pay for this, but it has not focused on how to change the current reimbursement system that rewards "proceduralists" and punishes "congnitivists." If health legislation that covers the uninsured does eventually pass without addressing this fundamental crack in our health care system, there will likely be no primary care physicians to see all these newly insured patients (see what happened in Massachuesetts). The few primary care physicians that do accept the newly insured will likely have limited access and see more patients in less time....kind of like the good Dr. Mendez-Villamil. Whereas the typical psychiatric patient might be on 3-4 meds, the typical Medicaid and Medicare patient is on a great deal more medications. Primary care physicians, get your pens ready! 100,000 prescriptions a year will seem like nothing.