Tuesday, October 20, 2009

Primary Care Doctor Hits "Non-Reimbursable" Nail on Head

I would like to introduce you a remarkable article by Edward J. Volpintesta, MD, a 65year old solo primary care doctor in Bethel, Connecticut. Dr. Volpintesta is a veritable writing machine and has been published in the Wall Street Journal, the New York Times, medical journals, and other publications. His articles cry for a deeper understanding of primary care dilemmas.

A “Typical Day” in the Office

In the October issue of Connecticut Medicine, Dr. Volpintesta hits the primary care dilemma on the head by simply recording a “typical day” in his office, in this case, a “half-day,” lasting 9 hours. The power of his entry is the simple recording of events of his day – including details of 7 office visits, 9 telephone conversations, and reviewing, signing, or taking care of some 25 documents, faxes, referrals, and other paperwork.

What struck me about his chronicle is how many of his activities were non-reimbursable. In Denmark and other countries, these activities tend to be reimbursed through a combination of management fees for serving a patient panel, fees for responding to telephone calls and emails, and fee for-service during office visits. Not being paid for telephone calls, which can take up to 1/3 of a doctor’s time, is a particularly egregious example of what should be paid for any reform measure to have impact in the clinical trenches.

Keep in mind doctors like Dr. Volpintesta are the workhorses of our health care delivery system. These physicians , which deliver most of initial care in this country, are generally in independent practice, are underpaid compared to specialist peers, represent a threatened species, and are short by 50,000 doctors, scheduled to reach 160,000 in a decade.

I have long maintained pundits like myself and health reformers in Washington should spend a day in the office of busy solo practitioner. Only then can we begin to appreciate travails of primary care – the hours spent on such non-reimbursable activities as paperwork, phone calls, and prescription writing and renewals.

These activities require knowledge possessed only by the physician. In my opinion, these activities, because of the time and know-how required, ought to be reimbursed. That would make primary care more rewarding and would close the satisfaction and monetary gap between primary care and specialty care.

Two golden rules for writing are:

One, if you have a nail to hit, hit it on the head.

Two, be concrete, not abstract.

The health reform nail I’ve been hitting in my book and frequent blogs is this: the next big health reform crisis will be lack of access to primary care physicians.
In the concrete, this will occur when 78 million baby boomers turn 65 in 2011, and, if and when, Obamacare reforms propel 25 to 30 million uninsured into the market in 2012 or thereabout.

Primary care doctors, already overworked, will be swamped, and waiting times to see doctors will escalate. Waiting have already grown to twice to three times the national average in Massachusetts, now 3 years into its universal coverage plan.

Proposals and Events on Ground Designed to Close Primary Care Gap

• Expanding medical schools to produce more primary care doctors.

• Increasing the number of primary care residencies.

• Instituting payment reform by paying primary care doctors 10% more and narrowing the gap between what Medicare pays primary care and other specialists.

• Implementing 100 Medicare and Medicaid “Medical Home” demonstration projects throughout U.S.

• Hospitals hiring more primary care doctors so hospitals can offer a more coordinated one-stop shopping approach to chronic disease care.

• Doing away with “fee-for-service” for primary care, specialty care, and hospital care so “accountable care organizations” can deliver budgeted or capitated care, now being considered in Massachusetts.

• Pushing widespread development of more “integrated group practices” with hospitals, primary care doctors, and specialists acting in tandem, as in now done in 15 or so large megaclinics, such as Mayo, the Cleveland Clinic, Kaiser, and Geisinger.

• Incentivizing and rewarding doctors and hospitals to install ubiquitous electronic medical records, and by so doing, systematizing care through standardized protocols complying with comparative research effectiveness results and creating more effective virtually integrated groups

Two Primary Care “Donut Holes”

These approaches have virtues, but they have three gaping reform holes:

One. How to fill the “ primary care donut hole, “ namely, between now and the 10 years it takes to produce a newly-minted primary care physician.

Two, How to pay for the many “non-reimbursable” activities that primary care physicians must endure.

Three, how to address the needs of “independent” physicians in private practice, who comprise at least 80% of doctors providing care on the frontlines.

Until pay is increased for present “independent” primary care doctors through commonsensical reforms and working conditions of these doctors is understood, the primary care shortage is unlikely to be alleviated, and expansion of access will be a pipe dream.

Dr. Richard Reece is author, blogger, speaker, and innovation and reform commentator. Dr. Reece’s latest book, Obama, Doctors, and Health Reform (IUniverse.com) is available at amazon.com and barnesandnoble.com. His blog is www.medinnovationblog.blogspot.com

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