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Our U.S. system pays much more for procedures than for the medical management of illness. In my specialty of orthopedics, Medicare will approve a charge of approximately $60 for my most common office visit but will permit a charge of over $350 for carpal-tunnel-release surgery and over $1,100 to fix a fractured hip. The carpal-tunnel procedure takes me as long as a simple office visit, whereas the hip surgery routinely requires the time of three patient visits. The great extent of these variations in reimbursement cannot be rationally justified.
Addressing these inequalities must be a part of any health care reform package. Our country cannot tolerate a reduced supply of primary care physicians and the corresponding decreased health of our citizenry. We specialists should be quite proud of the enormous contributions that we make, but we cannot claim that our therapies are more important than the medical management of illnesses such as heart failure and diabetes. We need to view reimbursement from the vantage point of our primary care colleagues; specialty physicians have long opposed Medicare's relatively modest sustainable-growth cuts in reimbursement. Can we envision accepting a 60% cut? We would never willingly tolerate that level of compensation, but it is the current average for family physicians.6 In a recent survey of primary care physicians, only 17% felt that their practices were "healthy and profitable."5 Specialists should support reimbursement rates that close the gap among physicians and thereby improve the viability of primary care. Although new rates would come at a cost to specialists, the benefit to our patients' health must be our primary concern.
James Rickert, M.D.
Society for Patient Centered Orthopedics
Bloomington, IN
jrickert1123{at}comcast.net
References
Potential primary care physicians are lost at two critical branch points. The first occurs during medical school, when many students match directly into subspecialties. The second occurs later, during residency, when trainees rely on on-the-job experience to inform decision making. Here, a number of frustrations seemingly underlie my generation's avoidance of primary care practice, and not just the ones mentioned in recent survey literature.2 With many resident clinics being understaffed and serving impoverished populations, the frustrations of modern primary care practice are amplified exponentially for us, and the true joy of caring for patients becomes obscured.
Further inquiry, beyond surveys, is needed. In learning more about the experiences of modern trainees, we stand to learn more about potential solutions. Unfortunately, no one seems to be asking us directly.
Thomas W. LeBlanc, M.D.
Duke University Medical Center
Durham, NC
thomas.leblanc{at}duke.edu
References
Norman H. Edelman, M.D.
Stony Brook University
Stony Brook, NY
norman.edelman{at}sunysb.edu
References
We agree with Edelman that nurse practitioners and physician assistants are key contributors to the primary care workforce and perform as well as physicians in many primary care tasks. But primary care is as broken for nurse practitioners and physician assistants as for physicians. The percentage of physician assistant graduates entering primary care is consistent with the trend for the percentage of medical school graduates entering primary care — each shows the same steep drop. Data are less clear for recent nurse practitioner graduates, but there is suspicion that a growing percentage of these clinicians are also entering specialty practice. We need to develop and pay for new models of practice that make primary care a more hospitable and satisfying career for clinicians of all stripes — physicians, nurse practitioners, physician assistants, and other professionals and staff members collaborating in these practices. Primary-care-team models are evolving in which physicians, nurse practitioners, and physician assistants provide clinician-level services, with other team members — registered nurses, pharmacists, medical assistants, and health coaches — taking on delegated roles in routine long-term and preventive care services.
Despite the partisan rancor evident in the current health reform debate, there are portions of health care reform bills that everyone can agree with — increasing financial investment in primary care, transforming primary care practices throughout the country into high-performing patient-centered medical homes, and launching a nationwide system of primary care extension agents (practice facilitators) to assist practices in making needed improvements.1
Thomas Bodenheimer, M.D.
Kevin Grumbach, M.D.
University of California, San Francisco
San Francisco, CA
Robert A. Berenson, M.D.
Urban Institute
Washington, DC
References
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