Why there's a shortage of primary care doctors

Two recent articles illustrate how healthcare policy consistently creates barriers to advancing primary care.

In the first, Debra L. Glasser, MD boldly declares that internal medicine primary care is dead, and she offers a powerful summary of the reasons for the decline:

"Why are they not choosing primary care? Primary care is the lowest-paid specialty at a time when medical education is not strongly subsidized (medical students can incur up to $500K of debt). It no longer offers professional satisfaction, continuity of care, and collegiality.

Primary care physicians are the most overburdened by administrative tasks. They are increasingly pressured to see more patients in shorter time slots, and it feels impossible to offer quality care. Many work for large systems where they feel powerless to effect change.”

The second article by Randy Dotinga reports on recent research documenting the excessive burden of numerous and diverse quality measures required of physician value-based programs. One physician group had 57 different quality measures across multiple insurers. The research concluded that “The magnitude of that number surprised us…Primary care physicians and their practices have a lot on their plate. Now we know one of those things is a very large number of different quality metrics to pay attention to, measure, report on, and implement.”

By the way, there is little evidence that using these burdensome quality measures improves the quality of care.

In summary, we have a severe and increasing shortage of primary care physicians to serve the growing elderly population, and we have intentionally created a health policy to make it worse. We need to immediately start creating health policy to promote and support primary care physicians. That policy needs to pay them better and dramatically simplify their work environment. My book The Journey’s End offers one path to make that policy a reality.

The Problem Isn’t So Much Insurer Vertical Integration as it is the Use of Coding to Measure Risk for Payments

The recent New England Journal of Medicine article on the dangers of private health insurer vertical integration/consolidation raises critical issues for health policy. Ironically, a recent investigative Wall Street Journal article also raises concern about the dominance of the private health insurer United Healthcare. The NEJM article describes the issues well in their title: The Dangers of United Healthcare for All.

One of the critical points of both articles is the explosion of Medicare and Medicaid patients being converted into private insurers - and United Healthcare leads the conversion. This privatization of government insured patients was meant to encourage competition, improve quality and lower costs. Of course, none of these benefits have materialized. The evidence suggests that the government pays more for these patients' care in private insurance. The quality of care declines and importantly, the caregivers are paid less by private insurers than they were by the government. At the same time we are “placing a handful of insurance companies in control of the healthcare delivery system.” 

Sadly, the remedies offered in both articles will not work because they don’t understand the real causes of the poor results. 

Coding makes healthcare payments insanely complex and the cost of the coding is not worth the results. Coding complexity invites fraud. Private insurers use coding to make everything more complex - the denial claims, the denial of coverage and the level of payments. The private insurers use coding complexity to justify these activities and to optimize their profits. More coding changes, more fraud oversight and more antitrust oversight will not fundamentally fix the abuses of coding complexity - we have decades of experience to demonstrate these remedies do not work. 

Serious reform efforts need to focus on simplification and the reduction of coding to determine provider payments and insurer premiums. These adjustments will reduce insurers' abuse of the system, improve quality, and lower costs. Go to www.thejourneys-end.org for more details on these solutions.

Coding corruption and the lost billions

This Wall Street Journal article (Insurers Pocketed $50 Billion From Medicare for Diseases No Doctor Treated) is exceptionally well done and more importantly, it accurately diagnoses what is wrong with the US health system:

When Congress conceived of the Medicare Advantage program decades ago, the hope

was that insurers would make Medicare more efficient. In traditional Medicare, doctors

and hospitals get paid for each service they provide, an incentive to offer more. The idea

behind Medicare Advantage was to pay private insurers a lump sum to cover all services,

giving them an incentive to keep patients healthier.

To protect insurers from the risk of winding up with sicker-than-average patients, the

government allowed bigger payments for certain serious health conditions.

Partly because of that, Medicare Advantage has cost the government an extra $591billion over the past 18 years, compared with what Medicare would have cost without the help of the private plans, according to a March report by the Medicare Payment Advisory Commission, or MedPAC, a nonpartisan agency that advises Congress. Adjusted for inflation, that amounts to $4,300 per U.S. tax filer.

The most critical problem in healthcare today is the corruption of the payment system,

which is complex coding. It has destroyed primary care and hospice and invited massive

fraud into health care. The article does a great job making the point that coding invites fraud:

John Gorman, a former Medicare official and founder of two companies that review

records and conduct home visits on behalf of Medicare insurers, says “Any time you base a system like this on diagnosis codes, there’s going to be rampant abuse of the system. [Insurers] will find something else to make up the revenue.”

The article artfully illustrates how private insurers use coding to increase their payments -

and defend it as appropriate. Medicare has known this abuse has been going on for years.

But they are unable to prove the abuse. Why? Because coding complexity is full of gray

space. The abusers live pretty well in that gray space.

The only problem with the article is that it offers no meaningful solutions. More fraud

oversight by Medicare will fail because of the inevitable gray space in coding. There are meaningful solutions to the problem - beginning with eliminating coding from the payment formulas. My website offers more details on eliminating this fraud and improving healthcare.