The Medical Education Futures Study Blog

A brand new survey from the Kaiser Family Foundation, National Public Radio, and Harvard University add new input to the discussion about reforming the health care delivery system. While many academics and ivory tower intellectuals feel that in order to improve our health care system we must (1) improve the coordination of care (2) pay health care providers for quality and not simply for activity, and (3) ensure access to primary care, the American people describe their views on these priorities.

One way touted to improve the coordination of care is changing the practice of medicine from one where a “doc-in-the-box” practices in isolation to an integrated and electronically shared health care system. While three out of every four Americans realize that electronic medical records would be a major breakthrough for our health care system, they are not duped into thinking that health information technology would make our system cheaper. Even scientifically rigorous studies have failed to show significant cost improvements as a result of information technology; mixed results exist for the myriad of quality measures reported. However, it does not negate the obvious fact in the minds of many Americans and many physicians that 21st century medicine will require an integrated, interoperable, real-time information system. Surprisingly, over half of Americans do not think we even have a problem coordinating care. Almost every doctor I work with thinks otherwise.

Probably the largest challenge facing health reform (other than providing coverage to the uninsured) is how to compensate health care providers in a reasonable and fair manner. A large majority (70%) of Americans think that the best way to compensate physicians is by fee-for-service, where the doctor gets paid for every visit. One-quarter of Americans think that capitation is a better payment methodology. Perhaps private insurers (and for that matter Medicare, MEdicaid, and other public payers) should heed these numbers and provide a mixed reimbursement package based on both per-member-per-month calculations and utilization metrics. The remaining 5 percent of the doctor’s income could be determined by pay-for-performance measures.

The new Kaiser/NPR/Harvard survey does not explore the primary care workforce directly. But considering that Americans often have to wait for doctors appointments (I certainly see plenty of primary care type visits in the ER because “the doctor didn’t have an appointment available to see me”), we all know that we could use a few more primary care doctors. Better yet, we need these often poorly compensated physicians to serve in areas of the greatest need - urban enclaves and rural towns. I hope that the pollsters start asking questions about how to accomplish this difficult feat. If we simply follow the advice of the American people, fixing the health care system might not be so hard after all.

Cedric K. Dark, MD, MPH
Founder, www.policyprescriptions.org

The Medicare Payment Advisory Committee’s (MedPAC) March 2009 Report to Congress repeats its previous recommendation to Congress to:

1. Establish a budget-neutral primary care adjustment to the physician fee schedule
2. Direct the Secretary to adjust the calculation for the relative value units for expensive imaging machines in order to redistribute payments to other physician services.

Both are attempts to address Medicare physician fee schedule distortions which promote specialty care at the expense of primary care.

Since 1992, Medicare has relied on the Resource-Based Relative Value Scale (RBRVS) to determine the physician fee schedule.  Every physician service is assigned a relative value which is then multiplied by a conversion factor to determine the amount of payment.  The Relative Value Update Committee (RUC) advises the Centers for Medicare and Medicaid Services (CMS) on the work component of the total relative value of each new service and also assists with revaluing the work component of existing services. CMS itself is responsible for making decisions that determine the practice expense component of the total value of each of the 7000 services that CMS reimburses.

The RUC is sponsored by the American Medical Association and largely made up of members assigned by specialty societies.  Annually, CMS accepts more than 90% of RUC’s recommendations as part of a public rule-making process.  Fee schedule distortions which have emerged then are based on a combination of mis-estimates of work provided by the RUC and flawed assumptions about practice expenses that CMS has made. One might ask the question after 17 years of the Medicare Fee Schedule based on RBRVS why CMS still relies on estimates of components of the relative value units rather than empirical measurement. These empirical measurements would be available not only from other governmental units, such as the VA system, but also from health plans and providers. For example, why should Medicare pay on the basis of self-interested specialty estimates of the time it takes to perform a surgical procedure rather than actual “skin-to-skin” times and associated pre- and post-operative times available from actual OR logs.

Private insurers increasingly rely on Medicare’s RBRVS values in setting their own fee schedules. They have a direct stake in wanting the relative prices in the Medicare fee schedule to accurately reflect the real world – and, indeed, commonly complain that the Medicare Fee Schedule seems tilted in favor of technical and procedural services, while undervaluing primary care and evaluation and management services.  Yet, the private payers have been quiet about these perceived distortions, even as they rely on the Medicare relativities in their own negotiations with physicians.

MedPAC recently has taken up the issue of fee schedule distortions and there are signs that Congress is beginning to understand the problem.  The fact is that the Medicare Physician Fee Schedule is subject to notice and comment rule making, according to the Administrative Procedures Act, which guarantees that the public at large can have input into the rule making. As obvious stakeholders, purchasers’ and commercial insurers’ general and technical views would have to be given important consideration by CMS when reviewing RUC recommendations on work values and in its own estimates of practice expenses. The situation is not that of a single payer, imposing its bureaucratic will on the country — that then private purchasers and plans are stuck with.

The RUC is powerful but that is partly because other stakeholders have allowed it to be,   Thus far, the purchaser and plan community have appeared to opt out of the rule-making process, allowing the fee schedule to become overly responsive to specialist and corporate vendor interests.  CMS can’t easily reject RUC recommendations if no one else in the public — especially other affected stakeholders — don’t provide comments that reflect different perspectives and analyses from what the RUC process produces.

Bob Berenson, MD, Senior Fellow, The Urban Institute

The total number of PGY-1 residency positions offered and filled increased again this year, with 400 (1.9%) more PGY-1 positions filled.  However, despite a promising increase in family medicine position filled last year, the number of positions offered and filled is down again this year - 100 fewer positions were offered and there were 75 fewer positions filled (Figure).

Figure. Results of the NRMP, 1997-2009, for Family Medicine Positions Offered and Filled (Source: AAFP)

The number of internal medicine and pediatric positions offered and filled rose incrementally, but increases in these PGY-1 positions will not necessarily equate to more primary care as more and more of these residents are choosing to further specialize after their initial “primary care” residencies.

Congress is increasingly recognizing the physician workforce and medical student specialty choices as critical components to developing a health care system in the U.S. that is equitable, accessible and cost-effective.  But the 2009 Match is another step in the wrong direction and hopefully it sends a message.  The time to act is now.  

While much of the primary care stimulus funding was cut out in the Senate version of the Stimulus package, it was restored in a modified form in conference and signed into law by President Obama on February 17.  The final law gives a significant boost to community health centers - $500 million for services provided at CHCs and $1.5 billion for construction, renovation, equipment, and health information technology systems - and to the National Health Service Corps - $300 million for recruitment and field activities.  Primary care training funding received a modest boost of $200 million for Title VII and Title VIII of the Public Health Service Act and grants to training programs for equipment.

While increased support for CHCs and the NHSC are critical steps towards increasing care and access to underserved / uninsured communities, the relative levels of funding for these programs in comparison to the funding levels of the primary care training programs indicates a denial of what is and will be a core problem in providing health care to these communities and the nation.  Ultimately the question is - who will provide the health care that is funded through these programs?

CHCs and the NHSC rely heavily on primary care physicians to staff health centers and provide care in underserved areas.  But primary care is in crisis.  Medical students are entering primary care fields at all time low rates.  Yet the National Association of Community Health Centers (NACHC) report health centers currently need over 1,843 primary care providers and if they are to increase their reach, they will need over 15,000 additional primary care providers by 2015.

Solving the primary care problem in the U.S. will require changes in the physician payment system to reduce the income gap between primary care and specialist physicians and changes in the physician practice to maximize evidence based, quality care.  However, changes also need to happen in the primary care pipeline to ensure future medical students will choose to enter primary care fields and be ready to practice in the changing health system.  Many factors have been shown to promote primary care field choices - such as recruitment of students who intend to practice primary care, positive primary care experiences during medical school and strong primary care faculty - all of which are currently supported by Title VII grants.

Change needs to happen across the spectrum of the physician workforce - from practice and payment to recruitment and education.  It’s time to prioritize this issue and recognize the quick fix of funding CHCs and NHSC, without building the primary care workforce, will only lead to a future collapse of the system… to bright shiny health centers without the people to provide the health care within.

The current House Stimulus Package specifies $600 million dollars for strengthening primary care.  The funds are specifically targeted for:

• Training primary care nurses, physicians, and dentists under Title VII and VIII of the Public Health Service Act.
• The provision of health care personnel under the National Health Service Corps.
• The patient navigator program under Title III of the PHS Act.  

The Senate version maintains the $600 million for primary care training without the specificity of where the funds will be directed.

What would $600 million do for primary care?  

Based on FY08 appropriation levels for each of the specified House programs, distributing the stimulus funds based on the current distribution of appropriations and assuming a 2 year distribution of stimulus funding, the package would nearly DOUBLE each programs annual funding if baseline appropriations are maintained at the FY08 funding level.

The stimulus is a start and an opportunity to build these into the robust programs they need to be in order to truly address the problems of primary care, underserved areas, and health care disparities that are persistent and growing problems in the US health care system.

It almost makes too much sense. Students with more debt should choose higher paying specialties than students with less debt. Therefore, we should reduce the debt load of students to increase the likelihood that they enter primary care fields.

Although this argument is sound, it is not valid because a number of studies have demonstrated that debt level has little, if any, influence on students’ residency and career choices (1). If anything, those with MORE debt may choose primary care residencies more often than those with less debt (2).

While I am not advocating the doubling of tuition and fees of medical school attendance, I do want to ensure that we have enough primary care providers to meet the needs of patients in our current and any reformed healthcare system. Increasing their number will make health care reform more effective and more efficient. The question asked, then, is how set up systems that reproducibly increase the number of medical students choosing careers in primary care.

Reframing the aforementioned findings can help us propose such systems. One way to look at the findings is that is to realize that students choose to enter a primary care field (pediatrics) even at high debt levels. Our task is to find people who are intrinsically interested in pursuing such career paths.

A study published over a decade ago observed that students from rural regions and those who are underrepresented minorities are more likely to pursue primary care and work in environments with relatively less resources, respectively (3). Without spending any money, admissions committees at schools whose mission it is to educate the primary care providers of tomorrow could redouble their efforts to identify such students.

Once again, the challenge appears to be deceptively simple. If our goal is to have increasing numbers of medical students pursuing primary care then we should recruit and train those who want to pursue primary care. Combining these recommendations with ongoing empirically-derived efforts will help us to provide even better care for our patients.

David E. Myles, MS III

Yale University School of Medicine

1. Grover A. When Money Doesn’t Change Everything. Annals of Internal Medicine. 2008; 149 (6): 429-430

2. Jolly P. Medical School Tuition and Young Physician Indebtedness. AAMC. 2004: 1-25

3. Senf JH, et al. A Systematic Analysis of How Medical School Characteristics Relate to Graduates’ Choices of Primary Care Specialties. Academic Medicine. 1997; 72 (6) 524-533.

As President Elect Obama prepares to assume office he faces unprecedented challenges, including the worst economic crisis in decades, military conflicts and a volatile international arena.   Winning with a platform promising change, government accountability and educational and health equity for all, expectations for the new president are unlike any before.

As this new administration begins to build a domestic policy agenda, health reform - and its choking economic impact- will be a first priority. We now know this effort will be capably lead by soon-to-be Secretary Tom Daschle.  If he can keep to his core vision that any re-crafting of our health system must be comprehensive and heavily weighted in favor of outcomes and effectiveness, then efforts to address lack of health insurance, high (and rising) costs of care, access to care, improving quality and reducing medical errors, may be within our collective reach.  However, central to addressing any and all of these broken, costly components of our health care system is, having an adequate number of scientifically well-trained, culturally – competent, racially and ethnically diverse health professionals.   

Today we have a significant , and  in some cases and places, desperate shortage of health professionals in nursing, medicine, pharmacy, public health and other health professions.

To make our healthcare system “work” – to make it a cost effective, outcomes driven system that can deliver quality care to ALL our citizens,  policy reforms are needed that can begin to immediately address this lack of trained manpower.

The increasing diversity of our nation’s population makes it imperative that efforts be made to develop a health workforce which is more diverse – racially, ethnically, and culturally.   One of the commentaries in The Sullivan Commission 2004 report, Missing Persons: Minorities in the Health Professions, was “the fact that the nation’s health professionals have not kept pace with changing demographics may be an even greater cause of disparities in health access and outcomes than the persistent lack of health insurance for tens of thousands of Americans.” 

Just last Friday, December 12^th, 2008,  a new report released by the Institute of Medicine, HHS in the 21^st Century, Charting a New Course for a Healthier America  identified “Strengthening  the HHS and U.S. public health and health care workforces” as one of   five key areas for recommended action.   

We have a new administration with a public commitment to develop a diverse, well trained health professions’ workforce to support our citizens in the 21^st century.

I am personally encouraged by the steps being taken by the President Elect and his senior leadership to engage the country in this crucial process.  I look forward to supporting policy changes that will directly and immediately begin to address and to close significant gaps in our nation’s health care workforce.

Louis W. Sullivan, M.D.

Chairman

The Sullivan Alliance 

With support from the Kellogg Foundation, The Sullivan Alliance was formed in 2005 to address the need for more diversity among the nation’s health professionals in efforts to improve access to health services for medically – underserved populations

In 1954, Darrell Huff wrote a book entitled, “How to Lie with Statistics” which suggests the way statistical analyses are chosen and presented can bend the truth.  This month’s Health Affairs web exclusive suggests we could all use a review of this lesson.

On Dec. 4, Health Affairs released a package of web exclusives - a sort of point-counterpoint examining the relationship between physician supply, workforce composition and health care quality.  Buz Cooper’s article: States with More Physicians Have Better Quality of Health.  Baiker and Chandra’s response: Cooper’s Analysis is Incorrect.

For the non-statistician, Baiker and Chandra’s arguments are at times confusing and Cooper’s graphics appear compelling.  Cooper finds that states with more physicians per capita generally rank higher in state health care quality rankings.  He also finds that states with more specialists are associated with higher state incomes per capita. 

But, does this mean that more specialists result in better quality (Figure A) or does it mean that higher income results in better quality and incidentally more specialists (Figure B)?  Where is the true causal relationship?  Are more specialists only a representation of higher income and otherwise unrelated to quality?

In this case, income might be considered a “confounding factor” – in other words, income is related to both quality and the number of specialists, and the failure to control for income in the analysis may lead to an inaccurate conclusion that more specialists equals better quality.  These are hypothetical arguments.  I have not done the analysis either to support or negate Cooper’s arguments.  However, Baiker and Chandra find that when they compare areas with the same number of total physicians, areas with higher generalist to specialist ratios have better quality and lower costs.

State by state a health care service crisis has emerged. There are not enough primary care physicians to care for the people in our communities. Providing health insurance to all will not address the problem. Insurance will not suffice when there are not enough primary care physicians to provide the needed care.

The short supply of primary care physicians has been caused by a long term decline in the numbers of students choosing careers in primary care. The primary care specialties of Family Medicine, general Internal Medicine and general Pediatrics have each experienced a decline. The deans of most medical school hide this issue by telling the public that they graduate sufficient numbers of graduates to the primary care specialties. By counting all students who choose careers in Family Medicine, Internal Medicine and Pediatrics (some even include students choosing OB/GYN) to their primary care head count, the deans and the organizations that represent them have misled the public.

For decades, a growing percentage of those entering Internal Medicine and Pediatric residency programs have added fellowship training to their preparation so they can practice in a sub-specialty field when they enter practice. Currently, only 10% of those choosing Internal Medicine residency training will practice as a primary care physician. In Pediatrics 65% of the graduates of a residency programs will practice in primary care

The deans respond to their critics by claiming that they are not responsible for the choices of their graduates. They argue that it is the marketplace and not the medical school that is responsible. Their graduates choose sub-specialties because they will earn a substantially higher income as a sub-specialist.

No doubt the marketplace plays a role but so do the deans and the leadership of their medical schools. At a recent meeting of the Society of Teachers of Family Medicine: NorthEast Region in Baltimore, MD, a series of speakers addressed these issues. Representatives from Jefferson Medical Center, Boston University, the National Association of Community Health Centers and others provided a compelling response to the deans. In sum their data indicates that when a medical school creates a program that selects and supports students with an interest in primary care and practice in a rural community, substantial numbers of graduates will choose to practice in primary care following their residency training. This approach has been demonstrated in a number of medical schools across the country.

The deans wish to attract the best and brightest students to their schools. The problem is how they measure the students’ suitability and the people they choose to rank the candidates. High grade scores and high MCAT scores are insufficient measures of future performance. In addition, a selection process overwhelmingly dominated by basic science and sub-specialty faculty members is also problematic. The first principle of selection is that people have a strong tendency to pick candidates who “look like” themselves. If you want to select a pool of students who will later choose sub-specialist careers, ask a group of sub-specialists to interview and rank the candidates.

It is time for the deans to take responsibility for who they select as students and how they support their students’ career development. The programs that select students who are likely to practice as primary care physicians actually deliver the goods. Every medical school is capable of producing the students needed to serve through careers in primary care and as future physician investigators.

Given the deans efforts to increase their class sizes it would make sense that they designate a portion of the growth to a program that selects and supports students interested in primary care. It’s time to stop pretending they have no options. The deans can satisfy both their inner yearnings to produce sub-specialists and physician investigators and the public’s need for physicians who will care for the people. Acting as though this is an either/or issue when it is a both/and issue, reveals a lack of imagination. Our medical schools can do better.

Laurence Bauer, MSW, MEd is Chief Executive Officer of the Family Medicine Education Consortium (www.fmec.net) a not-for profit organization that supports the growth of academic family medicine in the northeast region of the US. He can be contacted at laurence.bauer@sbcglobal.net

On Nov. 10, the Wisconsin Council on Medical Education and Workforce released an update to its 2004 report Who Will Care for Our Patients?  The report is well researched and well thought out.  It concludes Wisconsin has a current maldistribution of physicians within the state and a current shortfall of 374 primary care physicians.  However, one of the report recommendations particularly struck me.  The recommendation -

     Attract physicians to Wisconsin and keep them here.

In fact, the physician workforce issue is a national issue.  In Oct. 2008, the AAMC reported on 22 state reports on physician shortages and 5 national studies on the physician workforce.  Simply pulling physicians to our own state of choice will not solve the problem.

Wisconsin is at the head of the class on the physician workforce issue.  The very existence of the Council on Medical Education and Workforce, a result of the 2004 report, is an indicator of the level of collaboration of both private and public organizations within the state to address this critical issue.  And it is appropriate to have state level organizations examining this issue, as physician workforce needs will vary depending on current state and local workforce compositions and needs for healthcare.  But the question is - if Wisconsin is successful, what happens to the workforce needs and the health status of the states they recruit from?

The Wisconsin recommendation points to the need for a national level “council” to develop a US physician workforce that meets the needs of all states and communities.  It is quickly becoming clear that a well thought out physician workforce will be a critical component to any kind of health care reform.  It’s time to make this issue a priority and develop a national level health care workforce institute with the funding and political will needed to provide the research, analysis and guidance to create this workforce.