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Primary healthcare services crisis - how does Obamacare address it?
Posted on 11/17/14 at 10:05 am
Posted on 11/17/14 at 10:05 am
Since Medicare sets low reimbursement rates for regular office visits to primary care physicians, do major health insurance companies follow their lead in negotiating reimbursement rates? It seems like the name of the game for PCPs is patient volume….meaning less time with patients, increased wait times, large service providers with outsourced back office/administrative work, far less patient interaction (which I know motivates many family practice, internists, and pediatric physicians), and much longer hours. It’s no mystery why fewer and fewer MD and DO school graduates are going into primary care roles.
Is there a solution to this problem, such as student loan forgiveness packages or expedited training programs for certain primary care specialties? How does Obamacare address the primary healthcare services crisis that many parts of this country has experienced over the past couple of decades? It almost seems like it would exacerbate the problem and continue chasing talented medical professionals into more specialized fields.
Perhaps someone in the know could address this. I know we have a few physicians and nurses that post here that could possibly shed light on this. It seems like real medical care reform would not be complete without addressing primary health care services.
Is there a solution to this problem, such as student loan forgiveness packages or expedited training programs for certain primary care specialties? How does Obamacare address the primary healthcare services crisis that many parts of this country has experienced over the past couple of decades? It almost seems like it would exacerbate the problem and continue chasing talented medical professionals into more specialized fields.
Perhaps someone in the know could address this. I know we have a few physicians and nurses that post here that could possibly shed light on this. It seems like real medical care reform would not be complete without addressing primary health care services.
This post was edited on 11/17/14 at 10:13 am
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Posted on 11/17/14 at 10:09 am to dewster
quote:Accuse doctors of racism if they don't go primary care route
Is there a solution to this problem?
Posted on 11/17/14 at 10:15 am to dewster
quote:
Since Medicare sets low reimbursement rates for regular office visits to primary care physicians, do major health insurance companies follow their lead in negotiating reimbursement rates?
CMS has increased PCP reibmursement as a part of Obamacare, but that increase has been immediately nullified by federal "incentives" that require significant capital outlay to implement them. EMR implementation, meaningful use, PQRS reporting, etc... all cost a shite ton of money and human capital, and offices with 3 or less physicians don't have the economies of scale to pull them off. So they are hit with a 1% reduction in CMS reimbursement for each incentive they can't meet...and there goes the increased reimbursement.
Private payers do follow CMS with regard to pricing, usually + 3%-8%.
quote:
Is there a solution to this problem?
More residency opportunities for primary care? Better tuition reimbursement programs for med students who go into primary care? Redesign some of the EMR incentive programs to accomodate small practices? Increas reimbursement for consult and f/u codes for PCPs?
quote:
How does Obamacare address the primary healthcare services crisis that many parts of this country has experienced over the past couple of decades?
Pilot payment systems based on quality (won't work) and slightly increase reimbursement for PCP's.
quote:
Would real medical care reform be complete without addressing primary health care services? How would Washington go about encouraging more medical professionals to enter primary care specialties? Is that even possible?
Yes, primary care would need a revamp for any successfull healthcare "redesign", but we seem to just be headed for primary care provided by mid-levels with minimal phsyicians supervision.
Which personally, I'm fine with, but I'm a 35 year old healthy person with connections to many medical specialties and a PA for a wife.
I'm not sure the 68 year old diabetic with COPD and an abnormal liver panel wants his treatment from a NP or PA.
ETA: Medicaid is also a HUGE problem for PCP's. MCD reimbursement does not cover the cost of providing care, forcing docs that see mostly MCD patients to herd them through clinic as fast as possible in order to simply break even. Obamacare has only made this problem much worse by adding so many uninsured to MCD rolls. Particularly when most PCP's won't even take it at this point if they don't have to.
This post was edited on 11/17/14 at 10:20 am
Posted on 11/17/14 at 10:19 am to MSMHater
Your post has so many acronyms I gave up after the first paragraph.
Posted on 11/17/14 at 10:23 am to Al Dante
shite, sorry! 
PCD =- Primary care physician
PQRS = Physician quality Reporting System
ACA = Obamacare
NP = nurse practitioner
PA = Physician assistant
EMR = Elec medical record
COPD = chronic obstructive pulmonary disease
PCD =- Primary care physician
PQRS = Physician quality Reporting System
ACA = Obamacare
NP = nurse practitioner
PA = Physician assistant
EMR = Elec medical record
COPD = chronic obstructive pulmonary disease
This post was edited on 11/17/14 at 10:23 am
Posted on 11/17/14 at 10:25 am to MSMHater
quote:
Pilot payment systems based on quality (won't work) and slightly increase reimbursement for PCP's.
So basically nothing is really changing?
quote:
Which personally, I'm fine with, but I'm a 35 year old healthy person with connections to many medical specialties and a PA for a wife.
I'm not sure the 68 year old diabetic with COPD and an abnormal liver panel wants his treatment from a NP or PA.
I agree completely. I don't see much of an issue with going that route, but as you've said, I can see the concern with a very diverse patient load.
Wouldn't this eventually push PAs and NPs out of traditional family medicine much the way they are currently chasing MDs and DOs into more specialized practices without some added incentive to move into primary care specialties?
quote:
Medicaid is also a HUGE problem for PCP's. MCD reimbursement does not cover the cost of providing care, forcing docs that see mostly MCD patients to herd them through clinic as fast as possible in order to simply break even. Obamacare has only made this problem much worse by adding so many uninsured to MCD rolls. Particularly when most PCP's won't even take it at this point if they don't have to.
This is also my concern. The added MCD patient rolls would hurt the bottom line for primary care professionals such as your wife, thus providing less incentive to enter primary care specialties out of allopathic/osteopathic medical schools, PA schools, or nursing schools.
This would hit the rural area like my home town especially hard. It's not uncommon for my parents to have to wait a week or more to see their doctor for a 10-15 minute appointment.
quote:
MSMhater
Thanks for the insight.
This post was edited on 11/17/14 at 10:38 am
Posted on 11/17/14 at 10:29 am to dewster
quote:
Is there a solution to this problem, such as student loan forgiveness packages or expedited training programs for certain primary care specialties?
Yes, plus increase reimbursement. The life of a PCP under ACA is not an easy one, and telling a med student to accept that for 150-180K when they could do a surgical subspecialty for 350K will yield the current results.
Posted on 11/17/14 at 10:35 am to dewster
quote:
Wouldn't this eventually push PAs and NPs out of traditional family medicine much the way they are currently chasing MDs and DOs into more specialized practices?
Nah. They can specialize in the same way a phsyician can. My wife is a fellowship trained hepatology PA. She would have no business seeing you in a primary care setting, but she can get you a new liver. Honestly, I believe prgrams are actively encouraging mid levels into primary care fields b/c they know the situation at hand, and it's really eazy to find opportunities in primary care for mid levels right now.
quote:
So basically nothing
Correct
quote:
My wife is starting med school next year (and seems to be interested in pediatrics),
Pediatricians are pediatricians b/c they love treating kids. There is very little money to be had (relative to hours worked) simply as a Pedi. She would need to further specialize (i.e. Pedi-onc, Pedi-ortho, etc...) to make good money.
quote:
and I'm trying to develop an opinion on the challenges PCPs face in today's medical field and I'm trying to understand what impact Obamacare would have on the PCP shortage (particularly in rural areas).
As people are charged more and more for insurance, they are eventually going to get tired of that and just pay the doc directly to keep him on retainer. Without change, that is the direction we are headed. Boutique/Concierge practices for the "wealthy", and long lines for access to mid levels or foreign graduates for people with insurance.
Foreign medical graduates already make up a staggering percentage of rural physicians. I'll see if I can find the data.
ETA: 19.3% of rural physicians are foreign medical graduates. LINK
This post was edited on 11/17/14 at 10:39 am
Posted on 11/17/14 at 10:46 am to MSMHater
quote:
Nah. They can specialize in the same way a phsyician can. My wife is a fellowship trained hepatology PA. She would have no business seeing you in a primary care setting, but she can get you a new liver. Honestly, I believe prgrams are actively encouraging mid levels into primary care fields b/c they know the situation at hand, and it's really eazy to find opportunities in primary care for mid levels right now.
What do you mean by "mid levels"?
quote:
19.3% of rural physicians are foreign medical graduates
Thanks for the link. I see where it says that allopathic physicians specializing in internal medicine and osteophatic physicians make up 19.3%....but I'm trying to find the stat for foreign medical graduates. Please forgive me for not understanding clearly....but by foreign medical graduates, I'm assuming you mean from medical schools outside of the US?
I'm not kidding when I say that my parents are, at any given time, a week away from seeing their PCP, who can't be more than a few years away from retirement. They hardly ever go to the doctor, which is kind of shocking for their age.
I know Louisiana, Indiana, Oregon, and Tennessee all have reimbursement programs for physicians that practice in rural, under served areas. It doesn't seem to be working very well from my perspective.
This post was edited on 11/17/14 at 10:49 am
Posted on 11/17/14 at 10:47 am to MSMHater
quote:
Foreign medical graduates already make up a staggering percentage of rural physicians. I'll see if I can find the data.
And as we continue with this PCP shortage, expect this to increase. There are only so many ACGME accredited med schools in the US, the demand could never be met. Plus, its much easier for foreign grads to match into primary care US residencies from a competitiveness standpoint then compared to the other specialized fields.
Posted on 11/17/14 at 10:47 am to dewster
quote:
What do you mean by "mid levels"?
NPs, PAs
Posted on 11/17/14 at 10:50 am to onmymedicalgrind
quote:
its much easier for foreign grads to match into primary care US residencies from a competitiveness standpoint then compared to the other specialized fields.
Didn't know that. Why?
Their curriculum?
Posted on 11/17/14 at 10:52 am to dewster
quote:
but I'm trying to find the stat for foreign medical graduates.
quote:
DOs comprised 4.9% and IMGs 22.2% of the total clinically active workforce. However, they contributed 10.4% and 19.3%, respectively, to the rural PCP workforce,
IMG's = Foreign grads
Posted on 11/17/14 at 10:52 am to MSMHater
quote:
Didn't know that. Why? Their curriculum?
No its simply a product of the fact that many of the more competitive fields just do not rank foreign MDs high (if at all). If you are an international MD you can forget matching in a field like derm, ortho, ent, etc. Contrast this with a field like family medicine, which is loaded with foreign grads.
Posted on 11/17/14 at 10:53 am to MSMHater
quote:Yep..see it now. I was reading that as internal medical grads, which I figured was a typical DO or MD specializing in internal medicine. Thanks for the correction.
IMG's = Foreign grads
My wife works at a Level 1 Trauma Center staffed with allopathic and osteopathic physicians from all over the country.....and one or two allopathic physicians they have are from Caribbean schools. I didn't know there were so many of them.
quote:
DOs comprised 4.9% and IMGs 22.2% of the total
clinically active workforce. However, they contributed 10.4% and
19.3%, respectively, to the rural PCP workforce, although their relative
representation varied geographically. DO PCPs were more
likely than allopathic PCPs to practice in rural places (20.5% versus
14.9%, respectively). IMG PCPs were more likely than other
PCPs to practice in rural persistent poverty locations
Not that there is anything wrong with IMG, but I had no idea that there were so many of them.
quote:
Correct
I'm shocked that we'd go through this entire ACA ordeal with a claimed effort to "fix" our "broken" medical system, but not do a damn thing about increasing medical school enrollment or incentivizing primary care specialties in any way, shape, or form.
I don't know how anyone would honestly categorize Obamacare as health care reform.
This post was edited on 11/17/14 at 11:05 am
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