Better care is primary

Globe Editorial

DoctorDR. JOSEPH PEPPE is happy to get help in repaying his medical school loans. He and 46 other primary care doctors received this benefit in exchange for agreeing to work at a Massachusetts health center for two to three years. “I very much enjoy the work I do,” he said a few days ago at the South Boston Community Health Center.

Loan repayments total up to $75,000 over three years. The program is a recognition that physicians need incentives to practice in primary care instead of a higher-paid specialty. A year or two longer in residency to become a specialist can result in a doubling of income, from perhaps $150,000 to $300,000.

Primary-care physicians are in short supply in high-cost Massachusetts. The state Medical Society reported last year that 51 percent of internists were accepting new patients, compared with 66 percent in 2005. Primary care ought to be widely available to cope with the influx of people newly insured under the 2006 Health Reform Law.

The health centers are in particular need because they usually pay less than physicians can earn in private practice. The Massachusetts League of Community Health Centers figures that its 52 centers, with 700,000 patients, have a 10 percent vacancy rate for primary-care positions.

The loan-relief program is a joint effort of the League; state government; Neighborhood Health Plan; Partners Healthcare; the Blue Cross Blue Shield Foundation; and the Bank of America Charitable Foundation, which contributed the largest share, $5 million. Local interventions like these, while welcome, don’t get at the root of the problem afflicting medicine throughout the United States: a piecemeal approach to reimbursement that elevates individual procedures by specialists over care coordinated by a primary-care doctor.

Medicare, the largest single payer of healthcare services in the country, inadvertently encourages uncoordinated, excessive care. In 1992 Congress established a physician payment system intended to limit costs, but the federal government gave advisory authority to a committee weighted in specialists’ favor. This committee offers payment recommendations for more than 7,000 different procedures, and the more physicians do, the more money they make.

To improve primary care, the federal government wants to add a management fee to the usual visit payment. An informal coalition of primary care providers favors an approach that does away with piecemeal reimbursement, which has led to rushed visits, reduced access, unhappy patients and demoralized physicians. The coalition is trying to get insurers in Massachusetts interested in a “Medical Home” model, in which primary-care practices would receive a comprehensive payment in return for high-quality, patient-friendly care.

A patient’s Medical Home would include a multidisciplinary team (say a nurse practitioner, nutritionist, and social worker), enhancing patient support while allowing the physician more time to take a patient’s history, diagnose his or her condition, devise a treatment plan, and provide unhurried explanations. In exchange for achieving better outcomes, the primary-care practice would get a higher overall payment from the insurer than under the current system.

This sounds a bit like the old managed care model, which physicians and patients decried in the 1990s for its inadequate payments and frequent denials of care. However, the coalition would make the payments higher and adjust them depending on how medically needy the patients are and how well the practice achieves good results. Last month the Capital District Physicians’ Health Plan, in Albany, announced a two-year trial in which they will implement the comprehensive payment plan.

Dr. Bruce Nash, medical director of the Capital District plan, said the Albany area is experiencing the same primary-care shortage as Massachusetts. For the Albany experiment to succeed, it must produce savings without diminishing the quality of care. “We can’t pay physicians more unless they create value,” Nash said.

The United States spends more per capita on healthcare than any other nation, yet doesn’t produce the best outcomes, and leaves 47 million Americans without health insurance. Specialists aren’t the villains here. They are essential for treating complicated conditions, but they benefit from a system that is badly out of whack.

Community health centers like the one in South Boston have been trying to provide a medical home for patients, many of them with low incomes, since the late 1960s. The US healthcare system has resisted extending a comprehensive model of care to all segments of society. The Albany experiment offers hope that incentives can be changed to improve the quality of medicine and provide more physicians with the job satisfaction that Peppe enjoys.

© Copyright 2008 Globe Newspaper Company.

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