UCSF study: Lower pay for primary-care doctors threatens system

San Francisco Business Times
by Chris Rauber

The number of U.S. medical students choosing careers in primary care or family practice medicine has drastically fallen in recent years, threatening the stability of the overall health-care system, according to a study released Tuesday by the University of California, San Francisco.

This “impending crisis” is largely caused by a significant and widening income gap between primary care physicians and specialists, said Thomas Bodenheimer, M.D., MPH, a UCSF professor of family and community medicine.

Bodenheimer discussed results of this gap in the Feb. 20 issue of the “Annals of Internal Medicine,” as lead author of a perspective piece on the topic. “We are seeing a resulting decrease in the population of primary care physicians,” Bodenheimer said. “Payment reform to narrow the income gap is essential if the United States is to maintain a good primary care base and a cost-effective health-care system.”

Medical specialists earn almost twice as much as primary care physicians for working the same number of hours, according to UCSF. A 30-minute routine procedure performed by a specialist, for example, is often reimbursed two-and-a-half to three times the amount paid to a primary care physician who spends the same amount of time with a complicated patient.

The impact is particularly acute in the Bay Area, where similar trends, together with the high cost of living have made it difficult for many medical practices to attract young primary care doctors. That’s given an advantage to huge systems like Kaiser Permanente and Sutter Health that use the medical foundation model to pay young primary-care doctors more and provide more income security and benefits than many much smaller groups. But Bodenheimer told the San Francisco Business Times Tuesday that even Kaiser is concerned about the trend. “They’re very worried about the (primary care) pipeline,” he said.

“It’s really a problem in San Francisco” proper, Bodenheimer added. He left private practice four years ago, when he joined the UCSF faculty, and his former medical practice still hasn’t replaced him, “and they’re tried and tried and tried.”

Many medical practices in San Francisco aren’t accepting new patients, due to a lack of primary care doctors, he told the Business Times.

Past studies have shown patients with a regular primary-care physician have lower health care costs than those without, and health-care costs are lower and quality is higher in geographic areas with more primary care physicians, Bodenheimer said.

Bodenheimer’s article comes in the wake of a similar warning of an “impending collapse” of adult primary care made last year by the American College of Physicians. In 1998, it noted, 54 percent of internal medicine trainees planned careers in primary care rather than specialty medicine. By 2004, that had dropped to just 25 percent.

Similarly, the percentage of medical school graduates choosing family medicine fell from 14 percent in 2000 to eight percent in 2005. As a result, Bodenheimer argues, patients are having an increasingly difficult time finding a primary care physician, waiting times for appointments are growing, and some patients may have compromised outcomes due to the short, rushed office visits that physicians must maintain in order to stay afloat financially.

In his article, Bodenheimer blames several factors for the growing gap, including what he considers the limited usefulness of the “resource-based relative value scale” or RBRVS, a system designed in the early 1990s to lessen the fee disparity between office visits and specialty procedures.

Since its implementation in 1992, however, the RBRVS system has failed to decrease the income gap, he said, in part because the process for reviewing and updating physician fees is heavily influenced by a specialist-dominated committee of the American Medical Association.

Other factors include the growing volume of specialty services such as diagnostic and other imaging procedures, which are increasing more rapidly than office visits, contributing to faster income growth by specialists. Private insurers also tend to reimburse specialists at higher rates than primary care physicians.

His proposed solutions include in the short term, changing the composition of the AMA committee that reviews and updates physicians’ fees, and inspiring the federal Medicare system to take action. “Medicare has to get more involved in this,” Bodenheimer told the Business Times. “We need a policy on primary care. Otherwise, it’s going to die.”

Longer term, he suggests, some specialties may need to take drastic cuts in pay, and the nation may need to revisit some of the cost-cutting mechanisms that have worked to some extent in California, such as HMO-style capitated payments to doctors, rather than fee for service.

“Patients, specialists and the entire health care system need a healthy primary care base,” said Bodenheimer. “Unfortunately, primary care practice is not viable without a substantial increase in resources for primary care physicians.”
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