AMSA Follies: Primary Care and Health Policy

A pair of physician-researchers from an AAFP-funded research institute spoke about integrating a career in medicine with a career in policy research. That was interesting to me as a medical student, but of general policy interest was their take on the future of primary care:

• They were surprisingly genial about specialists, and avoided playing the blame and recrimination game. This was welcoming and refreshing. Medicine is divided enough as it is.
• They count Nurse Practitioners and Physician Assistants as primary care providers. I would think that this undermines their cause slightly (“hey, if non-physicians can do the job…”), but I’m sure they have their reasons.
• I overheard one of the speakers talking to a student in the hallway after the main presentation. I caught a bit of their discussion about Qliance. They were both of the opinion that that sort of market-based, patient-centred model will be important to revitalizing primary care. The AAFP speaker was trying to cram the Qliance model into the “ACO” box, but hey… no one’s perfect. It’s great to see some of the professional societies recognize the need to get off the government-dependence gravy train before it derails completely.

Also of note was the following… special moment: one of the students in the audience objected strenuously to the speakers’ use of “industrial,” “corporate” terms like — wait for it! — “supply,” “demand,” “surplus.” He wanted to know how the sky would keep from falling so long as we keep referencing “that paradigm.”

Oy.

What one hand giveth, the same hand taketh away

Here are two health policy developments from the past week… near-poetic juxtaposition:

Via John Goodman, a link to Cato’s Michael Cannon writing at Kaiser Health News to take on the White House’s contention that the PPACA’s new insurance regulations collectively represent “consumer protections” that Republicans should be wary of tampering with. Cannon argues that this is a mis-branding, and that while these protections are superficially appealing, they will have (and have had) deleterious effects below the surface.

Via Jason Shafrin, an article by the American Health Lawyers Association outlining the existing legal barriers to the establishment of one of the PPACA’s much-hyped cost-control/delivery-improvement mechanisms: the Accountable Car Organization (ACO). The list of existing regulations that may need to be waived is extensive, including elements of the Stark Law, prohibitions on balance billing Medicare beneficiaries, and various anti-kickback provisions… the sorts of things that one might characterize as consumer protections.

Truly delicious, isn’t it?

This raises the question: if these longstanding consumer protections intended to prevent physician conflict-of-interest and Medicare beneficiary exploitation need to be brushed aside (for some entities, anyhow) to allow the Next Big Thing in health policy to go forward, what does that say about their worth and utility more generally?

Why should we be any less wary of tampering with these “consumer protections” than the ones allegedly found in the PPACA?

If you support “consumer protection” generally, especially those added in the PPACA, I’m curious: if the latter set of regulations do end up getting waived for nascent ACOs, as I expect they will in at least some cases, will those ACOs’ patients be worse off for the lack of protection?

This is why we can’t have nice things anymore

For someone like me — young, healthy (knock on wood), and with no need for frequent contact with the health care system — a primary care physician is a nice thing to have.  I can go to my family physician for medical school checkups, vaccines, minor acute illnesses… but honestly, if I were to wind up “medically homeless” it wouldn’t be the end of the world.

For someone older or in poorer health, maybe with a chronic medical condition or two, a primary care physician is much more than “a nice thing to have.”  Chronic condition management, specialty consult management, generally looking after all the patient’s medical problems… that can wind up being the difference between well-managed illness on the one hand and an expensive trip to the emergency room on the other.

As I’m sure you’ve heard, there’s a growing consensus that the US does not have enough primary care physicians.  Why not?  There are a lot of potential answers to that question floating around out there, some of which are probably correct at least in part.  Opinion tends to coalesce around the following explanations:

• Primary care physicians tend to earn less than other physicians
• Primary care physicians’ lifestyles are not as enviable as those of some other physicians
• Primary care practice is perceived as being relatively more exposed to the hassles and red tape of third-party payers
• Medical students aren’t sufficiently exposed to primary care/good primary care role models and/or medical students encounter too much disrespect for primary care from faculty in other specialties.
• There aren’t enough primary care residency positions relative to specialty residency/fellowship positions.

I can believe all of these to varying degrees, though I’d hazard that the first two (to me, the third is a subset of the second) on the list are the main causes right now.  The last one doesn’t strike me as all that persuasive.  Residency slots have to be filled by international medical graduates, or simply stay unfilled, because not enough US medical students want to go into those fields.  Increasing the number of training positions in primary care won’t solve anything without an increase in medical student willingness to fill these slots.  The problem is clearly medical student demand, not training position supply.

Many of the proposals to “fix” primary care have rightly focused on the most plausible causes for the shortage.  Some professional organizations would hope to narrow the pay disparity by either cutting specialist pay, tweaking the Medicare pay formula to better compensate “Evaluation and Management” service codes, or simply by going back to Congress and begging for more money (sense a theme here?).  Others believe the solution lies in expanding retainer practice, which would have the added bonus of improving pay and lifestyle/regulatory hassle issues.  There are some who think that the “Patient-Centred Medical Home” and “Accountable Care Organization” will save primary care (or not).

Others would take more roundabout routes to creating more PCPs.  Instead of (or perhaps, in fairness, in addition to) changing the nature of the job to make it more desirable, they would take steps to essentially hoodwink medical students into choosing primary care as a field.  Some people think that Nurse Practitioners and Physician Assistants can and will step in to fill the void left by medical students (while “can” may be questionably questionable, the “will” is an even more uncertain proposition).

Yet others have jumped the shark entirely.  Via John Goodman some time ago, and KevinMD more recently is a summary of an AMA expert report on the real reason more students aren’t going into primary care:  it seems that we’re too nerdy, insufficiently altruistic, and (*gasp!*) bad at advocacy and community organizing.  Too much problem-solving acumen, not enough passion for social justice!

Because clearly, primary care has nothing to do with problem solving.

The links above point out the many, many flaws in this line of reasoning.  There are two big ones that come to my mind, however.

The first is the issue of “social justice.”  It’s a nice phrase, and an amorphous concept.  I’m in favour of social justice, and for certain methods of achieving it.  Ask a typical left-liberal what they think of my conception of social justice and my preferred means of advancing it, and you’ll likely provoke a good deal of rage, sputtering, and denunciation.  It’s one of those terms that’s thrown around a lot without being defined.  That said, it’s really only one segment of the political spectrum that has a high affinity for that phrase… when you see the AMA using it, you can be pretty sure what it is they’re referring to.  According to them, medical school admissions should be based on a political orthodoxy because, well… apparently it will produce more primary care physicians.

This isn’t even the biggest problem with the proposal.  Remember how I mentioned earlier that one of the reasons students aren’t going into primary care fields is because of pervasive disrespect for them in the medical academy?  The lack of role models and exposure?  The constant denigration by medical and surgical specialists?  The idea that someone is “only” a primary care physician?

How does the implication that primary care work doesn’t require problem-solving skills do anything other than contribute to these sorts of perceptions?  The very idea amounts to a proclamation that primary care is “lesser” medicine!  “Primary care physicians aren’t real doctors… I mean… the important skillset for them is community organizing for social justice!”

While this report may have its heart in the right place, I’m sure that medical students will be smart enough to read between the lines and see that it’s merely confirming the prejudice that they’re seeing in all other areas of their training.

This is the medical academy’s solution to save primary care.  And that… that is why we can’t have nice things.

Around the Mediverse: August 18, 2010

What with this whole commencement of medical school, it’s been a while since the last edition.  So I bring you slightly more than usual

Fun tidbits, health-related and otherwise, from around the ‘tubes:

• Worthwhile Canadian Initiative reminds us that counterintuitive though it may be, there is an optimal amount of forgetting.  Dr. Bob Centor suggests that proposed performance payment for physicians forgets the role of patient preferences in steering therapy.  Sticking with patient preferences, two posts at KevinMD argue that the long-term viability and feasibility of the PCMH care model should be determined by patient desires.  That is, if the PCMH model is workable to begin with… an arguable proposition.  Of course, if recent trends with retail clinics are any indicator… well, it could indicate many things.  You be the judge.

• Beware economists bearing dynamic stochastic general equilibrium macroeconometric models!  Beware surrogate endpoints in clinical research!  Beware constitutional challenges to the PPACA!  Beware Robin Hood… libertarian rebel?  Beware overly alarmist bullet points!

• End-of-life spending has gotten some attention.  The DMCB and Health Affairs alike aren’t convinced that reducing this spending will be easy, or that the savings are in fact possible to realize, at least as conventionally measure.  Relatedly, a guest poster at KevinMD points out that in medicine, sometimes “more is more.”  Not all potential cost-savings are “free lunches.”

• The Happy Hospitalist argues that data on physician reporting on impaired colleagues shows that the profession’s ethical standards are quite high.  Dr. Wes points out the ethical shortcomings of conducting large-scale policy experiments without any concept of research subject welfare as found in clinical research.  Arguably least ethical of this bullet point is Congressional exemption of the SEC from most FOIA requests.

• Pretty pictures!  Congressional Republicans give us charts explaining new government agencies created by the PPACA and the criteria for obtaining small business health insurance tax relief under the act.  The Denver Post posts some extraordinary colour photos from the Depression era.  Of course, sometimes making use of pretty pictures (and text) will cause one to run afoul of the federal government, as with the ADA actions taken against universities piloting Kindle usage among their students.

• Let’s talk unintended consequences of government actions.  Start by guessing which Senator takes exception to certain provisions of the PPACA?  Hint:  his name rhymes with “Hairy Reed.”  Elsewhere, the recession has forced two entrepreneurs to decamp to Canada because of the arcana of the E-2 visa.  What happened to new bond issues after the passage of the Dodd-Frank financial reform bill?  Would “disaster” be hyperbolic?  Becker and Posner ponder the effects of the administration’s pro-union attitude on business uncertainty and the recovery.  Megan McArdle discusses the optimal level of regulatory enforcement, whereas another blogger discusses the “tyranny of big ideas” in the context of regulatory change and improving human welfare.

• On lighter notes, we have a farmer who reminds the world that old-school farming isn’t all it’s cracked up to be, and a brief history of Tibetan Buddhism that is markedly different from the sort of thing you’d probably expect.

• Rounding out this week’s edition…  Medical schools, broadly speaking, do three things.  They educate physicians, produce research, and care for patients.  As someone just starting medical school, it’s nice to read things like this post from Dr. Centor arguing that the primary mission of medical schools should in fact be medical education.