The pathophysiology of primary care dwindels

There are two recently published sources of important information regarding a major cause of the primary care exodus. One is in JAMA ( JAMA,November 21, 2007) Vol.298,no.19, pg 2308, " The Unintended consequences of Resourced-Based Relative Value Scale reimbursement", Goodson, J.D.) and unfortunately as important as this is, you need a subscription to read it. The other source is free and we can thank The Happy Hospitalist for his insight.

The major cause is decreasing take home pay. This plus increasing third party requirements and mandates and the threat of malpractice and the perceived greener pastures of the non primary care branches of medicine add up to the perfect storm.

And the cause of the decreasing take home pay is the system of CMS payment fee schedule. What follows is a description of how the price controls on physician's fees are implemented. In 1992 the RBRVS was put into place allegedly to mitigate the payment gap between procedure type docs and those who just see patients. Over the past 15 years it seems to have had just the opposite effect.

These price controls seems to have disproportionately impacted the income of the primary care sector. Until recently I was not ware of the role the AMA and a group known as the RUC played in this story. The AMA web site give a rather sterile and uninteresting rendition of who and what the RUC is. It is a group that gives advice to CMS about the details of the price controls.According to the JAMA commentary, their "advice" is put into motion about 80 % of the time by CMS. The committee is disproportionately represented by surgical and other non-primary care physicians. Of the 30 members, 27 have no term limits and the meeting are not made public.The proceedings are said to be proprietary (the AMA owns the CPT (current Procedures and Terminology to which the RVU ( Relative Value Unit) systems is linked.)

"All animals are equal but some animals are more equal that others."

So the story seems to be that the "remedy" set up in 1992 to make more equitable the payments from CMS to procedure and non procedure physicians has been largely controlled by a group of physicians who do procedures and the gap between the two broad groups has now so widened that there is now much scurrying to leave a sinking ship.

To summarize and embellish. There are wage controls on physicians fees. These are implemented by CMS with advice and consent from a procedurist dominated, AMA sanctioned group, the RUC. The third party payers follow suit. Wage controls lead to shortages (of primary care docs who are disproportionately impacted ),poorer quality and increased waiting times. Every year the AMA goes to Congress to plead, beg and weakly threaten them to not cut the overall CMS funding by as much as proposed. This dysfunction "system" is not going to correct itself.

I make no claim to the "answer". One approach that resonates in my libertarian consciousness is that made by the American Association of Physicians and Surgeons. The following is copied from their website. It is basically an escape route away from the wage controls and favors individual choice over the current command and control arrangement.

“FREEDOM FOR PATIENT AND DOCTORS WILL MAKE A DIFFERENCE.

H.R. 580 Seniors”Health Care Freedom Act of 2005, and

Say “NO” to Government Cookbook Medicine

“We oppose the various bills playing with the Sustainable Growth Rates (SGR), such as HR 3617, HR 2356, HR 1162 and S. 1574. Instead of changing the SGR, we support H.R. 580, the Seniors’ Health Care Freedom Act of 2005” that would allow the use of private contracts under the Medicare program. This is a win for patients, doctors and taxpayers as well.

“Our survey shows that 63% of doctors would be more willing to treat Medicare patients if unrestricted private contracts were allowed. Patients could pay doctors more than Medicare allows if they think the service is worth it. It would be up to the patient.”

I know ,the chances of something like that passing have to be slim to none and as Dan Rather was fond of saying, "slim just left town."Still it is good to dream of the day when physicians could join the other professions (lawyers,accountants, dentists, veterinarians,etc) who do not go to Congress every year to beg for crumbs.