Thoughts from the 2011 Family Medicine Congressional Conference

Ok, I'll start out with a cheat sheet on the important issues and "asks" that we brought to Capitol Hill today. There was a definite sense of urgency to act, and our proposals focused on opportunities to incentivize primary care, without significant budgetary increases.

1) Fix the SGR. Stop kicking the can down the road and get realistic payment stability.
2) In regards to GME, consider a model that would secure a portion of funds specifically to primary care community and out-patient residency facilities.
3) Encourage investment in Title VII funding (specifically section 747) and further support for National Health Service Corps
4) Decrease the gap that exists between primary care and specialty salaries

Now for some reflections on the issues and discussions for family medicine here in Washington, D.C. at the FMCC:

7:00am: Wow, breakfast buffet is great! The AAFP really takes care of their own. Next, I walk into a room of over 200 family doctors convened and eager to descend on Capitol hill tomorrow and breakfast becomes an afterthought. Talk about wow - I'm speechless. I wish every medical student could be here for this program and for the good of the future of medicine.


Hot issues:

Monday, 8am: Models, models, model. You'd think with all the talk of models, their would be a Paris runway close by. Then again, I wouldn't complain if some Hawaiian tropic spokespeople walked through the doors right now.

In all seriousness, there is so much talk of models and systems. I can see that this sort of dialogue is important, as a means of establishing a strong foundation. The reality is that a 400+ pg proposal has been put forward, and we are still in the comment period prior to the final product. But the frustrating aspect is that family physicians function at the ground floor of health care delivery. Its tough to listen to mostly generalized and broad goals, when we all know how important the details really are. I do very much look forward to the proverbial "meat" at the heart of these proposed systems. I am eager to move forward and to see how these models function and to see them in place.

10am: AMA question and answer forum. This session quickly turned into a soundboard for comments. This tells me that family docs know the facts, and are more prepared to have their voice heard than the need to have questions answered. The people in this room have done their homework, and family doctors are hungry for parity and a successful balance in medicine. I'm encouraged by all of this discussion.

11am: Robert Phillips, MD, Director Robert Graham Center. This man is a visionary and his poise is inspirational. He first offers the difference between "Reducing costs vs restraining costs". This a perspective that isn't often considered. Everyone is looking for ways to lower cost, when in fact we should be looking for opportunity to curb spending growth.

Workplace continues to be framed in terms of supply and demand. Figures are often thrown around at the national level that "this many tens of thousands" of physician workforce shortage. The paradigm shift on this is to consider the implications of physician distribution. In fact, when you look at physician demographics, it is apparent that the number of physicians serving in areas of excess could cover the areas that demonstrate a shortage.

That said, it seems that the focus has shifted away from workforce and on to economic impact. That is fantastic news for the primary care front - their is amazing data on the number of local jobs, the economic impact, and cost effectiveness of family physicians. Most importantly, it has been shown that an increase in family physicians in a community led to a correlative decrease in readmissions. Every other specialty showed increases in readmissions with increased workforce in community.

Thought: data, data, charts, graphs and data. Proof and facts are the name of the game in directing change.

One thing that really sticks out to me is the continual rhetoric and future tense employed by many speakers. It seems that words such as "planning", "committee" "considering" "taking suggestions" "reviewing proposals" far outweigh any directions or indication of activity. Right now its a waiting and planning, and few seem to want to take the first step. Which is counter intuitive to the needs of medicine. We have an outmoded system that is functioning on an outdated payment schedule. In order to meet the demands of the modern health care climate, we need to stop the rhetoric and start the reaction. It was clear from the medical student voice, that we demand as quick resolve to act as any group.

2pm: Panel on health reform movement. After spending the better part of the past year and a half focused on health reform, it seems that their is a general health care fatigue on Capitol Hill. On top of this, the magnitude of the funding deficit makes any movement in the positive direction extremely challenging.

Two of the COGME recommendations that struck me: to adequately meet the needs of American health care, it is recommended that the physician workforce be composed of at least 40 percent primary care. The second recommendation was to encourage enhancement in medical school social accountability in training. See my most recent post on this site for some of my thoughts that are right in line with this.


Some other random thoughts:
1). Check out Wellmed a non-hospital aco based in san antonio that is producing outlier numbers in reduced mortality, cost saving, and family physician salaries. (http://www.wellmedmedicalgroup.com/)
2). Its inspiring to meet and see all of the energetic and engaged medical students here. Debt is a huge issue, but these passionate students are willing to sacrifice for the goals of primary care. More apparent is the medical student urge for activity. We are saying, we can't wait, we can't put things off - we need to act now.

Does Building a Primary Care Workforce Start with Medical School Admissions Committees?

Between COGME’s 20^th report recommending expansion of the nation’s primary care workforce (see 1/28/11 post) and the health care rhetoric and legislation coming out of Washington over the past few years, it seems that those in health care industry and policy are in full agreement that a primary care shortage exists in the United States and that the number of primary care physicians we produce in the coming years will have a significant impact on both cost of and access to quality care.

But how do we as a nation produce more primary care physicians? And is setting a numerical goal (i.e. 40% of physicians will be primary care physicians by 2020) enough?

Assuming we can improve reimbursement for primary care physicians (both male and female – see 2/3/11 post on gender-based physician salary gaps) such that family medicine becomes a more desirable financial option for those students who see reimbursement as a barrier to a primary care career, we will still have to address the disparity in access to primary care that occurs between geographical boundaries in the U.S.

In 1970, the federal government created the National Health Service Corps (NHSC) in an attempt to combat the changes in access to care that had begun over the prior two decades as rural physicians retired or moved to cities, where medical practices offered higher salaries and job opportunities for spouses. With the passage of the act that created the NHSC (and its subsequent amendments), the government recognized that proportion of patients living in areas with a population to practitioner ratio of 2,000:1 as “underserved.” These geographical areas were termed Health Professional Service Areas, or HPSAs.

Currently, the Health Resources and Services Administration (HRSA) website states that

“As of September 30, 2009, there are 6,204 Primary Care HPSAs with 65 million people living in them. It would take 16,643 practitioners to meet their need for primary care providers.”

Although over the past two years President Obama has reversed a trend in dwindling HRSA funding and expanded HRSA health workforce programs (including doubling NHSC funding to $300 million in the fiscal year 2010 budget and increasing that number by an additional $27 million for 2011 along with increasing funding for community health centers), we have to realize that more federal funding alone isn’t the panacea for curing the problem of geographic health workforce disparities.

A study published in the November 2010 issue of the American Journal of Public Health analyzed interview responses from primary care physicians in Los Angeles County, California concerning their reasons for practicing in their particular geographic location¹. Only 24% (5 of 21) of interviewees practicing in underserved areas in the county chose their practice location because of loan repayment obligations, which seems to indicate that federal funding is a minor player in the eventual retainment of primary care physicians in such areas. Compare that to the 19% (4 of 21) of physicians in nonunderserved areas serving in their respective areas due to loan repayment obligations, and one starts to wonder whether loan repayment money really has an impact at all.

Digging deeper into the numbers of the study reveals that those physicians working in underserved areas were most likely to do so because of mission-based values (a “sense of responsibility or commitment to a particular community, a defined patient population, or a moral obligation”) and self-identity (including “language, personal, family, cultural, socioeconomic, and geographic backgrounds”). A 2003 study of a rural physician workforce in Florida provides similar insight, noting that physicians from rural backgrounds and physicians who were exposed to rural experiences in medical school and residency were more likely to practice in underserved rural areas². To further the connection between training and practice, a 2009 study in the Annals of Family Medicine looked at training residents in community health centers (CHCs) and found that family medicine residents who trained at CHCs were four times more likely than their colleagues to go on to practice at CHCs³.

In addition, among primary care specialties in the L.A. study, the vast majority of physicians practicing in underserved areas were family physicians, whereas internal medicine and family physicians shared an equal percentage of the total in the nonunderserved cohort.

So what does all this mean? It would appear that prior experience in an underserved community and a sense of responsibility to that community is truly the major motivator in where a primary care doc practices. It means that medical schools and residencies need to partner with CHCs to encourage graduates to work with the kinds of populations that frequent them. Even more importantly, it confirms what we should have known all along: the best medical school candidates are those who already enter with mission-based values and who self-identify with those communities that most require family physicians.

Easier said than done, but we can’t hope to rely on loan repayment opportunities and training alone to funnel more students into family medicine. Opportunities to train with an underserved population best stimulate those who already want to work in that setting. It’s up to medical school admissions committees to select medical students who fit that bill.

The Robert Graham Center (RGC), with private foundation money, is already producing objective data on how well medical schools and training centers are fulfilling their “social mission” (that is to say, how well they are meeting the health care needs of the public)⁴. The RGC uses geographical information systems mapping tools to display these results visually. The only limitation of this data is that it is elicited from the American Medical Association Physician Masterfile which, although fairly comprehensive, still is prone to a small amount of error.

Knowing that, I propose a more effective use of federal money to improve the primary care services in the United States: create a national database of registered physicians and their specialties and locations of practice; then, instead of tying the majority of a medical school’s funding to the amount of research it produces, tie a large portion to the percentage of each school’s graduates who end up working as primary care physicians in underserved communities.

It would be a carrot approach, much like President Obama’s “Race to the Top Fund” for improving primary school education, and perhaps it would create an incentive (to compete with incentives from research funding and alumni donations) for admissions committees to take a closer look at the values of their applicants.

References:

1. Odom Walker K, Ryan G, Ramey R, Nunez FL, Beltran R, Splawn RG, Brown AF. Recruiting and retaining primary care physicians in urban underserved communities: the importance of having a mission to serve. Am J Public Health. 2010 Nov;100(11):2168-75.
2. Brooks RG, Mardon R, Clawson A. The rural physician workforce in Florida: a survey of US- and foreign-born primary care physicians. J Rural Health. 2003 Fall;19(4):484-91.
3. Morris CG, Chen FM. Training Residents in Community Health Centers: Facilitators and Barriers. Annals of Family Medicine. 2009 7:488-494.
4. Bein, Barbara. Robert Graham Center to Study 'Social Mission' of Teaching Hospitals, Health Centers. AAFP News Now. 27 July 2010.

Analyzing COGME: Increase The Number of Primary Care Physicians

As mentioned by mdstudent31 mentioned, I plan on doing a 5-part series analyzing each of the recommendations behind COGME's report, Advancing Primary Care.

Before I look at the first recommendation, let's take a brief look at what COGME is and what it's authorized to do. COGME stands for the Council on Graduate Medical Education and is authorized by congress to make continuing assessments of physician workforce trends and training issues; recommend action to address identified needs; and advise the HHS Secretary and Committees responsible for health in the Senate and House.

Now onto the recommendations... the first COGME recommendation is: Policies should be implemented to raise the % of PCPs to at least 40%. This sounds like an ambitious goal given that the current level of PCPs is 32% and this number has been actively declining.

Add these 4 facts:

• In 1960, 50% of US physicians were practicing primary care
• For the past few year, 14-20% of US medical graduates have expressed interest in primary care
• Studies have shown that optimal health care outcomes and health system efficiency occurs when 40-50% of the physician workforce are PCPs
• If all those who are uninsured today receive health insurance, we will need an additional 122,000 PCPs to provide services to these patients

How can this goal be accomplished?

COGME suggests that:

• primary care needs to be made more attractive by improving compensation and providing support for restructuring practices
• changing the culture of medical student education to promote student interest in primary care
• creating policies that reward institutions for increasing GME commitment to primary care

Some short-term solutions that are proposed to better serve our patient population include:

1. Implement policies that increase non-physician clinicians (PAs, NPs, nurses and other staff positions for coordinated, integrated practice in primary care teams). This also means that we have to ensure that graduates from these programs enter program and not subspecialty care!
2. Provide incentives and regulatory reform so that all clinicians and staff work at the top of their degree. This means that primary care doctors, who have more training than PAs or NPs in terms of length and breadth of training, would move more towards coordination of care. This also helps manage health care costs.
3. Encourage and support the roles of other physicians to provide comprehensive, longitudinal primary care. It is possible for non-primary care doctors to provide some longitudinal care, although they are not fully trained for these positions. Possibly a short term response for now? Especially for some cardiologists or endocrinologists who already treat patients with chronic diseases.

Personally, I think these initial recommendations seem focused more on serving our growing patient population on the short-term but do not answer how we can best increase the % of primary care doctors so that we can better serve our nation's population. What do others think?

Next week: Recommendation 2 - changing physician payment and practice transformation for primary care (to help fulfill the first recommendation?)

Gender-Based Income Gap for Docs Should Elicit Call To Action

As the only female contributor to this blog, it seems only appropriate that for my first post I tackle some gender issues. The February 2011 Health Affairs Table of Contents came out today and the very first article I noticed was “$16,819 Physician Gender Gap”. This sort of article occasionally appears, long enough to elicit some guilty feelings and an apathetic hope for change, then disappears quietly until the next round.

In a world where over half of entering medical students are female, and a disproportionate amount of those are pursuing careers in primary care, the gender-based income gap is a huge workforce issue that we never really address. We’ve paid a lot of attention to disparate salaries across specialties, but not within our own profession. It’s something we toss out to the free market, assuming that the gap will close under the appropriate conditions. Some of us may even silently think things are fine as they stand.

This is issue is not unique to the specialty family medicine, and it is certainly one that appears across many non-medical professions. According to this graphic from the New York Times, physicians are actually at the bottom of the barrel where the income gap is concerned – that is to say we’re doing worse than lawyers, pharmacists, medical scientists, teachers, postal workers, and pretty much everyone else.

Lest you think I’m approaching this from a purely feminist angle, I have considered the free market argument potentially justifiable. I mean, women in medicine choose primary care careers, and take time off for children, and spend more time with patients for lower total reimbursement, right?

Wrong.

Let me rephrase – all of those points are true. However, these classic rationalizations have been proven inconsequential by the authors of the Health Affairs article. Men simply make more money than women for the same work.

The authors used survey data from New York State to examine salary trends from 1999-2008. Their data not only shows that an income gap exists, but that it has grown almost five-fold in the last 10 years, from a gap of 12.5% to 17%. To avoid confounders of experience and rank, they only looked at starting salaries. More importantly, this study is the first to my knowledge to show that disparities exist across specialty, practice type, and work hours. Controlling for these and other factors slightly reduces the gap, but does not eliminate it entirely.

The high prevalence of women in primary care has often been cited as a reason for the income gap; however, a decreasing proportion of women are choosing primary care. As the authors point out, this argument would predict the gap to decrease, rather than increase as it has in recent years. A stratified analysis of primary care versus non-primary care specialties revealed similar results – unfortunately, the analysis lumped family medicine together with pediatrics and internal medicine, three specialties that have very different post-residency workforce dynamics.

The vague concept of “productivity” has been another rationale for the discrepancy, often as measured by patient visits over time, rather than on the more clinically relevant measures of quality or outcomes. Results presented at the WONCA 2010 Conference show that among Canadian physicians, women spend more time with patients (17.8 minutes vs. 13.3 minutes), are more emotionally engaged, and allow more time for discussion and questions. Unfortunately, these women also report more signs of burnout and physical stress. Ultimately, studies regarding productivity have been mixed.

“Quality of life” is often used as a euphemism in these discussions to reflect the part-time and re-entry options available to balance family and work obligations. The authors postulate that quality of life may be a direct cause of the discrepancy. As more practice options become available, “female physicians may be seeking out employment arrangements that compensate them in other – nonfinancial ways.” Women are the typically beneficiaries of these changes, but men are increasingly attentive to quality of life concerns as well. I remember a professor of mine, a retired physician, who recalled (with a smile) a successful presentation at rounds some fifty years ago because he chose to stay at the library all night instead of returning home to his wife and newborn. It is fair to say this is not the current day expectation. And no, he was not a family physician.

While causality data for the gap is patchy and contradictory, evidence does exist that debt load and anticipated future income affects specialty choice. The average debt for a medical senior graduating in 2007 was $145,000 for public schools and $180,000 for private schools, and over 23% of students had debt above $200,000. Less than 8% of those students are pursuing careers in family medicine, a majority of them women.

The COGME Report included a recommendation to increase primary care physician income to 70% of the median level of specialists. I propose we pay equal and special attention to the less discussed income gap in medicine that exists along gender lines. With women as a historical majority of the primary care workforce, and female graduates increasingly choosing subspecialty fields, income discrepancy may be contributing more to workforce dilemmas than we realize.

With that said, I challenge to you to think about this - what can family medicine do to lead the change?

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References:

(1) Sasso AT, Richards MR, Chou C, Gerber SE. The $16,819 Pay Gap For Newly Trained Physicians: The Unexplained Trend Of Men Earning More Than Women. Health Affairs, 30, no.2 (2011):193-201.

(2) Palmert M, Pipas C, Wadsworth E, Zubkoff M. Economic Impact of a Primary Care Career: A Harsh Reality for Medical Students and the Nation. Academic Medicine, 85, no.11 (2010):1692-1697.

(3) Sullivan MG. Women Physicians Connect Emotionally With Patients, But Are More Stressed Out. Elsevier Global Medical News. Published online on June 29, 2010. Available at http://www.medconnect.com.au/tabid/84/s22/Neurology/ct1/c337421/Women-Family-Physicians-Connect-Emotionally-With-Patients-But-Are-More-Stressed-Out/Default.aspx. Accessed February 3, 2010.

(4) Why Is Her Paycheck Smaller? New York Times. Published online May 18, 2010. Available at http://www.nytimes.com/interactive/2009/03/01/business/20090301_WageGap.html?src=tp. Accessed February 3, 2010.