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Sunday, April 20th 2008

Four Myths of The Primary Care Crisis

If there’s a bigger single topic discussed in the medical blogosphere than the primary care crisis I’m not sure what it is. It permeates blogs (here and here and here) and the media (here and here and here).

I do believe that the distribution of primary care physicians to specialists in this country is askew but I’ve taken a critical view of some of the claims made by the primary care community. In part there is an argument that the efforts of the organized primary care and the medical blogosphere are merely rhetoric. No one pays attention until there is a ‘crisis’ and the flamboyant and exaggerated claims on the condition of primary care are perhaps merely part of a PR campaign. But in a deeper sense I think that the ‘whining’ coming from primary care is actually contributory to the primary care crisis. I’ve made several posts to that effect.

I thought what was in order was one summarizing post on the issue, something that might stir up some comments. That’s what I’ve put together here: the four myths of the primary care crisis.

The conclusions I reach are based on what I feel is sound data, but the post is obviously far from comprehensive. If there is data from non-interested parties that I didn’t consider or arguments I’ve ignored then let me know in the comments.

Myth #1:There Is A Worsening Shortage of Primary Care Physicians
I’m just going to flat out say it, the fact that physician bloggers and agenda minded think tanks continue to substitute anecdotal evidence of a shortage as a surrogate for the actual figures is distressing. Take this recently touted article from the WSJ. While I won’t speak to the Massachusetts experience the cited study about a nationwide PCP shortage is flimsy.

One of my biggest pet peeves is that these primary care physician-scientists seem to refuse to characterize the evidence they use in their opinions. I would hope that we can all agree that the HSC Community Tracking Study Physician Survey, cited in the WSJ article, falls short of the best evidence on primary care physician numbers. A 6000 physician sample with nearly less than a 50% response rate. Lovely.

The same can be said of the claims for the organized primary care think tanks.

This Graph Is Meaningless

Indeed, the HSC survey is the only original dataset put together by a non-involved entity that I can find that seems to back up a drop in the per capita primary care workforce.

While we have seen a drop in allopathic medical students going into primary care it has more than been offset by IMGs as the GAO says.

From 1995 to 2005 Using AMA and AOA Master Files and HRSA Data

There are probably regional deficiencies in the primary care physician workforce but there are regional shortages for physicians no matter their specialty and it does not speak to a systemic problem facing primary care.

Nor is there good data that demand for primary care will grow with an aging population and cause a shortage. Such predictions by organized primary care are pretty low on the pyramid of evidence. While such a deficit may pan out, trying to predict such (even if you think it is just sooooo obvious a conclusion) is notoriously difficult. Predicting the physician requirements of this nation a decade or more out is essentially impossible. See this IOM report from the mid-nineties on efforts to do such. That’s why the major players over the past decade have flip flopped on whether we need to be graduating fewer or more doctors.

Certainly, even if the above scenario plays out, it would be hard to imagine it as a “crisis.”

I think the best evidence says there is not a general primary care shortage. At least not a new one. As I said, I think we have always needed more primary care physicians in this country but the situation isn’t getting worse. The primary care per capita numbers have been maintained and probably even grown a bit over the decades thanks to an influx of international medical graduates. Let that claim rest in peace.

Myth #2: The RBRVS and RUC Are Responsible For The Primary Care Income Disparity
I’ve posted long and hard on the RBRVS and the AMA’s RUC. I admit that I do not believe that primary care physicians are compensated appropriately and I may even buy that the RUC has not done enough to fix the primary care-specialists income disparity. That being said, the evidence clearly supports that the primary care physician has not done worse versus the specialist since the implementation of the RBRVS.

The RBRVS came into existence in 1992. I think a larger review of income data backs me up but for the sake of this post let me take a couple of examples to highlight the condition of primary care before the RBRVS in 1988 versus today. The data sources are the 1988 Health Care Financing Administration’s PPCIS and the 2007 AMGA Physician Income Survey.

I understand the limitations of comparing these two survey datasets, constructed under two different methodologies by two different groups. For example, below I have to use family medicine income as a surrogate for all of primary care. Even today the major physician income surveys show some wide discrepancies but I do believe that comparing this data gives us at least a general idea that the RBRVS has not screwed the primary care physician. In the end, that is the general point of the myth – the RBRVS and RUC have been bad for primary care. Such doesn’t appear to be the case.

In 1988 all self employed Family Medicine physicians earned a median of $102,500. In 2007 the median Family Medicine physician earned approximately $185,700. That is an increase of 81% in 20 years.

That is better than the orthopedic surgeon (56%), the cardiologist (61%), the anesthesiologist (78%) over the same time frame. There are medical specialties that made off better over that time frame (see radiology) but in general the RBRVS has been progressive for primary care physician income.

Nor, in terms of hours worked, are family practice physicians working more than they did immediately pre-RBRVS.

If you include all primary care physicians the primary care physician earned 65% of what the medical specialists did in 1988 (i.e. the cardiologist, the gastroenterologist, the pulmonologist, etc) and 44% of the average income of all surgical specialists.

2006 data put together from various sources by the Congressional Research Service says that the primary care physician today earns 70% the medical specialist and surgeon.

No the RBRVS may not have closed the gap in the income disparity completely and/or appropriately but it has made some progress and has not contributed to a worsening of the gap. The income disparity has narrowed since the advent of the RBRVS and the creation of the AMA’s RUC. End of story.

Myth #3: Income Potential Is The Single Biggest Reason Allopathic Students Have Abandoned Primary Care
The potential to earn is certainly something that medical students take into consideration in selecting a specialty but it is not far and away the most important factor. As we’ve seen the comparative income of the primary care physician versus some key specialists is actually less today than it was in decades past where more allopathic medical students went into primary care.

Nor is the growing debt level of graduating students necessarily making income potential a more important factor and thus working against primary care.

The Best Fit Line Is Imprecise

What does rise to significance in specialty selection is perceived lifestyle.

The implications of this for primary care aren’t well studied and so all I can offer is a dreaded anecdote. As I’ve said before I perceive primary care physicians as extremely unhappy. I have my impressions on why such is the case (some of those impressions backed up by evidence cited here) and some of it just my personal observations. The reasons aren’t important though, the fact that primary care physicians appear so unhappy and offer up so many complaints about their profession could potentially play a role in defining the perceived lifestyle of the specialty for medical students. It certainly does for me.

That is one of the biggest reasons I offer criticism of some of the claims of the primary care physicians about the condition of their specialty. Not because I don’t believe primary care is important but because I believe the strategy of complaining which seems to have been adopted by a good chunk of the specialty is counterproductive for the reason above.

Myth #4: Primary Care Physicians Can And Will Abandoned Medicare
This final myth needs a disclaimer. I’m not saying that PCPs won’t alter their behavior. They don’t all have to abandon Medicare, they may just limit new Medicare patients or stop taking them altogether. What I want to do is contest the heart of the claim – that enough primary care physicians will be able to alter their behavior in such a way as to significantly inconvenience everyone who has Medicare and thus force government change.

The refutation of this myth is backed by less data than the others but I stand by my claim that most Medicare beneficiaries reading this will likely be able to sleep fine at night knowing there is a primary care physician to see you.

There will always be individuals who have trouble finding a primary care physician and certain regions will face time limited troubles but those stories are all you see cited by the medical blogosphere in supporting this claim.

The fact is that Medicare alone accounts for more than a fifth of all health care expenditures. Throw in the other government programs and the government controls nearly half of spending. Yeah, the collective primary care physicians hold all the cards versus the single largest physician payer (sense the sarcasm).

In the next twenty years the number of Medicare enrollees is expected to increase approximately 40% and Medicare expenditures as a percentage of all health care spending is projected to increase.

The implication is that, unless practices are actively losing money on Medicare patients, physicians will not be able to abandon the Medicare payments en masse. Certainly not in numbers great enough to actively influence Medpac recommendations or to turn the dial on primary care reimbursements up. Sure, in the short term you’ll continue to read about some primary care physician practices doing that, but there simply are not enough private pay patients for a huge number of primary care physicians to curtail their Medicare patient population.

Cite all physician practice stories you can, cite all the mainstream media accounts of a Medicare beneficiary who cannot find a primary care, cite all the limited surveys you want. In the long run the potential impact is negligible and will not be near enough to force Medicare’s hand.

Okay, if you’ve taken the time to read this verbose treatise then I think I’ve made my position pretty clear. The goal of this post was to put down my pet peeves concerning the discussion of the primary care crisis and to leave the issue there. My plan is to limit my future commentary on this issue; I’ve said all I have to say on my blog. Hopefully this post will stir up some discussion which is sorely needed because most of the medical blogosphere seems to have bought into the four myths of the primary care crisis.

With all of that laid out, there is almost certainly data out there which I didn’t come across. I want to see any data from disinterested parties which refutes my claims above. I’m sure it is out there, so please leave it in the comments section and challenge my claims.