Primary Care & Medicare
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I’ve written before about the negative impact Medicare payment policy — which favors specialization and procedure-driven health care — has had over time on primary care. And since Medicare is the driving force behind all provider payment policy in this country, what Medicare does really matters. Someone sent me a blog the other day on this topic that makes for fascinating reading. It’s written by Brian Klepper. I don’t want to spill the beans on Klepper’s post — but suffice it to say that he does a better job of explaining why Medicare payment policy has been so detrimental to primary care. He also makes a pretty compelling case that if CMS and Medicare just keep doing what they do now, primary care — as a profession — will simply go away.
What an excellent post. I come away from it with a few thoughts: First, without having mentioned such an idea in his writings, Mr. Klepper is presenting some pretty strong evidence towards the need for a National Best Practices Institute (as mentioned before on this site). When coupling the cost analyses cited in the post for specialty procedures, along with evidence pointing to the number of these procedures that are potentially unnecessary (or defensive), the argument becomes pretty strong. The case is made even more compelling when the idea of ‘disappearing primary care’ is introduced. By shifting medical focus away from these unnecessary, costly procedures, an institute as such could both control costs, and preserve the value of primary care.
Second, if, as proposed by Dr. Goldfield, a system of primary care physicians practicing ‘patient advocacy’ - in regards to specialty care - were to develop, special care would be needed to ensure that the potential for coercion from drug and device manufacturers was eliminated. As the system is currently constituted, it is not hard to imagine that these manufacturers are pleased that they have a larger than needed pool of specialists available to prescribe and apply their products. Again, a case could be inserted for a Best Practices Institute as a means of defending against such lobbying, including that from the AMA. It must be ensured that rather than open up a new market of practitioners to these lobbyists, such reforms would help put in place safeguards that prevent any potential unethical persuasion.
My last thought was just how shameful it was that the AMA cites their First Amendment right to petition the Federal Government as grounds to commit this sort of institutionalized price gouging.
The post (and it’s reference material) is a great read – thanks for sharing.
The behind-the-scenes exposure of who is involved in setting medical payments is enlightening. Unfortunately, as Klepper states, it is not just the primary care profession at risk, but many future career opportunities for generations of Americans. With the concurrent inflation of higher education costs along with medical inflation, what direction do we send our children in to secure their future as they think of potential careers? Opportunities should be expanding, and we apparently have the knowledge to end this out-of-control spiral that has taken hold of our economy. Klepper’s blog reminds me of the story of the molasses flood of 1919 in Boston –those who had the ability to change the situation were not able to see beyond the immediate rewards. We should be able to reconstruct the current system before the tank gives way!!
Unfortunately, Brian Klepper’s blog, though interesting, reminds us of only one side of the story. The doctors’ lobbies (not just the AMA) have done much to distort prices and restrain competition, in order to artificially raise doctors’ incomes. An important aspect of this is their role in limiting the broader use of nurse practitioners.
Indeed the use of nurse practitioners, and perhaps medical social workers, could be an important solution to the primary care problem.