Thursday, June 25, 2009

Holodeck Thinking from the New England Journal on Primary Care and It's Time for the AAMC Members to Step Up in Fixing the Primary Care Crisis

Academicians Thomas Bodenheimer, Kevin Grumback and Robert Berenson are holding forth in the latest issue of the New England Journal of Medicine in an effort to influence Washington DC healthcare reform debate. Their message is that the reform needs to include a 'three stranded' lifeline to primary care practitioners. The article is available gratis without a subscription.

Don't bother reading it; they should pay YOU to do so. The authors are recycling the same tiresome policy ingredients for an intended audience that does not include the more sophisticated real-world denizens of the Disease Management Care Blog. After all, we know better. Rather, the Journal piece is aimed at giving their allies in Congress another reprint to pass around the room from a notable paper-based journal - even if it is of fading importance - to support their ideology in the D.C. beltway policy debates.

Essentially, Tom's, Kevin's and Bob's three strands are:

1. More money, because primary care physicians earn less than their specialist colleauges. They say these docs should be given special dispensation from the zero sum game that has capped the global physician payments to physicians. They think a 5% to 10% increase over several years would be reasonable. In addition, they say loan forgiveness should be extended to young physicians who go into primary care. Additional sources of cash should also be extended via monthly payments for care management services for medical home activities or in the form of bundled payments, perhaps as part of 'accountable health organizations.'

2. Outpatient practice infrastructure modernization, starting with electronic records across all specialties. However, the American Recovery and Reinvestment Act (ARRA) funds should be disproportionately and urgently allocated toward the primary care docs. What's more, they should be given "technical assistance" to expedite the adoption of 'medical homes.'

3. Funding for graduate medical education should be increased and wrestled away from hospitals (where the education takes place) and channeled toward the residency programs themselves.

For another perspective, Dr. Steinbrook obliquely points out in a separate opinion piece in the same issue of the Journal that money is not the only reason why docs pursue their career paths. He's right. What is known is that gender, socioeconomic background, belief systems and rural vs. urban background also play important roles in choosing primary care over a speciality career. Once docs are in practice, income plays a role in career satisfaction, but so do autonomy, control over personal time, and administrative hassles. Not only does all that go unsaid in the Journal, but what is also lacking is any mention of the ability of US medical schools to select students that are already predisposed toward primary care.

While the point about graduate medical education is a good start, the DMCB thinks the American Association of Medical Colleges (AAMC) has been remarkably unhelpful in matching their members' undergraduate medical student recruitment, selection and financial support process to the nation's manpower needs. Given how much public money these institutions receive, the DMCB asks if it's time to ask them to stop being so self-serving and step up to the plate when it comes to doing their part on behalf of health reform.

We also still don't know how many primary care physicians in doctor-owned businesses/practices will a) embrace the kind of profound practice transformation that will lead to the creation of a medical home and/or b) readily cooperate with being pushed into relationships with local hospitals to form accountable health organizations. The authors are fancifully assuming that a model of care that has been the topic of research in physician-salaried settings, in Medicaid programs and a pending Demo will work today everywhere in every town in every State - if only Congress would throw money at it. The DMCB doubts that and so does, by the way, the Congressional Budget Office.

Last but not least, the population-based care/disease management community has an emerging track record of working in and with in wide variety of practice settings to promote better coordination of care. Funny how that evidence was skipped over in the Journal's published narrow-minded holodeck construct.

The DMCB thinks there are many primary care physician practices nationwide that already provide excellent care. They need more than money and Boston-style central planning built on wishful thinking about half-proven concepts. The Journal's readers deserve better and so do whoever is getting copies of this opinion piece.

The DMCB's advice is to step toward the holodeck door and press the reality button.

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