Fixing the Primary Care Physician Shortage

I’ve written several times here on Substack about the propensity for the U.S. government to throw money at problems without coming up with useful solutions. The money usually funds committees who “study” the problem and come up with suggested fixes, usually involving creating yet more committees. In “The Nursing Shortage That Isn’t” I expressed my opinion that the government’s legislating that nurses should be responsible for no more than three patients doesn’t solve the nursing shortage but instead exacerbates it. In “Centers of Excellence and Maternal Mortality” I again suggested that the $168 million dollars to fund committees to create a checklist for hospitals to be awarded a gold star for their care of pregnant women was not going to create safer hospitals, only hospitals with gold stars.

KFF Health News recently published an article titled “Compensation is Key to Fixing Primary Care Shortage.” Would that it were so simple! Christopher Holler of the Milbank Memorial Fund describes the situation well:

“We need primary care to be paid differently and to be paid more, and that starts with Medicare.”

The KKF Health News article describes how Medicare sets reimbursement for physicians and how Medicare tends to pay for procedures, leaving much of the oversight of patients by primary care physicians ignored. There is no acknowledgment on the part of Medicare that primary care oversight will prevent a patient’s chronic health problems from becoming referrals to specialists or prevent patients from winding up in emergency rooms.

To my mind, one of the most important revelations in this KFF Health News article is the behind the scenes work of professional medical associations to prevent increasing payment to primary care physicians. The article notes the American College of Surgeons is diligently working to prevent increased payment for primary care. Their reason? Because they fear their salaries will be decreased to increase payment to primary care physicians. Nice collegial rapport here.

“If they want to keep it, they need to pay for it,” said Christian Shaigian, director of health policy for the organization [American College of Surgeons]. He says his organization will continue to oppose any increase in primary care payment unless member payment remain untouched.

Although money is a serious problem, it is by no means the only problem for primary care doctors.  It is actually only one of the many frustrations for those of us who have been active in primary care for decades.

For more than four decades, I practiced primary care. For almost two decades, I trained family practice doctors to do primary and secondary obstetrics in our North Dakota rural health care deserts. Later on in my career, I returned to my roots in rural North Dakota and practiced primary and secondary obstetrics and gynecology.

I owned and managed my own clinic twice and I’m very well versed in the problems associated with running and owning a primary care clinic, as well as practicing in rural healthcare deserts.

Problem #1: billing and coding

In my first practice from the late 1980s until year 2000, I had 26 employees including three mid-level’s, my own lab, my own ultrasound, and three other doctors besides myself. One of those 26 employees managed billing and coding. The majority of my patients were Medicaid. I was reimbursed approximately $1500 in one payment for all of the prenatal care and the delivery of my patients. This low level of payment for months of care worked for me only because I had a large number of patients.

Later, in my second clinic, I had approximately 12 employees. I was the only physician and I had two mid-level providers.  In this clinic I had to have three people for billing and coding, not one. Most insurances are hard to deal with. If they pay six months late, that’s a nice interest-free loan for them. And if insurances refuse to pay a claim enough times, many billers will simply stop requesting payment. That’s an old tried and true method to abuse the provider and the consumer. For details of how North Dakota Medicaid plies the claim rejection scam, you might take a look at “North Dakota Medicaid and Erectile Dysfunction.”

The prize for being most difficult to deal with goes to North Dakota Medicaid. They can dream up dozens of reasons to deny payment or pay much less than the full claim. For example, if an IUD cost my office $750 and I had seen the patient, explained the risks and benefits, and inserted the IUD, ND Medicaid would reimburse me only $600. So there would be an automatic $150 loss not just on the IUD, but also for any care I provided the patient in my office.

One time our biller had to submit a claim to North Dakota Medicaid 11 times before receiving payment. They were 11 different excuses, including the wrong sized paper. Yes, because the claim had been resubmitted so many times, ND Medicaid began requiring paper claims faxed as well as electronically submitted claims from our clearinghouse because we had had the audacity to continually question why the claim was no paid. How a standard Medicaid claim form mailed and faxed to North Dakota Medicaid could somehow be on the wrong size paper remains a mystery.

Then there’s North Dakota Medicaid’s refusal to pay our claim for a woman who came to our clinic on the same day she was released from the hospital after the birth of her baby. She came to the clinic because she was released from the hospital without treatment for an infection after her delivery.  She knew she needed treatment and came to my clinic the same day she was released from the hospital. ND Medicaid paid the hospital for her delivery but were unwilling to pay a second claim on the same patient in my clinic because they won’t pay for a second claim to a different provider on the same day. Better to let the patient die from an untreated postpartum infection.

And then there was the payment for the prenatal care of one of my patients which ND Medicaid took back two years later without notice or explanation. I can’t get paid for a claim that’s more than a year old. But ND Medicaid feels comfortable taking back payment long after that year is past.

Years ago ND Medicaid sent me a letter four years after a surgical service requesting a complete refund of the money they had paid me. I had never received any such payment because I had had nothing to do with the surgical procedure. ND Medicaid was adamant I must refund the money anyway. I finally had to send ND Medicaid a check for a refund on a surgical procedure I had never performed and for which I had never been paid in the first place.

Problem #2: Medicare

Compared to North Dakota Medicaid, Medicare is relatively reasonable, However, that is still not saying very much. Medicare is remarkably discriminatory. There are 51 different pay scales, depending upon in which state a doctor practices. Former Senator Kent Conrad often spoke out publicly against variability of Medicare payments based upon geography. He noted that North Dakota consistently rated at the top of Medicare’s list for the quality of care doctors in the state provided Medicare patients. However, the Medicare reimbursements for the services physicians in the state provided were at the bottom of the pay scale. In other words, doctors in 49 states get higher Medicare reimbursements for the same service. This problem could be resolved by Congress, but the reimbursement discrimination remains unaddressed.

Problem #3: The Electronic Record

There is nothing about the electronic record that makes anybody’s life easier or better. Quite to the contrary. For a ten-minute patient visit, the provider might spend 10 to 20 minutes trying to get a chart note done and that time in many cases will be spent after the day is done, so the provider gets to add two or more hours of meaningless chart work to a ten-hour day.  In large organizations there may be “scribes” to take notes on the doctor-patient visit, but many physicians have no such luxury.

When a physician has no scribe to record the visit, the physician has to work on it during the patient visit. Doing a good patient interview takes time and lots of attention. Nobody describes this relationship between a physician and a patient better than Hans Duvefelt. And anybody who has a modicum of understanding or knowledge of how this works would know how important attention and good eye contact are. The provider also has to listen to the patient closely enough to ask the right questions and develop an understanding of the consumer’s condition to formulate a reasonable treatment plan and follow-up.

The whole point of a patient visit is to develop a relationship that is equivalent to a partnership. All of the distractions of the electronic record simply eviscerate the relationship with the patient which the provider is trying to establish or maintain. A relationship the physician and patient must have for patient care to be successful.

And of course, there is a false sense of accuracy, a big problem with  ICD 9 and ICD 10 coding. Very often the condition the patient has isn’t one of the numerous choices so the coding system prevents payment for an accurate diagnosis.

Problem #4: Prior Authorization

Prior authorization is a mess on several levels. In the first place, it’s remarkably time consuming and clinic schedules have no place to schedule the time it takes trying to deal with prior authorization. This may take an hour or more in the middle of the day when you’re supposed to be seeing patients. I can either be 90 minutes late for three patients or I can not make the phone call for prior authorization if I want to stay on schedule. Often, if I turned the prior authorization over to someone else, the results would get so messed up and I would have to spend even more time later correcting problems.

With prior authorization, sometimes I could be on hold on the phone for a half hour waiting to talk to somebody that’s called a “peer,” but indeed a person who is often an LPN and often one who is not a native English speaker. There should really be no one but a physician talking with a physician about prior authorization, but the system has made “peer” review a misnomer. Again, Hans Duvefelt describes this disconnect very well.

Primary care physicians need to be paid for supplying the care that keeps patients out of the hands of specialist referrals. It’s time CMS, Medicare, Medicaid, and all other payers to get rid of their excuses to withhold payments from primary care physicians. It’s time the federal and state governments stopped stonewalling paying primary care physicians. Primary care physicians are specialists—in keeping patients out of the high cost specialist track. It’s time for CMS, Medicare, and Medicaid organizations to actually act as if they care about the health of the people they cover. These interlopers need to care enough to actually solve all the payment problems which are exponentially driving up the cost of healthcare and destroying primary care.