Primary care’s eroding earnings: Is Congress concerned?

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Original Research

Primary care’s eroding earnings: Is Congress concerned?

J Fam Pract. 2008 September;57(9):578-583

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References

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The SGR dominates discussions on physician payment

All respondents had a functional understanding of the SGR and desired reform, but few understood how the SGR contributes to the payment gap. Many staffers would like to do away with the SGR, but CBO estimates show that this would be cost-prohibitive.²⁴

FAST TRACK

Several major insurers are beginning regional experiments in raising fees for primary care visits in an effort to avoid greater costs down the road

A few staffers believed that SGR reform may not happen until 2009, after the next president takes office. Some participants also predicted that SGR reform will not happen until more physicians refuse to see Medicare patients. To date, MedPAC has reported each year that there is no Medicare access crisis. Staffers from rural districts, however, affirmed that constituents are having difficulty finding primary care doctors who take Medicare.

Staffers uniformly agreed that nobody has the answer to fix the SGR. Several staffers commented on the complexity of the problem, pointing out that MedPAC’s March 2007 SGR report did not achieve a consensus on how to restructure the rate. Many participants were disappointed with the MedPAC report and want solutions to fix physician payment that are more directed and “convincing.”

Some expressed a need for “hands-on models and demonstration projects.” Although these staffers have heard of models that would split the SGR by specialty or geography, they remain skeptical about such proposals without evidence of efficacy. Staffers were also wary of splitting the SGR by specialty, believing it would cause infighting among physicians.

Staffers know far less about RBRVS than they do about the SGR. One staffer admitted, “I won’t pay attention until something is at a crisis point or we have a hearing or a vote.” A few staffers asserted that there should be a more rigorous RUC review to examine what services are over- and undervalued.

Government agencies are not asked to address primary care. At the time of interview (March 2007), staff from MedPAC, GAO, and CBO said that Congress had not asked them to study issues in primary care. One CBO analyst asserted that “nobody’s been able to demonstrate significant changes in volume or outcome [as a result of investing in primary care]…we need empirical data.” The analyst also mentioned CMS demonstration projects as a way to gather data. According to a Capitol Hill veteran, the CBO believes that even if primary care extends a person’s life, this may not necessarily save money.

Discussion

Although most of the interviewed congressional staffers recognize the payment gap and understand that the number of physicians entering primary care is decreasing, Congress has not taken action to address these issues. Several factors explain this.

SGR is the 800-pound gorilla. When discussing physician payment, congressional staffers appear far more concerned with reforming the SGR than addressing problems in primary care. This perception is supported by the fact that Congress has asked MedPAC and CBO to investigate the SGR, but has not asked them to examine issues in primary care. For Congress, the dilemma is to hold down physician spending while keeping physicians in the Medicare market. Staffers are dissatisfied with SGR reform proposals from MedPAC and are eager to learn about new possible solutions.

No one perceives a crisis in access to Medicare providers. According to annual MedPAC reports, the number of primary care doctors accepting Medicare patients is sufficient. Staff for members of Congress from rural areas, however, contend that some constituents cannot find a primary care provider who accepts Medicare.

Congress is not convinced that primary care saves money. Although some staffers believe that primary care can reduce costs, the CBO argues that this is not necessarily true. It is indeed difficult to prove cost savings from investing in preventive services because there is greater upfront cost, and extending people’s lives could incur higher future costs. Research, however, shows that primary care-oriented systems reduce preventable hospitalizations, which decreases costs.^4,5,7,8 It seems that either the existing evidence is insufficient to convince the CBO or the evidence has not been communicated effectively.

Strategic leverage moving forward

The time is ripe for SGR reform because most staffers conveyed a desire for solutions. Because the SGR appears to take priority over primary care issues, it must be dealt with first. It is possible, however, for policy makers to address the SGR and RBRVS reforms while simultaneously investing in primary care. The SGR and RBRVS reforms could hold specialties accountable for their own volume growth and protect specialties with minimal volume growth.