Critical Condition

The new JAMA features two commentaries viewing with alarm the prospects for primary care as the health care reform legislation takes effect. Liselotte Dyrbye and Tait Shanafelt frame their concern around physician "burnout," which basically means the doctor feels a lot of work related stress, has difficulty empathizing with patients, and wants to quit. Joel Zinberg puts the problem in more straightforward terms: physicians will be increasingly squeezed financially.

The burnout problem comes mostly from excessive caseloads. There is a shortage of primary care physicians and once more people who are currently uninsured start showing up, they'll either get turned away or the docs will just have to work even harder and neglect the rest of their lives even more.

The money problem is a bit more complicated. The legislation expands the population eligible for Medicaid but once the 100% federal funding for the expanded population goes away in 2016, the states are going to have to pick up part of the cost and they are a) largely broke and b) not necessarily inclined to spend more on Medicaid anyway. Medicaid already pays less than other insurance and the states will no doubt respond by ratcheting down reimbursement even further. Second, Medicare reimbursement rates are scheduled to decline, which is not actually a feature of the Affordable Care Act but is one of the assumptions about how to pay for it. The original idea was to gradually decrease the spread in payment between specialty procedures and primary care but Congress kept putting it off so now we face a cliff.

The Act does propose lower payment rates to specialists which is supposed to reflect productivity improvements, but Zinberg argues that the result will be a reduction in physician income. Finally, the Independent Payment Advisory Board can recommend reductions in spending starting in 2014 if Medicare spending exceeds the overall rate of medical inflation, and until 2020, all of that effect will fall on physicians.

Zinberg doesn't think physicians are overpaid, given their medical school debt and delayed entry into the workforce associated with long training. That's debatable, in the case of many specialties, which is exactly the point here. We need to increase the supply of primary care providers, and we need to give them better pay and more satisfying working conditions. At the same time, we have too many specialists, who do too much, and they are overpaid relative to primary care providers. So I would say that hidden in Zinberg's essay is what really amounts to a plea for the privileges of specialists, which he happens to be. (He is a surgeon.)

We do face a real challenge in meeting the primary care needs of the population, and it does threaten to undermine health care reform and cause real hardship for patients and primary care providers. It's a difficult political challenge in part because medical specialists are well to do and politically powerful, and they aren't willing to give up their $200,000 a year plus incomes. Actually they might not have to if there were fewer of them and they did fewer unnecessary or harmful procedures, such as CABG and stenting and prostate removal and imaging -- all of which are overdone, among others. But primary care docs do have a real gripe. Graduating students aren't going into primary care even as more and more older doctors are retiring, so the situation is just going to get worse, at least in the near future.

But getting from the current situation with its powerful vested interests to where we need to be, well, there's no clear road.