The State of Primary Care
http://www.100md.com
《新英格兰医药杂志》
To the Editor: In his Perspective article (Aug. 31 issue),1 Bodenheimer accurately describes the assault on primary care medicine. Insurers deny payment and bureaucrats add onerous record keeping, while the needs of patients increase. We persist only because of the rewards that are documented in the accompanying Perspective article by Woo.2
It seems unlikely that macrosystem improvement will occur in the near future. For small practices, rhetoric about efficiency and quality produces more problems than solutions. Pay for performance is a good example. In the 1990s, the "golden age" of health maintenance organizations and capitation, my partner and I were the beneficiaries of a bonus. The reward for a 3-month period — during which we earned a score above 95% in patient satisfaction, adhered to prevention guidelines, and provided same-day appointments and evening office hours — was $6.98.
In contrast, microsystem improvement is available now, through reversion to having patients pay for service. Five years ago, my practice stopped participating in all insurance programs with the exception of Medicare.3 We require no membership fee and adjust for financial hardship. We offer same-day appointments, after-hours coverage, lower overhead, and coordination with specialists. The demand for services from patients led us to add two more physicians to our practice. I offer this optimistic note to other primary care practices.
Jane H. Chretien, M.D.
Bethesda Physicians
Bethesda, MD 20814
bethesdaphysicians@verizon.net
References
Bodenheimer T. Primary care -- will it survive? N Engl J Med 2006;355:861-864.
Woo B. Primary care -- the best job in medicine? N Engl J Med 2006;355:864-866.
Lowes R. No coding, no insurers -- no kidding. Med Econ 2004;81:44-48.
To the Editor: Bodenheimer errs in dismissing international medical-school graduates (IMGs) in a single sentence. With American medical-school graduates showing a decline in interest in primary care residencies and practices, IMGs are increasingly the "safety net," satisfying the staffing needs of practices and community health centers throughout the country.1 In the 1990s, with an oversupply of physicians a looming fear, some observers advocated a severe restriction in the training of IMGs. With the current undersupply, such action would be untenable.2
The IMG migration has been described as a "brain drain," but given the constraints of rigid and suffocating domestic academic atmospheres and poor remuneration in their own countries, IMGs have tended not to return home.3 This situation appears to be changing, as shown by the trend of outsourcing images for reading by U.S.-trained IMG radiologists in their native countries.4 As IMGs, we believe that any examination of the future of primary care must involve a more detailed discussion of the role of IMGs and their contributions.
Rohit R. Das, M.B., B.S., M.P.H.
Boston Medical Center
Boston, MA 02118
rohit.das@bmc.org
Ranjani N. Moorthi, M.B., B.S., M.P.H.
Tufts–New England Medical Center
Boston, MA 02111
References
McMahon GT. Coming to America -- international medical graduates in the United States. N Engl J Med 2004;350:2435-2437.
Whitcomb ME. Correcting the oversupply of specialists by limiting residencies for graduates of foreign medical schools. N Engl J Med 1995;333:454-456.
Patel V. Recruiting doctors from poor countries: the great brain robbery? BMJ 2003;327:926-928.
Wachter RM. International teleradiology. N Engl J Med 2006;354:662-663.
To the Editor: Bodenheimer precisely describes the complexities of providing primary care in an environment that is constrained by inadequate reimbursement, an overwhelming scope of practice, and a decreasing number of physicians. He notes that "many nurse practitioners and physician assistants who could join the primary care workforce are instead going to work in wealthier specialty practices." Recent data regarding nurse-practitioner practices do not support this statement.
As is consistent with their role, 85% of nurse practitioners currently practice in primary care.1,2 Nurse practitioners are more likely than physicians to care for the underserved, work in rural areas, and provide health-promotion services.2,3 In 2005, schools of nursing enrolled more than 18,000 students in programs for primary care nurse practitioners and graduated more than 5000.2,4 More than 11,000 of these students were enrolled in programs for family nurse practitioners.4 In contrast, 1132 graduates of U.S. medical schools enrolled in family medicine residencies in the same year.
Clearly, the paradigm for the provision of primary care services is changing. The dwindling supply of primary care physicians suggests that nurse practitioners may become the future gatekeepers of primary care.
Kathleen Lent Becker, M.S., C.R.N.P.
Sara Carleton, B.S.N., R.N.
Grace Ihsiu Lin, M.S., R.N.
Johns Hopkins University School of Nursing
Baltimore, MD 21205
kbecker@son.jhmi.edu
References
Goolsby MJ. 2004 AANP National Nurse Practitioner Sample Survey, part I: an overview. J Am Acad Nurse Pract 2005;17:337-341.
Hooker RS. Physician assistants and nurse practitioners: the United States experience. Med J Aust 2006;185:4-7.
Hooker RS, McCaig LF. Use of physician assistants and nurse practitioners in primary care, 1995-1999. Hosp Q 2001;5:32-36.
Fang D, Wilsey-Wisniewski S, Bednash GD. 2005–2006 Enrollment and graduations in baccalaureate and graduate programs in nursing. Washington, DC: American Association of Colleges of Nursing, 2006.
To the Editor: In the United States today, there are various kinds of primary care providers, with various levels and types of training. There are also various types of patients: elderly people with multiple chronic, serious conditions; others with dangerous acute illnesses; and healthy people seeking preventive care. There are problems for which self-treatment is suitable (upper respiratory infection, for example) and other conditions (such as obesity) that may be more responsive to public health measures. When we lump all the health problems together as "primary care" and use the same payment method for each, we essentially pay an average: not enough for complex cases and maybe too much for simple ones. Increasing the amount of reimbursement for every visit because an office has an electronic system and ancillary personnel will not fix this problem. We need to restructure the coding system to place greater emphasis on the complexity and number of problems that patients have and less emphasis on the extent of our examination.
Caroline Poplin, M.D., J.D.
6113 Wynnwood Rd.
Bethesda, MD 20816
cmpoplin@aol.com
To the Editor: I know from my personal experience the perilous status of primary care. A student recently remarked to me that students seeking residencies in internal medicine are perceived as being too weak to obtain any other type of residency. Another student requested a letter of recommendation for a radiology residency with an alternative version for use in securing a fallback position in internal medicine. When one internal medicine resident requested an additional day per week of continuity clinic to help prepare for a career in primary care, his peers pressured him to withdraw the request, because they would have had to cover his inpatient responsibilities during those hours.
An increasing shortage of faculty further threatens the discipline. Instruction in physical diagnosis, traditionally performed by internists, is now sometimes directed by anesthesiologists. My own patient panel has had several influxes of new patients as our residency alumni leave primary care and refer their patients back to the training site. Thus, I see both patients whom I inherited from my retired mentors and patients inherited from my prematurely retired trainees.
Let us again foster the social and political movement toward more equitable health care.
Stuart Oserman, M.D.
Advocate Lutheran General Hospital
Park Ridge, IL 60068
stuart.oserman@advocatehealth.com
To the Editor: The country's two largest medical organizations for primary care physicians are working purposefully to answer Bodenheimer's call for a national policy to rescue primary care. The American Academy of Family Physicians and the American College of Physicians have joined together to advocate for a patient-centered medical home based on a patient's continuous relationship with a personal physician. We believe that this model not only is what patients and physicians want but also promises to make health care more effective, more efficient, and more equitable.
However, the success of this model is predicated on macrosystem reform. The patient-centered medical home requires a different way of compensating physicians. Payments should reflect the value of services involved in coordinating care, support practices in acquiring needed information technologies, and reward measurable and continuous quality improvement.
We have a plan to make a patient-centered medical home a reality for all Americans. In return, government and payers must invest in primary care by eliminating a flawed system that rewards fragmented, high-volume, overspecialized, and inefficient care and adopting a payment system that facilitates high-quality and efficient care centered on the relationships of patients with their primary care physicians.
Larry S. Fields, M.D.
American Academy of Family Physicians
Leawood, KS 66211
Lynne M. Kirk, M.D.
American College of Physicians
Philadelphia, PA 19106
Dr. Bodenheimer replies: The responses from the correspondents all contribute to a better understanding of the situation of primary care in the United States. Regarding the letter from Das and Moorthi, a detailed examination of IMGs can be found in Mullan's 2005 article in the Journal.1 Poplin wisely suggests that the coding system needs to be restructured in order to focus on the complexity and number of problems that patients have. Many ideas for fixing the coding system or moving away from fee-for-service payment to more blended payment modes have been proposed, and Poplin's proposal is one possibility. The fear is that the coding system will not be reformed and will continue to ignore the increasing intensity of care provided by most primary care practices.
Oserman eloquently describes the distress of training programs for primary care physicians. But not all is dismal. Currents of reform are stirring in residencies in family medicine and general internal medicine, with the potential for making primary care training far more attractive.
The letter from Becker et al. about nurse practitioners brings up an important issue. Until recently, I believed that nurse practitioners would become the primary care clinicians of the future, and having worked with excellent nurse practitioners and physician assistants, I have great confidence in these advanced practice clinicians. The references provided by Becker et al. are compelling. But recently, I have heard many anecdotes of nurse-practitioner graduates who are having difficulty finding jobs in primary care (owing to the unstable finances of many primary care practices) and are opting for positions in cardiology or other specialties. It is too early to tell, but the next few years may show us whether this is the start of yet another trend away from primary care.
Thomas Bodenheimer, M.D.
University of California, San Francisco
San Francisco, CA 94134
References
Mullan F. The metrics of the physician brain drain. N Engl J Med 2005;353:1810-1818.
It seems unlikely that macrosystem improvement will occur in the near future. For small practices, rhetoric about efficiency and quality produces more problems than solutions. Pay for performance is a good example. In the 1990s, the "golden age" of health maintenance organizations and capitation, my partner and I were the beneficiaries of a bonus. The reward for a 3-month period — during which we earned a score above 95% in patient satisfaction, adhered to prevention guidelines, and provided same-day appointments and evening office hours — was $6.98.
In contrast, microsystem improvement is available now, through reversion to having patients pay for service. Five years ago, my practice stopped participating in all insurance programs with the exception of Medicare.3 We require no membership fee and adjust for financial hardship. We offer same-day appointments, after-hours coverage, lower overhead, and coordination with specialists. The demand for services from patients led us to add two more physicians to our practice. I offer this optimistic note to other primary care practices.
Jane H. Chretien, M.D.
Bethesda Physicians
Bethesda, MD 20814
bethesdaphysicians@verizon.net
References
Bodenheimer T. Primary care -- will it survive? N Engl J Med 2006;355:861-864.
Woo B. Primary care -- the best job in medicine? N Engl J Med 2006;355:864-866.
Lowes R. No coding, no insurers -- no kidding. Med Econ 2004;81:44-48.
To the Editor: Bodenheimer errs in dismissing international medical-school graduates (IMGs) in a single sentence. With American medical-school graduates showing a decline in interest in primary care residencies and practices, IMGs are increasingly the "safety net," satisfying the staffing needs of practices and community health centers throughout the country.1 In the 1990s, with an oversupply of physicians a looming fear, some observers advocated a severe restriction in the training of IMGs. With the current undersupply, such action would be untenable.2
The IMG migration has been described as a "brain drain," but given the constraints of rigid and suffocating domestic academic atmospheres and poor remuneration in their own countries, IMGs have tended not to return home.3 This situation appears to be changing, as shown by the trend of outsourcing images for reading by U.S.-trained IMG radiologists in their native countries.4 As IMGs, we believe that any examination of the future of primary care must involve a more detailed discussion of the role of IMGs and their contributions.
Rohit R. Das, M.B., B.S., M.P.H.
Boston Medical Center
Boston, MA 02118
rohit.das@bmc.org
Ranjani N. Moorthi, M.B., B.S., M.P.H.
Tufts–New England Medical Center
Boston, MA 02111
References
McMahon GT. Coming to America -- international medical graduates in the United States. N Engl J Med 2004;350:2435-2437.
Whitcomb ME. Correcting the oversupply of specialists by limiting residencies for graduates of foreign medical schools. N Engl J Med 1995;333:454-456.
Patel V. Recruiting doctors from poor countries: the great brain robbery? BMJ 2003;327:926-928.
Wachter RM. International teleradiology. N Engl J Med 2006;354:662-663.
To the Editor: Bodenheimer precisely describes the complexities of providing primary care in an environment that is constrained by inadequate reimbursement, an overwhelming scope of practice, and a decreasing number of physicians. He notes that "many nurse practitioners and physician assistants who could join the primary care workforce are instead going to work in wealthier specialty practices." Recent data regarding nurse-practitioner practices do not support this statement.
As is consistent with their role, 85% of nurse practitioners currently practice in primary care.1,2 Nurse practitioners are more likely than physicians to care for the underserved, work in rural areas, and provide health-promotion services.2,3 In 2005, schools of nursing enrolled more than 18,000 students in programs for primary care nurse practitioners and graduated more than 5000.2,4 More than 11,000 of these students were enrolled in programs for family nurse practitioners.4 In contrast, 1132 graduates of U.S. medical schools enrolled in family medicine residencies in the same year.
Clearly, the paradigm for the provision of primary care services is changing. The dwindling supply of primary care physicians suggests that nurse practitioners may become the future gatekeepers of primary care.
Kathleen Lent Becker, M.S., C.R.N.P.
Sara Carleton, B.S.N., R.N.
Grace Ihsiu Lin, M.S., R.N.
Johns Hopkins University School of Nursing
Baltimore, MD 21205
kbecker@son.jhmi.edu
References
Goolsby MJ. 2004 AANP National Nurse Practitioner Sample Survey, part I: an overview. J Am Acad Nurse Pract 2005;17:337-341.
Hooker RS. Physician assistants and nurse practitioners: the United States experience. Med J Aust 2006;185:4-7.
Hooker RS, McCaig LF. Use of physician assistants and nurse practitioners in primary care, 1995-1999. Hosp Q 2001;5:32-36.
Fang D, Wilsey-Wisniewski S, Bednash GD. 2005–2006 Enrollment and graduations in baccalaureate and graduate programs in nursing. Washington, DC: American Association of Colleges of Nursing, 2006.
To the Editor: In the United States today, there are various kinds of primary care providers, with various levels and types of training. There are also various types of patients: elderly people with multiple chronic, serious conditions; others with dangerous acute illnesses; and healthy people seeking preventive care. There are problems for which self-treatment is suitable (upper respiratory infection, for example) and other conditions (such as obesity) that may be more responsive to public health measures. When we lump all the health problems together as "primary care" and use the same payment method for each, we essentially pay an average: not enough for complex cases and maybe too much for simple ones. Increasing the amount of reimbursement for every visit because an office has an electronic system and ancillary personnel will not fix this problem. We need to restructure the coding system to place greater emphasis on the complexity and number of problems that patients have and less emphasis on the extent of our examination.
Caroline Poplin, M.D., J.D.
6113 Wynnwood Rd.
Bethesda, MD 20816
cmpoplin@aol.com
To the Editor: I know from my personal experience the perilous status of primary care. A student recently remarked to me that students seeking residencies in internal medicine are perceived as being too weak to obtain any other type of residency. Another student requested a letter of recommendation for a radiology residency with an alternative version for use in securing a fallback position in internal medicine. When one internal medicine resident requested an additional day per week of continuity clinic to help prepare for a career in primary care, his peers pressured him to withdraw the request, because they would have had to cover his inpatient responsibilities during those hours.
An increasing shortage of faculty further threatens the discipline. Instruction in physical diagnosis, traditionally performed by internists, is now sometimes directed by anesthesiologists. My own patient panel has had several influxes of new patients as our residency alumni leave primary care and refer their patients back to the training site. Thus, I see both patients whom I inherited from my retired mentors and patients inherited from my prematurely retired trainees.
Let us again foster the social and political movement toward more equitable health care.
Stuart Oserman, M.D.
Advocate Lutheran General Hospital
Park Ridge, IL 60068
stuart.oserman@advocatehealth.com
To the Editor: The country's two largest medical organizations for primary care physicians are working purposefully to answer Bodenheimer's call for a national policy to rescue primary care. The American Academy of Family Physicians and the American College of Physicians have joined together to advocate for a patient-centered medical home based on a patient's continuous relationship with a personal physician. We believe that this model not only is what patients and physicians want but also promises to make health care more effective, more efficient, and more equitable.
However, the success of this model is predicated on macrosystem reform. The patient-centered medical home requires a different way of compensating physicians. Payments should reflect the value of services involved in coordinating care, support practices in acquiring needed information technologies, and reward measurable and continuous quality improvement.
We have a plan to make a patient-centered medical home a reality for all Americans. In return, government and payers must invest in primary care by eliminating a flawed system that rewards fragmented, high-volume, overspecialized, and inefficient care and adopting a payment system that facilitates high-quality and efficient care centered on the relationships of patients with their primary care physicians.
Larry S. Fields, M.D.
American Academy of Family Physicians
Leawood, KS 66211
Lynne M. Kirk, M.D.
American College of Physicians
Philadelphia, PA 19106
Dr. Bodenheimer replies: The responses from the correspondents all contribute to a better understanding of the situation of primary care in the United States. Regarding the letter from Das and Moorthi, a detailed examination of IMGs can be found in Mullan's 2005 article in the Journal.1 Poplin wisely suggests that the coding system needs to be restructured in order to focus on the complexity and number of problems that patients have. Many ideas for fixing the coding system or moving away from fee-for-service payment to more blended payment modes have been proposed, and Poplin's proposal is one possibility. The fear is that the coding system will not be reformed and will continue to ignore the increasing intensity of care provided by most primary care practices.
Oserman eloquently describes the distress of training programs for primary care physicians. But not all is dismal. Currents of reform are stirring in residencies in family medicine and general internal medicine, with the potential for making primary care training far more attractive.
The letter from Becker et al. about nurse practitioners brings up an important issue. Until recently, I believed that nurse practitioners would become the primary care clinicians of the future, and having worked with excellent nurse practitioners and physician assistants, I have great confidence in these advanced practice clinicians. The references provided by Becker et al. are compelling. But recently, I have heard many anecdotes of nurse-practitioner graduates who are having difficulty finding jobs in primary care (owing to the unstable finances of many primary care practices) and are opting for positions in cardiology or other specialties. It is too early to tell, but the next few years may show us whether this is the start of yet another trend away from primary care.
Thomas Bodenheimer, M.D.
University of California, San Francisco
San Francisco, CA 94134
References
Mullan F. The metrics of the physician brain drain. N Engl J Med 2005;353:1810-1818.