Primary Care Should Fare Well Under Health Care Reform

Congress could pass a comprehensive health care reform bill this year that provides some type of payment increase for primary care physicians under Medicare. If a primary care bonus is passed as part of a comprehensive health care reform bill, however, it is not clear how much of an increase it will be, according to analysts interviewed by AAFP News Now.

"I have not heard any leading congressman say, 'We are not going to do something for primary care physicians to really raise the (payment) increases,'" said Robert Blendon, Ph.D., professor of health policy and political analysis at the Harvard School of Public Health in Boston. "But I think from Congress' point of view, they are not in a position yet to figure out how much money they actually have to do that."

Obama administration officials and key members of Congress have repeatedly cited the importance of primary care in any major health care reform initiative, describing primary care as a way to improve quality while containing costs. In a recent interview with AAFP News Now, Sen. Max Baucus, D-Mont., chair of the Senate Finance Committee, said "meaningful, comprehensive reform must increase the value placed on primary care and redefine the role that primary care provides in our health system."

"The medical home and other comprehensive care management models like it hold great promise for reinvigorating primary care and improving the value of our health care spending," said Baucus, chair of one of two committees in the Senate with jurisdiction over health care reform legislation.

The extent of health care reform -- and any ensuing payment increases for primary care physicians -- will be determined, in large part, by the state of the economy and the size of the federal deficit this summer and fall, as health care reform legislation moves through Congress, according to Blendon. "If the deficit is a lot bigger, it is going to be harder to do some things. If the economy is a little bit better and the deficit is not as big, Congress will have more money to play with," he said.

Blendon, like many analysts, thinks Congress will pass some type of health care reform bill this year. But he says the legislation could be more of a "down-payment type of bill" instead of a comprehensive measure that addresses every facet of the health care debate. And there is always the possibility that Congress will fail to enact any type of health care reform legislation in 2009.

The state of the economy also will determine whether Congress can eliminate the flawed sustainable growth rate, or SGR, formula, which has triggered steep reductions in Medicare physician payment rates during the past several years. Congress has stepped in each time to block pending SGR cuts, but it is not clear whether federal lawmakers will eliminate the SGR outright or simply provide a payment patch for the next few years. In the House, however, the three committees with jurisdiction over health care reform legislation -- Energy and Commerce, Ways and Means, and Education and Labor -- recently put forth a health care reform draft that calls for the elimination of the SGR.

Baucus said during an April press conference that primary care physicians are "grossly underpaid" compared with many subspecialists. "We have in America a system where doctors are not paid for thinking, they are not paid for cognitive work," said Baucus. "They are paid for performing procedures. Primary care doctors spend a lot more time with patients, talking to senior citizens … but they are not paid for that.

"My own view is primary care docs have to be paid quite a bit more, and we are going to provide for that," he added.

In April, the Senate Finance Committee issued a policy options paper (52-page PDF; About PDFs) for health care reform that would provide a bonus payment of at least 5 percent for primary care services under Medicare during the next five years and a 1 percent increase in the overall physician payment rate in 2010 and 2011.

Although the proposed increases are significant, they are far less than the amounts called for by the AAFP, the American College of Physicians and the American Osteopathic Association, which represent the vast majority of primary care physicians who provide care for Medicare patients in this country. The proposed increases contained in the options paper may serve as an acknowledgement on the part of the Senate Finance Committee that Congress can allocate only a certain amount for primary care increases under the constraints of a faltering economy, according to analysts.

Baucus told AAFP News Now that the "SGR is broken and simply does not work." But the finance committee's options paper does not call for the elimination of the SGR and proposes instead to mitigate the effects of the formula during the next few years as the Medicare payment system moves toward rewarding prevention and chronic care management.

Subspecialists, meanwhile, also could play a role in determining payment increases for primary care physicians, depending on how hard they push back against proposed increases. Not surprisingly, their level of opposition will be determined by how much they are asked to forgo to support primary care, Blendon said.

"If you don't ask anyone to give up anything, they are all for helping underserved specialties," Blendon said. "If you say (sub)specialists are going to have to take a substantial reduction of what they get in the future to help out primary care doctors, they probably are not going to go quietly into that good night."

Nevertheless, primary care proponents are optimistic about the prospects for primary care in any major health care reform measure. In fact, the Senate Health, Education, Labor and Pensions Committee introduced a health care reform bill on June 9 that would strengthen the nation's primary care workforce by providing grants to establish, maintain and improve academic units in primary care. It would give priority to programs that educate students in team-based approaches to care, which includes the patient-centered medical home, thus fulfilling a request made by the AAFP.

The bill also would increase funding for the National Health Service Corps, and would create a primary care extension program -- patterned after a program proposed by FP Kevin Grumbach, M.D., of San Francisco -- to educate and provide technical assistance to primary care health professionals about evidence-based therapies, preventive medicine, health promotion, chronic disease management and mental health. According to the bill, the federal government would award planning and program grants to state entities, including state health departments, state-level entities administering Medicare and Medicaid, and at least one health professions school.

In the House, the health care reform draft put forth by the three committees -- Energy and Commerce, Ways and Means, and Education and Labor -- calls for increased payments to primary care health professionals and the elimination of cost-sharing for all preventive services. It also would make key investments in the primary care workforce by expanding the National Health Service Corps, boosting the training of primary care physicians and increasing the pipeline of individuals who are going into primary care.

"I think health care reform is going to place an emphasis on prevention, wellness and coordination of care," said Elizabeth Carpenter, associate policy director for health policy at the New America Foundation, a think tank in Washington. "There is a real understanding that we need to incentivize primary care in this country and reemphasize it -- to go back to our roots. Primary care has a large role to play in our health system going forward."

Blendon agreed, saying, "Under all cases, efforts will be made to pay primary care physicians more money and to give them more organizational support so the practice of primary care is more fulfilling."

"I think the words 'health reform' will be positive for family physicians," he said.