Emery Steele English 305T Dec. 11, 2012 Paper Four Sec 1.

Being a family physician is laden with disadvantages not faced by other medical specialties. These disadvantages are most obvious when considering compensation, competition, and workload. Sec 2. The problem of family doctor inequalityas it relates to compensation, workload, and competitioncan be solved by reformation of the fee-for-service system. According to Decker, Medicare patients have worse access to primary care physicians, because Medicares fees are also decreasing over time, but Medicare patients enjoy superior access to specialists, because specialists are best suited to taking advantage of Medicares fee-for-service reimbursement system(1). Because the fee-for-service favors specialists, the earning ability for family physicians is greatly reduced (See attached document). The system itself enables the problems of workload and compensation. An increase of 1 primary care physician per 10,000 population in a state was associated with a rise in that state's quality rank by more than 10 places and a reduction in overall spending by $684 per Medicare beneficiary(6). By changing it and focusing on an outcome vs. prognosis compensation system, all specialties will have equal earning potential and will be incentivized to provide quality care as opposed to quantity care. By raising compensation rates, more residents will be attracted to the specialty due to the increased earning potential and will greatly reduce the shortage and the apparent need for replacements. Commonly cited reasons for unhappiness with managed care include the traffic of

patients in and out of care for insurance reasons, administrative paperwork, limitations on referring patients to specialists of the physician's choice, financial incentives to curb medical workups, pressure to see high numbers of patients, and limitations on the prescribing of drugs.12 All of these cited reasons for burnout and lack of interest in the field would be solved by eliminating the shortage and basing compensation on quality. By reducing the burnout rates, even if the workload were to increase it would be much better managed by an effective and careful physician as opposed to the in-and-out system currently encouraged by the insurance companies. Continuing to pay primary care physicians considerably less than other doctors discourages medical students from choosing primary care careers. A better balance of physician reimbursement for care is urgently needed.7 Again, by solving the fee-for-service payment system, all physicians will have an approximately equal earning potential based on skill and effort which will draw many new medical students to the field. When the field is sought after, the competition posed by nurse practitioners will likely diminish or at least limit their role to a support role as opposed to a replacement role. Though some have supported the idea of independent nurse practitioners because of the lower costs involved with training and employing nurses, the approach fails to consider that those savings may be offset by decreased productivity and less efficient use of staff resources.8 If adequate numbers of physicians are available and it is shown that they can provide better care, use fewer resources, and lower costs, family physicians will be the obvious choice over their recent competition in PAs and NPs. The problem of family doctor inequalityas it relates to compensation, workload, and competitioncan be solved by re-organizing the roles of mid-level caregivers and

support staff. Schaffer points out that, The diagnostic challenges primary care physicians face on a daily basis require they have extensive clinical exposure in order to perform efficiently. The depth of knowledge required to filter undifferentiated patients complaints and to understand the subtleties of management is vast.4 By allowing NPs and PAs to take over the roles of the primary care physicians, the effectiveness and speed at which patients are treated is greatly reduced due mainly to lack of training. If a doctor were placed at the head of a NP and PA team, the skills of the doctor and the skills of the NPs/PAs could be used more effectively. The doctor will get to see and process the patients, reducing chances for mistakes and ensuring qualified long-management, and the NPs/PAs can carry out the orders and educate the patient. According to Goertz, Granting independent practice to nurse practitioners would create two classes of care: one run by a physician-led team and one run by less-qualified health care professionals.8 Additionally, if the primary care doctors role was limited to supervision and coordination, it would greatly reduce the amount of fatigue and burnout experienced by most doctors. This would allow for working fewer hours and a more even distribution of work across the team as a whole. Considerable unhappiness is also caused by the many nonmedical roles doctors now have for which they were never trained. Saddled with regulatory duties, doctors serve as de facto double agents for insurers, government agencies, and courts.12 This facet, one of the main contributors to burnout and physician attrition, could be almost entirely solved if physicians changed their role to being strictly medical care providers and delegating the rest of the non-physician work to other members of the team. This could be done by hospitals paying for their support staff. Instead of the hospitals having the house and supply doctors themselves, the doctors

could still have their own practice and the hospital could take care of the logistics. Thus, the doctor could still maintain his/her own practice without outside interference, and the hospital could save money on the costs of office space and resources. The primary care physicians who do exist are badly distributed 90 percent of internal medicine physicians, for example, work in urban areas. Some doctors go to work in rural areas or the poor parts of major cities, treating people who have Medicaid or no insurance.14 If rural hospitals encouraged doctors to work in rural areas by offering those services, a more uniform distribution would be ensue and fewer nurse practitioners would be needed to replace them. The study also found that there was strong support for the role of the nurse practitioner in the rural emergency setting.2 By incentivizing movement out of urban areas and towards rural areas, primary care doctors could better serve where they are needed and reclaim much of the territory lost to nurse practitioners and other mid-level caregivers. However, in order for this happen, it is crucial that the roles of office management and insurance/government correspondent be relocated to support staff and leave physicians to practice. The problem of family doctor inequalityas it relates to compensation, workload, and competitioncan be solved by insurance companies and government agencies providing incentives for primary care doctors. By incentivizing doctors to go into primary care, the insurance companies and the government can save more money. An increase of 1 primary care physician per 10,000 population in a state was associated with a rise in that state's quality rank by more than 10 places and a reduction in overall spending by $684 per Medicare beneficiary.6 The savings associated with this would immediately mitigate the initial incentivizing investment, and after the amount is paid

back, the saving could then be passed onto the primary care doctors themselves. Primary care physicians work hard, but their compensation is not correlated to their work effort when compared with physicians in other specialties. This disparity contributes to student disinterest in primary care specialties.7 These incentives would spark interest in the field, especially among medical students, and cause an influx of doctors into primary care. This would immediately begin to minimize the shortage and would only be needed for a short time before the increase in pay permanently solve the problem. Empathy and compassion have been shown to be important in maintaining an effective therapeutic alliance with patients and in delivering effective and high quality health care. For some doctors, this may extend to a feeling that there is an ethical obligation to sacrifice their own needs for the needs of their patients.11 The increase in pay and reduction in hours worked will help to mitigate the feelings of sacrificing their own needs for their patients and would likely reduce physician burnout. In part its the money. Primary care doctors make less than specialists anywhere, but they take an even larger financial hit to treat the poor. Particularly in the countryside even with programs that offer partial loan forgiveness, its very hard to pay off medical school debt treating Medicaid patients, much less those with no insurance at all.14 By supplementing the current system with additional savings brought on by the decrease in long-term medical costs, the former system will be ameliorated to better compete with the financial security enjoyed by specialists. Granting independent practice to nurse practitioners would create two classes of care: one run by a physician-led team and one run by lessqualified health care professionals. Physicians are required to complete roughly 16,000 more hours of training than nurse practitioners.8 Because nurse practitioners arent as

proficient at utilizing resources and managing complex patients, the cost would increase as time went on. Even if cost didnt increase, if fewer physicians are around, the quality of care as a whole would decrease. This would require more training, more debt, and would eventually lead to the same situation we are in now. It would be much more effective to fix the current system and bypass that period of compromised care. Sec 3. The problem of family doctor inequalityas it relates to compensation, workload, and competitioncan be solved by reformation of the fee-for-service system. This can be done starting with a few key steps. 1. Pass a bill through congress that offers tax incentives or requires insurance companies to maintain certain requirements based on overall health. Because primary care physicians make the largest impact on overall health, they will be heavily favored. 2. Reduce the Medicare and Medicaid reimbursement system that is based on the performing of the system. Instead, make the reimbursement scheme based on statistical success on prognosis vs. outcome. This will get rid of unnecessary procedures and allow physicians to gain more earning potential to equate more to their contribution. 3. Legislate or encourage the private sector to ensure that procedures performed are done in the best interest of the client and not simply for the reimbursement. This will prevent specialists from exploiting the system and allow for more equal distribution of compensation.

The problem of family doctor inequalityas it relates to compensation, workload, and competitioncan be solved by re-organizing the roles of mid-level health care providers. This can be done starting with a few key steps. 1. Require the licensing body in each state to require a medical license. This will make NPs and PAs less independent and rely more on primary care doctors. 2. Allow NPs and PAs to work using the license of a trained primary care doctor. By doing this, it ensures proper oversight and acts as an fail-safe for complicated cases out of mid-level training. 3. Require all specialists and caregivers to coordinate with the primary care doctor in order to receive payment. This will also ensure that unnecessary procedures are not done and help to protect the patient. In addition this reinforces the doctor oversight of mid-level practitioners.

The problem of family doctor inequalityas it relates to compensation, workload, and competitioncan be solved by incentivizing the field of primary care. This can be done starting with a few key steps. 1. Require insurance companies to use part of the premium they receive strictly for training primary care physicians. By doing so, although the insurance company would lose money initially, the money they would save from insuring healthier patients would more than pay for it. Also, it would provide a monetary

reason to go into primary care, which lacks such an incentive compared to all other fields of medicine. 2. Make available government subsidized loans for primary care doctors that are easily forgivable or without interest. By making the avenue to becoming a primary care doctor easier than other fields, it will become a central reason medical students go into the field. The crippling debt that deters many primary care physicians will be eliminated or greatly reduced allowing those who want to pursue the field to do so. 3. Increase the pay of primary care residents. By increasing resident pay, primary care doctors will get a head start on earning potential compared to specialists. Additionally, because residents are often very short of money and are forced to live off a meager salary whilst trying to build a life, this will be very appealing and will likely draw a large numbers of medical students. 4. Provide a government funded supplement to primary care physicians during the first five years of practice. Setting up a practice requires tremendous amounts of money and is often very difficult. It takes several years to build up a client base large enough to make a living and is a major deterrent for many medical students. By ensuring a baseline salary from the government to help remain competitive in the medical field, the perceived hardships of many student doctors will be laid to rest and thus encourage much more movement into the field.