Pamela A. MacLean
RedwoodAge.com

A proposal by a federal Medicare panel to avert a looming shortage of general practice doctors through financial incentives may be a case of robbing Peter to pay Paul.

The independent federal oversight panel on Medicare payment has recommended an increase of up to 10 percent in the payments for primary care services.  But to offset the cost increases, the Medicare Payment Advisory Commission recommended Congress cut the pay for specialized medical services.

The proposal comes as the Obama Administration struggles to find ways to increase the availability of primary care doctors without breaking the Medicare bank. The doctor shortage is predicted to grow more acute as the population ages. Tens of millions of boomers will need more frontline care from general practitioners, and millions of currently uninsured Americans are expected to gain coverage under newly proposed legislation.

Fewer than 20 percent of medical school graduates say they intend to go into primary health care, according to the Association of American Medical Colleges.  And while the advisory panel reported to Congress in March that a 2008 survey showed Medicare recipients generally had good access to primary care doctors, a small fraction had troubles.

What may be a harbinger of troubles, the March report said of the 6 percent of people looking for primary care doctors, about one-third had trouble finding them. 

"Care coordination is rare, specialist care is favored over primary care, quality of care is often poor, and costs are high and increasing at an unsustainable rate," Glenn M. Hackbarth, chairman of the 17-member advisory commission, told a Senate Finance Committee April 21.

"Part of the problem is that Medicare's fee-for-service (FFS) payment systems reward more care, and more complex care, without regard to the value of that care," he said.  "We must address those limitations - creating new payment methods that will reward efficient use of our limited resources and encourage the effective integration of care."

Racial Gaps
The problems with access may have regional and racial differences. The 2008 survey found that minorities were more likely than whites to face delays getting general care physicians.

For 30 years Dartmouth's Center for the Evaluative Clinical Sciences has documented wide variation across the US in Medicare spending rates for service, according to Hackbarth.  Much of it is driven by the geographic concentration of specialists and technology in some areas.  

But tensions between fees for general care and specialist will remain based on predicted shortages in specialty fields.  Orthopedic surgeons have warned that the number of patients requiring hip or knee replacement surgery will soon outpace the number of surgeons able to perform the operations.

Applicants to specialize in cardio thoracic surgery training who treat heart and lung disease has fallen for the fifth consecutive year, a problem likely to limit access to care down the road.

And boomers may find themselves lacking the care and comforting of nursing and other health care staff professions as older nurses leave the profession and fewer join.

Hackbarth warned that the Medicare payment system bias favoring specialists over primary care "has signaled to physicians that they will be more generously paid for procedures and specialty care, and signals providers to generate more volume."  This results in an "oversupply of specialized services and inadequate numbers of primary care providers," he warned.