UC Prof. Warns of Health Care System Crisis

Skyrocketing health care costs and longer lines at the doctor’s office are met with harried physicians more concerned with trying to meet their quota for the day than listening to health problems: This is the future of U.S. health care, according to UC health policy expert Thomas Bodenheimer.

Arash Keshmirian/Guardian
Medical school student Sasan Massachi (right), wants to pursue a career in oncology, while Kevin Burnham is undecided. Students are increasingly choosing specialized fields over primary care.

A drastic decrease in the number of primary care physicians over the past decade prompted the attention of Bodenheimer, a UC San Francisco professor of family and community medicine whose background includes not only an M.D. but also a master’s degree in public health.

In a perspective piece published last month in the Annals of Internal Medicine, Bodenheimer and two other doctors blamed the income gap between specialty and primary care physicians for the decline. While the incomes of primary care physicians are by no means meager, the discrepancy in comparison to specialists has become large enough to “”discourage medical school graduates from choosing primary care careers,”” Bodenheimer wrote in the article.

The article said that the percentage of medical school graduates in the United States choosing primary care has dropped from 14 percent in 2000 to 8 percent in 2005, a figure that has been dwindling since the mid-1990s. Studies have indicated that patients under consistent primary care have lower health care costs, making the decline a serious situation, especially with the number of people affected by chronic diseases on the rise. The American College of Physicians has expressed a need to take action to prevent what they call an “”impending collapse”” of primary care.

At UCSD alone, the number of students choosing primary care as a career has dropped to roughly 10 percent of the graduating class over the past 20 years, according to Rusty Kallenberg, head of the division of family medicine at UCSD. Kallenberg said he believes one of the main factors fueling students’ decisions to specialize is the looming debt, averaging $130,000 to $200,000, after leaving medical school.

However, patients put themselves in potential danger when they see several specialists but no primary care physician, because the specialists often lack knowledge of the patient’s overall health, he said.

“”[If it is] no one’s job to coordinate everything, [it is] not good news for patients,”” Kallenberg said.

The Resource-Based Relative Value Scale, implemented by Medicare in 1992 with the intent of reducing the disparity costs between office visits and procedures, has become the mechanism fueling the income divide, according to Bodenheimer. Instead of paying for face time with the doctor, the difference in the relative value unit, or RVU, of a visit is based on the work that is done.

A colonoscopy costs more than a normal office visit because the intensity of the work – mitigated by factors of skill, effort, judgment and stress – is seen as greater for p rocedures, as opposed to doctors’ cognitive efforts. Over the years, the volume of procedures performed by specialists has increased more rapidly than office visits, contributing to the higher salaries of specialists.

In addition, several studies have shown that private insurers favor specialist procedures over primary care. A 2002 study revealed that, on average, private insurers pay 120 percent of Medicare’s fee for procedures over 104 percent for office visits, allowing specialists to negotiate higher rates than primary care physicians.

Bodenheimer’s report also highlighted the somewhat biased process of updating RVU values. The American Medical Association and other specialist societies created the Relative Value Scale Update Committee, which is designed to recommend RVU updates every five years. Of the 29 members of the committee, 23 are from specialist societies, and only 15 percent of the voting members represent primary care.

The paper alleges that specialist-heavy membership, along with specialist society influence in the committee, has led to the avoidance of increasing evaluation and management RVUs – the meat and potatoes of primary care physician income.

Revelle College junior Matt Wiepking is one of many premed students on campus. Originally, Wiepking had his sights set on being a general practitioner or pediatrician, but has since been considering specialist fields like radiology.

“”There is obviously a financial factor, but a lot of it is lifestyle, patients and decisions you get to make,”” Weipking said.

He said he believes that more than the money, students may be more interested in the immediate, tangible benefits from specialty fields. In being able to see a change in the patient’s condition, Weipking said students may feel more useful.

After watching doctors and spending many volunteer hours in hospitals, Weipking said he does not necessarily agree with current method of charging patients.

“”I think there is a definite lean on doing the tests, but that stems from fear of malpractice,”” Weipking said. “”A lot of unnecessary procedures done [are] not a good way to practice medicine. [It’s] not helping patients.””

Bodenheimer suggested in his report that experts seek out alternate payment models that work to suit each area’s approach to treating patients. In the short term, he recommended that Medicare and private insurers identify ways to modify their reimbursement approaches while primary care tries to bolster its ranks.

“”Do we need surgeons if you get hit by a bus?”” Kallenberg said. “”Of course, but we also need vibrant primary care to prevent disease from unhelpful behavior.””