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Patient-Centered Care: Helping Cure NJ's Primary Physician Shortage

UMDNJ third-year medical student Krysta Johns-Harris

A recently developed healthcare model known as a "patient-centered medical home" could improve the quality of care received by patients, the quality of life of the doctors who treat them, and even help slow or reverse New Jersey's growing shortage of primary care physicians.

That shortfall could become a crisis in the next few years, as the state's population grays and a significant number of uninsured are covered by federal healthcare reform.

Also contributing to the problem: simple economics. Newly minted doctors burdened by as much as $200,000 in student debt are understandably drawn to higher-paid specialties like radiology or orthopedics. They also worry that the long hours required to make a living in family medicine or pediatrics will leave them with too little time for their own families.

At the heart of a patient-centered medical home, or PCMH, is care coordination: the PCMH coordinates the care patients receive from specialists, with an eye to making sure patients actually get the care they need, and avoid overuse of potentially superfluous -- and expensive -- tests and procedures.

PCMH physicians also spend more time with their patients, seeking to improve health outcomes by addressing gaps in care, such as heart patients who haven't filled their prescriptions, or diabetics who are overdue for a check up.

The goal is for the PCMH to both improve patient health and lower healthcare spending, and for the practice to receive additional compensation for achieving those goals.

Insurers are taking note. Some have begun increasing payments to PCMHs, enabling doctors to both earn more and to have a more rewarding professional experience.

And primary care advocates are hoping that the PCMH model is giving medical students a reason to reconsider a career in primary care.

Horizon Healthcare Innovations, a new subsidiary of the state's largest health insurer, has taken the lead in advancing the PCMH concept. Its two-year old pilot program has worked with PCMHs to develop best practices for patient care, to better compensate physicians, and to hire the staff needed for care coordination.

Recently, HHI President Dr. Richard Popiel and several of the family physicians in the pilot met with medical students at the University of Medicine and Dentistry of New Jersey to give them an inside view of how the PCMH -- a credential awarded by the National Committee for Quality Assurance (NCQA) -- is transforming primary care, and to encourage them to consider enrolling in a primary care residency after medical school.

His message, Popiel said, was that primary care is changing for the better, and students who want to go into it can look forward to better lifestyles and compensation than in the past.

"All of the work that we have been doing around the PCMH has been to stabilize the primary care community and hopefully, over time, reinvigorate primary care as a viable, satisfying specialty at the center of the healthcare system," said Popiel, who intends to maintain a dialogue with medical students.

"Right now there is a fairly significant disadvantage for physicians who go into primary care. We just want to make the playing field level, so they can make the choice [between primary care and other specialties] based on their real desires."

Popiel indicated that a PCMH practice could reasonably expect to see compensation at twice the level of a traditional primary care practice. "So you can double the compensation to the practice, and in doing that you are improving quality, improving patient satisfaction and lowering the total cost," he added. "We are putting money on the table to jumpstart and really catalyze a focus around population management. We have an opportunity to make healthcare affordable and make a decent living available to these physicians."

Dr. Robin Schroeder, interim chair of the family medicine department at the UMDNJ New Jersey Medical School in Newark, helped set up the March meeting between Horizon and the students. She said that as far as she can recall, this is the first time an insurer has come to the medical school to talk to students about pursuing a career in primary care.

"It shows me that the whole idea of the PCMH is finally taking hold. Students who have a passion for primary care really want to be reassured that they can do this, and still be able to pay back their loans and make a living. I really feel as though we are on the cusp of change in New Jersey," Schroeder said.

Katerina Dukleska, a third year student at UMDNJ in Newark, has not yet decided whether to follow primary care or in a surgical specialty. She is doing a family medicine rotation in the office of Hillside family practitioner Dr. Walter Matkiwsky. "I'm seeing patients from pediatrics to people in their '90s, and a broad range of diseases. You see a healthy child, then a patient with cancer and other complicated diseases that require coordination with specialists."

The median income in 2010 for primary care physicians in the Eastern United States was $180,203 for pediatrics; $182,658 for family medicine; and $195,453 for general internal medicine, according to the Medical Group Management Association, the coalition of professional administrators of group medical practices. According to the MGMA, the median pay for all primary care physicians in the United States was $202,392 in 2010, while the median for specialists was $356,885.

Joel Cantor, director for the Rutgers Center for State Health Policy said "the reimbursement system is skewed toward specialty care, leaving primary care at a disadvantage." He said "tackling the disparity between specialty fees and primary care fees in the Medicare program is probably the most important step. It's an ongoing debate -- we'll see what happens."

Cantor said there is "no political appetite for taking the money away from specialists to give it to primary care," and increasing total spending to pay primary care doctors more will be difficult at a time when Medicare is trying to get its fiscal house in order.

While the income gap persists between primary and specialty care, there are some signs that the increased demand for primary care doctors is having an impact in New Jersey, according to Dr. Alfred F. Tallia, chair of the department of family medicine and community health at UMDNJ's Robert Wood Johnson Medical School.

Tallia said that four years ago the starting salary in New Jersey for a family physician who had just completed residency was typically around $110,000; doctors today can start as high as $150,000 to $160,000. But he said New Jersey competes in a national market for primary care doctors, and in the Pacific Northwest "they have staring salaries around $225,000 and the cost of living is lower and the practice environment is more favorable."

Tallia noted that physician groups are asking the state legislature to expand New Jersey's primary care loan redemption program, slated to receive $1.5 million in funding in the 2013 budget. In past years funding has been as high as $2 million. The New Jersey Council of Teaching Hospitals advocates income tax credits for doctors who set up their practices in New Jersey, and argues that by forgoing income taxes the state would generate more taxes from the jobs and economic activity created by new medical practices.

Horizon and other insurers, including Aetna and QualCare, have increased their payments to PCMHs. Tallia said this reflects the "realization that the more primary care physicians, the better the outcomes for patients. The purchasers of health care -- the businesses that insure people, and the government --have woken up to the realization that the relative absence or imbalance between primary care and subspecialty care is a problem that needs to be addressed."

Tallia added that "It is refreshing to see an organization like Horizon, which has a lot to say about how much primary care physicians get paid, being aware of the problem and trying to do something about it."

Most of New Jersey's PCMH practices care for adults, but pediatricians are also moving toward this model, according to Fran Gallagher, executive director of the New Jersey chapter of the American Academy of Pediatrics. The association was part of a consortium that received federal funds to help 30 New Jersey pediatric practices take steps toward becoming PCMHs. It also has joined another consortium seeking $22 million from the Centers for Medicare and Medicaid Services to create a "innovation challenge cooperative" that would enable 40 pediatric and 40 family medicine practices in New Jersey become PCMHs.

The CMS proposal is highly competitive. Gallagher said the agency received about 3,000 applications nationwide and will make the awards this month. But whether New Jersey's proposal is funded or not, "the creation of PCMHs is the vision we are looking towards, in order to improve the quality of health care and to lower the cost," she said.

The CMS proposals envisions creating four regional "medical home neighborhoods" in New Jersey, where hospitals, federally funded health centers, and pediatric and family practices would collaborate. Coupled with a program to reduce excessive emergency room use, and to increase preventive care, the project estimates saving $37 million in healthcare costs over three years.

So far efforts to improve primary care compensation have been focused on practices that treat adults, because the greatest opportunity to lower healthcare spending is associated with adult chronic diseases like diabetes.

Dr. Stephen G. Rice, president of the New Jersey chapter of the American Academy of Pediatrics, said insurers realize that "If I have an adult who is 35 and has diabetes, I have to care for that patient from now until the end of their life, so I sure as heck want to minimize complications and hospitalizations. So it is definitely cost-effective for me to pay more to the PCMH to control the cost of their treatment over the course of the life."

"But if a 12-year old gets diabetes, in six years that patient is out of pediatrics," Rice notes.

But Rice also points out that investing in the health of children leads to healthier adults, and he hopes insurers "will appreciate the importance of doing the same [investment] on the pediatric side. The patients will be better off, and the pediatricians will do better." He said that pediatricians earn between $110,000 and $150,000 a year in New Jersey, "and they work a lot of hours for the low end of the money in the beginning" of their careers.

According to Rice, New Jersey has a shortage of pediatric subspecialists, including pediatric behaviorists and developmentalists who identify children with autism and other disabilities. "Another dreadful shortage area is pediatric psychiatry; that is an area where more help is needed tremendously around the state."

Rice said economics plays a huge role in getting more primary care doctors to practice in New Jersey. "I'm amazed at how much today's students have gone into debt to go to college and medical school. There are people out there with $200,000 in loans: it's as if you have a mortgage, and you don't have a house yet."

He said the state's loan forgiveness program might be expanded to help increase the pediatric specialists that New Jersey needs more of, as well as supporting primary care doctors in general practice.

Dr. Steven Kairys, medical director of the New Jersey Pediatric Council on Research and Education, said pediatricians should be compensated for the care coordination and care management they provide -- whether or not they are able to navigate the time and expense involved in becoming a PCMH. To provide the best care, pediatricians need to devote time to conference calls with schools, families and other physicians.

Ideally, to deliver the highest quality of care, pediatricians should be spending more time with patients "doing screening assessment, preventive services, screening for developmental issues and autism. But what pediatricians do is try to see seven kids or so an hour, to make the dollars they need" to maintain the economics of the practice. "To provide high-quality care, a pediatrician should see 25 kids a day at the most, but many are seeing 40 a day to make ends meet."

UMDNJ third-year medical student Krysta Johns-Harris, who attended the meeting with Horizon, said she is considering going into primary care as an internist and was encouraged by what she heard from the PMCM physicians.

"There are a lot of misconceptions about primary care," she said. "A lot of medical students think primary care physicians work a ton of hours, the pay is very low and they are not happy, which was not the case from what I heard. They seemed very happy, and I wish more students could have heard them." Johns-Harris likes the fact that primary care physicians have long-term relationships with their patients and coordinate all aspects of their care.

But student debt is a major issue. Johns-Harris expects to start her medical career with about $250,000 in student loans, and believes she would earn about $130,000 a year starting out in primary care. So she is looking into enrolling in New Jersey's loan redemption program, which would repay $120,000 of her student loans if she works for four years in a medically underserved area of the state. Or she may decide to become a specialist, a route that internists often pursue -- but said her decision won't be based on purely financial concerns.

"I think you should make decisions based on what's going to make you happy. I'm going to be working for a long time. The loans will be there, but the most important thing is that I love the field of medicine I choose."

Dr. Thomas Howe is a medical director in New Jersey for Aetna, which in January began making bonus payments to the 222 practices that have been designated PCMHs by the NCQA. According to Howe, "We believe that primary care physicians who meet the [NCQA] standard provide an extra element of coordination of care and have the wherewithal to better manage folks that need primary care management, such as patients with chronic diseases."

Howe, whose career includes 19 years practicing internal medicine in Paterson and Fair Lawn, said "From the wellness point of view, primary care is the touchpoint for preventive care and for getting the necessary evaluations that avoid the downstream ill effects of diabetes, high blood pressure, and various cancers."

Annette Catino is chief executive of QualCare, which provides health plans to self-insured employer groups, and which last fall increased fees for doctors who earned the PCMH designation. "We have a shortage of primary care now, and it will get worse as more baby-boomers approach Medicare. The average Medicare patients sees a primary care doctor six times a year," while most younger adults go once a year at the most. She wants to encourage more practices to become PCMHs "because we believe the PCMH is a better model for primary care; it is more coordinated care and it produces better outcomes."

Dr. Ken Faistl's Freehold practice has been a PCMH for the past three years, and was one of the original practices to join the Horizon Healthcare Innovation pilot. He met with the UMDNJ medical students, and he said students want to go into primary care but have been discouraged by their high student debt and the relatively low salaries.

"The Horizon pilot project, Faistl comments, "is a combination of paying primary care doctors additional fees, not only to see the patients but to coordinate care, and that is a new model of care. What you are really looking at is paying physicians not only for the visits that they provide, but the outcomes of the patients they take care of."

A 38-year veteran family doctor, Faistl teaches medical school and "I can show students the passion I still have, and I think that is a key strategy for getting people interested in what we do."

He tells students, "Becoming a family doctor doesn't mean that you have to take a vow of poverty. You can make a good living and a comfortable living and you have to make a choice. Not everything is the currency you have in your pocket. It's the currency you have in your community, walking around town and seeing people who thank you for caring for their mother or father, or son or daughter. That's the thing you can't put into dollars and cents, but that is what really keeps you going."

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