Dr. Albert Puerini Jr. loves his job. He leaves home by 7:15 every morning to visit patients in the hospital, then heads to his Cranston office for a full day of physicals, blood pressure checks, and the fevers, coughs and other ailments that are a family doctor’s bread and butter.
In the big picture, as he sees it, physicians like him are more important for people’s health than any of their specialist colleagues. Yet they’re paid far less – and for much of what they do, such as taking patients’ calls and offering advice, they’re not paid at all.
Beyond Cash Donations: How New Forms of Giving Are Transforming Not-for-Profit Accounting
Evolving Funding Landscape for Not-for-Profits Not-for-profit organizations are being asked to do more with less,…
Learn More
So every day, to make ends meet, Puerini crams in about 25 patients. Some get his attention for as long as they need it, but many wait and wait just to be seen for 10 minutes.
Now, amid calls to make primary care the centerpiece of Rhode Island’s health care system, doctors such as Puerini are both welcoming the attention and warning that it won’t be easy.
You can’t expect primary care physicians to spend hours counseling patients about stress, diet and exercise, or check on diabetics every few weeks to make sure their blood sugar is down and they really did make it to the podiatrist, or work nights and weekends, yet not pay for any of it, they say.
And even if veteran doctors do all that, they warn, the next generation isn’t interested.
“We need a change of the system,” said Dr. Jeffrey M. Borkan, physician-in-chief of family medicine at Memorial Hospital of Rhode Island and chairman of family medicine at Brown University’s Warren Alpert Medical School.
If we really want primary care to flourish, Borkan said, we need to change how we pay for it, so doctors aren’t just reimbursed for individual procedures. “We have to begin to pay for things that are important to patients,” he said.
The good news is that, increasingly, insurers and policymakers recognize this. They talk about possible ways to improve the system; Blue Cross & Blue Shield of Rhode Island has made it a priority and plans to substantially boost primary care doctors’ pay, starting this summer.
Primary care is also at the heart of the R.I. Chronic Care Sustainability Initiative, a two-year project led by Health Insurance Commissioner Christopher F. Koller and Quality Partners of Rhode Island that aims to improve how people with chronic conditions are cared for.
And even UnitedHealthcare of New England, which primary care doctors have said pays and treats them poorly, recently expressed interest in a concept that many view as the future of primary care: the “advanced medical home,” which involves patients getting most of their care in a single place, with a primary care doctor coordinating it all.
It’s all “exciting,” Borkan said. But at this point, “there’s not yet much action on the ground.”
Dr. Gus Manocchia, chief medical officer at Blue Cross, offered a similar assessment. He’s enthusiastic about the insurer’s initiatives to boost doctors’ pay and to reward them for adopting electronic health records and improving quality, but he still sees doctors struggling.
That’s how Puerini feels: “You get caught in this wheel that just keeps spinning,” he said. “You’re doing your best, but you know you’re not doing as well as you could be.”
So what will it take to really change things?
For starters, many doctors believe, a partial return to how the much-maligned HMOs of the 1990s did business.
The HMO model was based on “capitation,” a system in which doctors are paid a fixed amount to meet each patient’s needs. The idea is to give providers an incentive to keep patients healthy: If a diabetic’s blood sugar is under control, he’ll avoid crises and just need quick routine checkups. If an 80-year-old gets her flu shot, she won’t end up with pneumonia.
Yet Manocchia said that, while he did OK with capitated contracts in the 1990s, many of his colleagues lost a lot of money. And Dr. Michael Fine, senior managing partner of Hillside Family and Community Medicine, said capitation can, in some cases, discourage doctors from seeing their patients.
The flipside is the current system, which Manocchia said pays $45 to $75 for a typical visit and $75 to $110 for a physical – and encourages doctors to see “as many patients as possible … so they can keep their head above water.”
(The same system also drives doctors across the state border, said Puerini, who is president of the Rhode Island Primary Care Physicians Corporation, an association that represents 151 doctors in small independent practices. A doctor in Attleboro, he said, makes 30 percent more than one in Providence, which is why Blue Cross’ plan to raise fees is so crucial, because it will bring local doctors’ pay up to the Massachusetts level within three years.)
Ultimately, both Fine and Manocchia said, what will probably prevail is a hybrid system that pays doctors a per-patient fee to cover the advice, care management and other now-unpaid services they provide, plus an additional fee for each procedure they perform.
But changing the payment system, most agree, isn’t enough. There has to be a broad-based collaboration, Manocchia said, including doctors, payers, employers and policymakers. And that is starting to happen. In addition, doctors are banding together to make their practices more cost-efficient and to campaign for change.
The next generation, however, is less and less interested in primary care. Across the nation, the share of medical school graduates entering primary care dropped from 56 percent in 2002 to 52 percent this year, said Dr. Philip A. Gruppuso, associate dean at Brown’s medical school.
At Brown, which has a proud tradition of promoting primary care, the rate dropped from 59 percent in 2002 to 38 percent in 2006, then rose to 53 percent this year. The latter was a nice surprise, he said, but he can’t explain why it happened, and he’s not sure it wasn’t a fluke.
Brown medical students graduate with an average of $115,000 in debt, Gruppuso said, and they are drawn in disproportionate numbers to specialties such as dermatology, urology and otolaryngology. Some teachers will tell them how “incredibly gratifying” it is to do primary care, but too many other doctors tell them it’s frustrating and badly paid.
A bill before the General Assembly aims to level the playing field by helping graduates who choose primary care to repay their student loans, Puerini said, but he’s not sure the measurewill pass.
And Gruppuso worries about next year at Brown. “I would be embarrassed,” he said, if Brown continues to drop below the national average for graduates entering primary care. “It would be inconsistent with Brown’s stated mission of treating medicine as a socially responsible, altruistic discipline.”
