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i like that-- if we can't measure it, it doesn't exist.better yet, if it doesn't exist, we don't have to pay for it.even better, we determine what can and will be measured, and how to do so, so we'll never have to pay you.no wonder patients make their lexus payment before their deductible, they make this same calculation, and have discovered that we're priceless, i mean, worthless!mark my words, this is precisely the slippery slope of p4p. it will only be used to reduce our pay.thank you, ben, for helping to clarify this, it had really been bugging me, and now i know what to do-- it's time to get out of medicine, and into the measurement of it!on a more serious note, if we really are to be paid more, then we must clearly demonstrate our value and worth.if the "how's your health" indices are validated (are they based on the sf-36 quality of life index?), and if one concurrently measured and therefore related various metrics, eg

hba1c, peak flows, with "how's your health"/sf-36 quality of life index in general, for diabetes, asthma, ie, a validated combination of various metrics and one's perception of one's health and care, both in general and wrt to various disease states, that is something which could be worth a lot, and could clearly demonstrate the value of IMP-style practice. the metric data would/could be readily available with emr's with patient registries.we could become new-fangled bean counters; we could elevate bean counting to a whole new level!LLLLBen Brewer wrote: I rather liked the $2 medical home piece, but I appreciate your comments. The total cost of providing a medical home and all associated visits emails and whatnot is obviously higher than $2-3 per person per month, but what would be a reasonable figure? $15? $25-30?Whatever your price point might be I would suggest it would probably seem low to those paying multiple hundreds in premiums for insurance. The bottom line in my opinion is that good primary care is not as expensive as many people have been led to believe. We are separated economically from the value we create. I wholeheartedly agree.Redefining Healthcare, a book by some Harvard gurus (http://www.hbs.edu/rhc/index.html) talks quite a bit about the value cycle in healthcare and how the value created by primary care is largely invisible and difficult to account for. Their answer seems to be that we should measure many, many things like a factory does to prove our contribution to the value cycle. To do this would require the hospitals and our colleagues to price the global cost of care for each episode and agree amongst ourselves how we would split it based on performance metrics. Much of what they discussed seems logistically very, very difficult. It seems geared very much toward the pervasive idea that bigger healthcare entities are better because they have better metrics. What is the value of timely intervention for the patients Lawrence mentions, or the patient with critical CAD saved by recognition of some vague symptoms and timely evaluation? A heck of a lot more than a level 3 office visit, but proving is going to take some serious effort.The reality is we're saving people major trouble all the time but we're going to be judged on what our patient's A1c levels rather than how many dollars we saved the system. As long as we're stuck at the minutiae level of A1c measurement as a surrogate of our abilities instead of our total contribution to the patient's care we'll be struggling over the scraps of the healthcare

dollar.One the preauthorization theme - I did do a piece on being rejected for Lantus insulin by Illinois Medicaid about 2 years ago. Ben Brewer M.D. [Practiceimprovemen t1] WSJ.com - Primary Health Care Needs Fixing Before Universal Care Can Work Good thoughts in the article. Not sure if the graph is correct. Surely the Peds Primary isn't filled with 43 US Seniors. I think the interesting thing is that the whole healthcare system is not following supply and demand...not that it has in a long time, but... If we go to a national Medicare system -- will fees continue to down, thus FP #'s go down -- shouldn't the fees go up as supply goes down? Next 5 years should be interesting. Locke, MD http://online. wsj.com/article_ email/SB12064793 6859463451- lMyQjAxMDI4MDI2N jQyNzY5Wj. html Return to Web Version Graph 5 Comparison of Primary Care Positions Filled with US Seniors in March (1997-2008) 2008 NRMP Results Download graph as PDF (136 KB). THE DOCTOR'S OFFICE By BENJAMIN BREWER, M.D. Primary Health Care Needs Fixing Before Universal Care Can Work March 26, 2008 Who will take care of the estimated 47 million uninsured Americans if they get health coverage promised by politicians? Few people seem concerned about whether the supply of primary care doctors is up to the task. But they should be. Even without health-care reform, the demand for family physicians is expected to surge by 2020, when the nation will need 140,000 family physicians, according to the American Academy of Family Physician's 2006 Physician Workforce Report. That's a 40% increase over the 100,000

family doctors at work in 2006. Low payments to primary care doctors are discouraging those of us in practice and are dissuading new doctors from entering the field. Medicare's proposed 0.5% fee increase to family doctors like me for the remainder of 2008 is well below inflation. None of my office expenses will rise less than 0.5% this year. To me, universal coverage looks like an empty promise. Just nationalizing health insurance by declaring Medicare for all isn't going to get the job done. Medical insurance coverage without a doctor to see is another big health problem -- not a solution. An expanded insurance

program based on Medicare or state Medicaid, another stingy payer, will prompt many doctors to opt out if they can. If doctors are forced to participate in a program with fees lower than their cost of doing business, I expect primary care doctors in private practices like mine will close up shop. Once displaced, they'll probably work in ERs, continuing to provide high-cost care for diseases that a properly designed and financed health system would have prevented or nipped earlier and more cheaply. Massachusetts, the state with mandated insurance coverage most like Sen. Hillary Clinton's health plan, has suffered a painful shortage of family doctors the last two years. More people signed up than predicted and higher costs have led to premium increases. It's apparent to me there is no increased access to care with this plan in many areas and no cost savings have materialized. That tells me that physicians in any universal coverage program will have to weigh the personal and financial risk of an access crunch. When a bad outcome arises, I expect lawyers will come after the overburdened primary care docs instead of the politicians who promised more than could be delivered. We won't see better health outcomes or any cost savings

from improvements in quality unless there are broadly trained primary care doctors available and willing to practice where they're needed. Some would advocate using nurse practitioners or physician assistants to fill this role, but I don't see that working as well. A family doctor's set of skills is much broader. In this case, you get what you pay for. If we add large numbers of patients to the underfunded, understaffed primary care system we have now, things won't improve. That approach will look good on TV for 15 minutes and then health care as most Americans experience it will continue to stink, just more expensively. Until we adequately fund primary care, we're not going to get the health system Americans

expect. Right now the U.S. is graduating about half the family physicians we'll need in the coming years, and the government proposes to cut funding to train more. The 2009 federal budget would abolish funding for training programs under Title VII of the Public Health Service Act, including Section 747 of the act, which provides the only federal grants for training primary care physicians. To fill the primary care gap, we could flood the U.S. with foreign trained doctors. In fact, we're pretty much already doing that in our training programs. Fifty-six percent of doctors starting family medicine residencies this summer are foreign graduates. Foreign grads practice mainly in larger cities so that doesn't help overall distribution of

doctors to smaller communities. Only 65 more U.S. medical students chose family medicine for their residency this year than last year for a total of 1,172. (See a chart on the primary care trends here.) Compared with the bleak decline of the last 10 years, a 2% increase in family practice residents is cause for celebration among family doctors. "We're extremely pleased with this year's match," said AAFP President Jim King, M.D., of Selmer, Tenn. Still, I would be happier if every one of those doctors had a sustainable practice to grow into. The fact is that costs are too high for an economically viable practice in many areas.

Payments from the government and large insurance companies don't adequately cover expenses and the burden of educational debt. The cost of malpractice insurance to practice the full range of primary care medicine, including obstetrics, is untenable for most. How can anyone rationally expect to build up the nation's health on that crumbling foundation? Family physicians could meet the needs of the uninsured, the underinsured and the baby boomers, but not without some fundamental changes in the way they are paid. Due to his schedule and the volume of email he receives, Dr. Brewer may not be able

to respond to all reader email. He does participate in his forum, where readers are urged to post. His email address is thedoctorsoffice@ wsj.com. Powered by * Please note, the sender's email address has not been verified. This guy agrees with you Click the following to access the sent link: WSJ.com - Primary Health Care Needs Fixing Before Universal Care Can Work* This article will be available to non-subscribers of the Online Journal for up to seven days after it is e-mailed. Get your EMAIL THIS Browser Button and use it to email content from any Web site. Click here for more information. *This article can also be accessed if you copy and paste the entire address below into your web browser. http://online. wsj.com/wsjgate?

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