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Society Of General Internal Medicine

Calling incentives to rebuild primary care "critical to the success of health care reform," the American Society of Internal Medicine (ASIM) has urged Congress to enact legislation to change the environment currently driving physicians away from primary care. In testimony before the Senate Finance Committee's Subcommittee on Medicare and Long-term Care, ASIM Executive Vice President Alan R. Nelson, M.D., called for increased funding for primary care training and reforms to reverse Medicare policies that undervalue primary care services in comparison with other services.

To start, Dr. Nelson said Congress should exempt primary care from further cuts in the Medicare budget, and provide preferential fee schedule updates for primary care in the future. He noted that the latest recommended fee updates from the Department of Health and Human Services would increase Medicare payments for surgical services by 10.2 percent, while only raising fees 6.6 percent for primary care services. Dr. Nelson said the recommendation is "in direct conflict with the goals for improving payments for primary care and attracting more primary care physicians."

ASIM is calling for congressional action that would prevent surgical services from receiving a higher fee increase than primary care services in 1994. ASIM is also lobbying for legislation to change Medicare's current formula for setting fee raises. Dr. Nelson said immediate action is needed to keep payments for primary care services from failing even further behind those for surgical services.

However, steps to stop the continued overvaluing of surgical services are not enough, claimed Dr. Nelson. He said that Medicare should also enact reforms that will close the current payment gap between primary care and surgical care. Such reforms, Dr. Nelson urged, should include Medicare "bonus" payments for primary care and coverage for clinically proven preventive and screening services currently not covered by Medicare.

In the area of medical training, ASIM believes several reforms are needed. Dr. Nelson said primary care training programs should receive a substantially larger share of Medicare's Graduate Medical Education dollars. He also called for loan forgiveness programs for students who enter and remain in primary care. Other reforms should fund training in office-based settings, establish programs to expose medical students to positive primary care role models, and expand the National Health Services Corps, he said.

Dr. Nelson disagreed with those proposing to increase the number of primary care physicians by limiting the availability of residencies in other specialties. Physicians forced to practice primary care "will do so unenthusiastically. They will resent the decision," he said. Physicians should go into primary care because they want to practice in the field, not because they are coerced into doing so, Dr. Nelson emphasized.

While educational reforms are critical, Dr. Nelson cautioned that such reforms "will not be successful, in the absence of other changes to tackle the economic and regulatory disincentives for choosing primary care." As long as primary care practice continues to be "underpaid, over-regulated, and micromanaged, the level of dissatisfaction among primary care physicians will worsen," he said.

A copy of ASIM's White Paper, Rebuilding Primary Care: A Blueprint for the Future, containing 44 recommendations to rebuild primary care, can be obtained from ASIM at (202) 466-0281.

Cost Shifting Pushes Up Outpatient Care

Rates, Analysis Shows

Although outpatient health care costs are significantly less than inpatient care cost, a higher percentage of cost shifting occurs at the outpatient level, according to a new analysis.

Cost shifting to the outpatient side of health care services has caused outpatient rates to increase more than 60 percent during a 5-year period, found the analysis, which was compiled from the Managed Care Information Base, an exclusive computer-based information retrieval program developed by American Business Publishing.

For most major employers and health insurance plans, the cost-containment focus has been on inpatient-related services. Employee health benefit plans often require second surgical opinions and encourage use of such ambulatory care services as same-day surgery and a host of other outpatient services.

"Although there has been a decline in inpatient admission to hospitals, outpatient care costs are soaring and most plans do not have methods in place to harness these costs," observed Robert K. Jenkins, publisher, American Business Publishing.

Analysts looked at several industry studies to reach the conclusions, including studies by the U.S. Congressional Budget Office (CBO), Blue Cross and Blue Shield, and the RAND Corporation. The industry studies all point to the need to adapt managed care principles to outpatient services, said Jenkins.

Nearly all of the impact of cost shifting occurs on outpatient services, according to a report by the CBO. Blue Cross and Blue Shield found that during a 5-year period outpatient costs increased 61.2 percent, from $103 in 1983 to $166 in 1988.

The Managed Care information Base can be used for decisionmaking, planning, negotiating, preparing presentations, performing analyses, and gathering statistics on vital managed care facts, including costs, premiums, enrollments, and utilization. It is available for $597 from American Business information Services, 3100 Highway 138, Wall Township, New Jersey 07719-1442; (908)681-1133; FAX (908)681-0490.

Pharmaceutical Manufacturers

Responding to Demand for Outcomes

Data

The 1993 Pharmaceutical Outcomes Activities (1993 POA) study, conducted annually by The Zitter Group and Technology Assessment Group, Inc., found that pharmaceutical manufacturers are responding to the health care industry's demand for more cost-effectiveness and quality-of-life data by adding more outcomes research staff and doubling the number of economic studies under way.

Twenty-nine U.S. pharmaceutical manufacturer representatives, most of whom are cross-departmental coordinators of outcomes projects (clinical and marketing), participated in the study. The results are reported and compared with the 1992 POA study results where applicable. The subjects addressed in this study include the number of staff devoted to outcomes activities, their level of academic training, and the formalization of outcomes positions.

The study organizes information into two primary sections: clinical outcomes research and outcomes-based marketing activities. The number and type of outcomes research are divided into economic, quality-of-life, and utility studies. The number and type of marketing activities are divided into informational services, educational services, and technical assistance. Both sections also address manufacturer reliance on outside consultants. The study concludes with anticipated changes in manufacturers' activities as well as their greatest resource needs to achieve these changes. For more information, contact Dominique Ritley at (415)495-2450.

AWARDS

Grant Funds Available to Curb the Spread

of Tuberculosis

To combat a resurgence in tuberculosis (TB), the Nation's largest health care philanthropy recently announced it will commit more than $5 million for projects that demonstrate innovative ways to provide comprehensive services for people exposed to and infected with the ariborne bacterial infection.

After decades of decline, TB has returned in a more virulent form and has become a serious health problem, said officials at the Robert Wood Johnson Foundation. Among the most significant issues changing the face of TB is the emergence of multiple drug-resistant TB, which is proving impervious to standard antibiotic therapy and more likely to be fatal.

During the next 3 years, the Johnson Foundation will provide funds under a program called "Old Disease, New Challenge: Tuberculosis in the 1990s," with grant awards aimed at establishing partnerships between local public health agencies and community-based organizations that are in contact with groups at highest risk for TB - drug abusers, people with human immunodeficiency virus, migrants, immigrants, refugees, and people who are homeless.

"Tuberculosis is a critical public health problem that until very recently has failed to attract public attention or support," said Steven A. Schroeder, M.D., president of the Robert Wood Johnson Foundation. "The foundation has a unique opportunity to bring together various groups providing TB care and in the process, improve this country's basic public health system. Our approach includes introduction of tracking measures so that further spread of this disease might be prevented," he said.

Under the Old Disease, New Challenge program, up to five projects will be awarded grants averaging $385,000 a year for 3 years, with a maximum of $1,155,000 per project.

The Old Disease, New Challenge program is directed for the foundation by Philip C. Hopewell, M.D., professor of medicine at the University of California, San Francisco, and chief, Division of Pulmonary and Critical Care Medicine at San Francisco General Hospital.

For more information, contact Marc Kaplan at (609)243-5937.

COPYRIGHT 1993 U.S. Department of Health and Human Services
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