Can oncology rescue primary care?
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Everyone bemoans the shortage of primary care physicians. Successful, cost-effective health care systems are built on a foundation of accessible primary care.
CMS adopted the AMA Relative Value Update (RVU) Committee’s restructuring of evaluation and management codes to support primary care physicians. However, CMS also lowered the 2022 conversion factor by $1.30, to $33.50 per RVU, so now the 99214 code pays $121.45 ($97.16 from CMS and $24.29 from the patient or secondary insurer). The proposed rule for 2023 will lower it another 4.4%. The overhead to provide care and get paid approaches 50%.
Primary care physicians prefer to see two follow-up patients per hour and to have 7 patient hours per day, with the rest of the time being used for prior authorization, charting, returning calls and filling out paperwork. Working five 10-hour days per week with 4 weeks of vacation, they could theoretically bill $612,108 per year and take home $300,000. They can make that much being a hospitalist working 26 weeks per year with better work-life balance. It is no wonder there is a shortage.
The problem for oncologists
Oncologists have become de facto primary care physicians for patients who don’t have one or can’t get in to see them. At New Mexico Cancer Center, where we implemented the medical home processes of COME HOME, a patient can call us with a complaint and be seen that day. Patients whose cancers were diagnosed 10 years ago still want to see us so that they can access our same-day appointments. Having survived both cancer and the dysfunctional health care system, they know that we will provide them assistance for problems we can fix and facilitate other care, as well. They know if they develop a recurrence or a second primary, they will see their oncologist quickly.
This begins to create problems for an oncology practice. Not only are appointment slots filled with people who don’t need an oncologist, those patients are asking us for care outside our area of competence. For example, the simple request, “Can you refill my metformin? I can’t get in to see my primary,” generates a dilemma. If the oncologist says “no,” the patient runs the risk for diabetes getting out of control. If the oncologist says “yes,” they find themselves managing the patient’s diabetes without checking retinas, feet or HbA1c. If the patient has a diabetes complication and sues the oncologist who is “managing” the diabetes, it will not go well. After all, oncologists are board-certified internists, so a claim on the witness stand that the oncologist was just trying to help is not going to be a winning argument.
Yet, 10% of new cancer diagnoses occur in patients who previously had cancer, and we don’t want to lose those patients to a competitor.
The benefits of embedded primary care
Our solution is to create a survivorship program and embed primary care in our practice for those patients who need it. We can then confidently refill the metformin and schedule an appointment to see our primary care physician for real management. Our schedules can open for more patients with cancer without losing our long-term patients. Patients know they can continue to be served by the practice while getting their chronic diseases managed and having access to the practice they want if they become acutely ill.
Our value-based care contracts are also enhanced. A patient who is acutely ill usually cannot be worked into a primary care schedule. Even when patients can be seen, the average primary care practice cannot manage the acute patient who needs hydration, IV antibiotics or imaging. The obvious answer is to send the patient to the ED, thus costing the system more and often resulting in an admission. Our primary care patients can get the lab they need, imaging, hydration or antibiotics in our center, without incurring hospital costs.
As oncologists do more genetic testing, we become responsible for ensuring that patients with a significant mutation get the appropriate screening. Changing recommendations make a written survivorship care plan obsolete and even dangerous. Screening modified for a patient’s genetic profile is more appropriately performed by a primary care physician, who can manage not only the screening but reach out to healthy family members and see that they are screened, as well. Not only will oncologists avoid the liability of not keeping a patient’s screening up to date, but the collaboration will allow more new patients with cancer into the oncologist’s schedule.
This model of embedding primary care with specialists could change our current delivery system for the better. With patient care at one location, primary care physicians can consult easily with specialists and can manage the comorbidities. The result: better health care, lower costs and happier physicians.
- For more information:
- Barbara L. McAneny, MD, FASCO, MACP, is a medical oncologist and former president of the AMA. She can be reached at New Mexico Cancer Center, 4901 Lang Ave. NE, Albuquerque, NM 87109; email: mcaneny@nmohc.com.
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