By Staff

A new survey revealed that key sources of headaches for primary care physicians are insurance companies and new performance measurements, not patient care.

In the annual survey conducted by the Commonwealth Fund and the Kaiser Family Foundation, primary care physicians were asked their opinions on issues ranging from payment reform to health IT to insurance billing.

The survey, which included responses from 1,624 primary care physicians, contains few surprises. Juggling new technologies, payment reform and performance measurements, physicians recognize the long-term benefits to their patients but struggle to make so many practice changes in a short time period.

The survey showed that 55 percent of primary care physicians are paid based on the quality or efficiency of care while 34 percent are paid strictly on fee-for-service. Three of 10 primary care physicians said their practice is qualified as a medical home or an advanced primary care practice. Twenty-nine percent participate in accountable care organizations.

The greatest concern the survey showed was that new models are changing the dynamics of payment and patient care. Fifty percent of physicians said the increased use of quality metrics has a negative impact on quality of care; 22 percent considered them positive. Many performance measures are established with the aim of improving the health of large populations rather than individual patients.

"You lose the concept of treating the whole person," said Robert Wergin, M.D. of Milford, Neb. "New reimbursements models 'teach to the test' and focus on one aspect. Studies show that if you focus on diabetic care other parameters are not noticed. The practice tends to focus on things they can do to meet performance metric targets."

Paying physicians based on collective results can reduce their flexibility and make care resemble an algorithm.

"There is so much emphasis placed upon on measurement that it becomes a burden that takes away from caring for the patient," Wergin said.

There may be no greater example of struggling in the present to benefit the future than health IT systems. It is often cited as a source of consternation, but 50 percent of physicians said it has a positive impact on patient care. Only 28 percent of physicians said it has a negative impact.

"This survey confirmed what physicians have said about the potential of technology to facilitate patient care," Wergin said. "They are still frustrated by the transition to EHRs (electronic health records) because of the lack of their application to the office workflow, the lack of interoperability and the difficulty with exchange of information."

Consolidation in healthcare is another concern for some physicians. Seventeen percent of physicians in the survey said their practices were purchased by or merged with a larger practice or a health system within the past two years, which can increase leverage with insurers.

"In our area small, independent practices are been acquired by health systems," Wergin said "There is pressure to move in that direction to get clout."

Practices that join a large network get some advantages such as greater infrastructure and improved IT support, but they lose the ability to change quickly.

"In an office with two physicians, if we want to change next week we could do it," Wergin said. "Then we can change back again if we want."

To maintain their voice, some small practices such as Wergin's join an independent practice association.

A major source of concern the survey revealed related to billing. Private insurers ranked high on reimbursement only in comparison to Medicare and Medicaid. Forty-six percent of physicians rated private payers "good" or "excellent" for their payment rates and 32 percent gave the same rating for their ease of administration. Both scores are substantially higher than those of Medicare or Medicaid.

Wergin noted that one large private insurer is notorious for delaying claims by requesting additional information or requiring practices to resubmit large claims, and frustration with insurers has led many physicians to opt for the direct primary care model.

"It's difficult to get payments across the board," Wergin said. "We depend on insurers for timely cash flow. If we aren't paid on time because they require more information, that delays cash flow and we still need to pay our staff and office expenses."

With heavy demands on their time, some physicians think about an early retirement. Forty-seven percent said recent trends in health care are causing them to consider retiring earlier than they planned. Still, overall levels of physician satisfaction have not changed dramatically during the past 20 years, according to the survey. Wergin said the retirement question could be more focused by breaking responses into age groups.

Nothing in the survey asked physicians about their views of meeting with patients and solving their problems or about the value of medicine, two principal reasons that keep them coming back to the office.

"Once physicians are in a room with a patient I don't hear any complaints about that," Wergin said. "The overall fundamentals of providing care one-on-one with patients are still the heart of family medicine."