Unintended consequences of resource-based relative value scale reimbursement.

MEDICINE’S GENERALIST BASE IS DISAPPEARING AS a consequence of the reimbursement system crafted to save it—the resource-based relative value scale. The US physician workforce is unique among developed economies of the world. Virtually all European countries have a broad generalist foundation comprising 70% to 80% of practicing physicians. The United States is the opposite. Starfield has summarized the benefits of a generalist workforce as access to health service for relatively deprived populations; care equal to specialists in most situations (recognizing the invaluable contribution of the specialist physicians but acknowledging that the diffusion of knowledge increases the ability of the nonspecialist to provide up-to-date care); improved preventive service delivery; efficient management of multiple simultaneous medical, surgical, and mental health problems in active and fully functional patients; provision of continuity in the health care experience, advice, and counsel where appropriate and access to appropriate diagnostic, consultative, and specialty services; and, in conjunction, reduced unnecessary specialty testing and consultation. Over the last 4 decades, medical and surgical practice has transformed from a reactive profession to a proactive profession. Evidence from numerous clinical investigations in many different settings shows that patients with any of the 3 most common conditions—hypertension, diabetes, hypercholesterolemia—benefit from early treatment. Conversely, failure to diagnose and treat increases the likelihood of poor outcomes. Well-designed studies have shown that the early and active treatment of disease in the asymptomatic phase has profound lifetime benefits. For instance, the Hypertension Detection and Follow-up Program demonstrated the reduced mortality derived from the early identification and treatment of hypertension with benefits occurring in those managed closely with inexpensive therapies. The Diabetes Control and Complications Trial showed that early and effective management of blood glucose levels for patients with type 1 diabetes reduced long-term risk for neuropathy, retinopathy, and nephropathy. The West of Scotland Study showed that patients with coronary heart disease and risk factors had lower mortality if their low-density lipoprotein cholesterol levels were managed actively. Targets for secondary prevention decreased with successive clinical studies, and targets for primary prevention of heart disease followed suit. The seventh Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) specifies that even the patient with normal blood pressure should be counseled about lifestyle modification to avoid later life development of high blood pressure. The JNC 7 urges clinician empathy for a patient who generally feels well. The implication is that some physicians will convince a patient with a silent disease to change dietary and exercise habits and perhaps take daily medications. The ever-expanding repertoire of interventions, screening tests, vaccines, and devices has dramatically increased the work of patient care for all physician specialties. As an indicator of this ever-expanding content, the total resourcebased relative value units per Medicare beneficiary increased by 45% from 1992 to 2002. For the generalist physician, this increase has been especially intense. Providing all recommended preventive services to a panel of 2500 patients could require up to 71⁄2 hours a day of physician time. Generalist physicians report that roughly 4 separate problems are addressed at each office visit for patients older than 65 years and even more issues are addressed for patients with chronic illnesses such as diabetes. For a hypothetical 79-yearold woman with 5 medical conditions, current clinical practice guidelines would support the use of 12 medications. Attaining the expected health benefits from early and effective treatment of symptomatic and asymptomatic illness will not be achievable without increasing the number of generalists. The United States is now served by highly trained but limited-scope practitioners, at the very time skillful and well-supported primary care physicians are needed. The overall workload is overwhelming the capacity for generalist care if not the individual clinicians. This problem will only be resolved with full recognition of its origins. Because physician decision making profoundly influences health care expenditures, the forces that affect these decisions must be addressed. Practice type and physician specialty are critical factors; both are associated with higher rates of test ordering and hospitalization. Gen-