The Primary Care Doc Shortage

One thing that Republicans, Democrats, and the Administration all seem to agree on is that Bruce Springsteen truly is the one and only Boss (just for you, Mom)…

And also that in order to support America’s health care needs substantially more primary care and family physicians will be needed. Politically it’s an easy and benign thing to say, and that doing something about the shortage is a much more controversial and political process.
Measures in health reform bills currently under consideration in Congress include:
• Income-related premium assistance for individuals living at up to three or four times the federal poverty level.
• The expansion of Medicaid for those at 133 to 150 percent of the poverty level.
• Shared employer responsibility for financing coverage for workers, with assistance provided to small businesses
About 10 million people would newly enroll in Medicaid, with most of those individuals previously lacking any coverage. Additionally, Senator Baucus set forth his proposal last week, which stipulates that “All plans sold to individuals and small businesses would have to cover basic benefits, including primary care, hospitalization and prescription drugs.”

TRANSLATION OF ALL THIS: LOTS MORE PEOPLE WHO WANT CHECK-UPS. LOTS. What is the first thing you do when you get a brand new Golden Ticket for comprehensive care? You go get all aches and pains you’ve been self-medicating or ignoring for years treated at your new primary care doctor. If you can find one. According to a report by the California Healthcare Foundation, the state overall has fewer primary care doctors than needed. California, for example, has 59 primary care doctors per 100,000 active patients, but studies say 60 to 80 are needed.

Massachusetts is also already facing this problem. Reading this NY Times Blog piece yesterday can tell you all about it. As Massachusetts’ experience shows, extending health care to 50 million uninsured Americans will only further stress the system and could force many of those newly insured back into costly emergency rooms for routine care if they can’t find a primary care doctor. According to Dr. Ted Epperly, president of the Kansas-based American Academy of Family Physicians. “It’s like giving everyone free bus passes, but there are only two buses.”

Why doesn’t anyone want to be a primary care physician? (Ali D, we’re all looking at YOU…Just kidding…)

Washington Post writer Ashley Halsey wrote a piece yesterday, “Primary-Care Doctor Shortage May Undermine Reform Efforts,” in which she pointed out that fixing the problem will require fundamental changes in medical education and compensation. Some people (Republicans) will stress that it’s hard to make money in primary care because of the cost of malpractice insurance. This is part of the problem, but it’s another issue for another day. Another less refutable cause is, as Halsey reports, “The disparity results from Medicare-driven compensation that pays more to doctors who do procedures than to those who diagnose illness and dispense prescriptions.” In other words, doctors right now don’t get paid unless they do something to the patient.

President Obama seems to understand, but would rather emphasize the extra-governmental problems. “We’re not producing enough primary-care physicians,” Obama said at a health care forum recently. “The costs of medical education are so high that people feel that they’ve got to specialize. New doctors typically owe more than $140,000 in loans when they graduate.”

If you look at this problem from another angle, there are even more layers of why this is a scary trend. Specialists performing procedures are traditionally reimbursed at a much higher rate than primary-care doctors who rely on reasoning and cognitive skills. In the long run, some would argue that health maintenance, disease prevention, and chronic illness management is where the real medical workforce will be needed. Already, specialists like Orthopedic Surgeons are being displaced by robotic equipment. Doctors may not always be needed for joint replacement, but they will always be needed to diagnose complex diseases involving multiple organ systems.

One doctor in an article in Philadelphia Business Journal says, ““Primary-care doctors feel very much they are at the bottom of the pecking order,” he said. “You also have the hidden curriculum, the neurologist who taps the medical student on the shoulder in a hallway and says, ‘You’re too smart to be in primary care.’”

Possible solutions:

Solution One. Recruiting Primary Care docs from abroad: In its 2006 report on primary-care providers, The US Government Accountability Office said the number of international medical graduates training in primary care had grown from 13,025 in 1995 to 15,565 in 2006.

Solution Two. The Senate Finance Committee bill might have a 5% bonus for reimbursement provided to Primary Care doctors (at the expense of reimbursement for procedures performed by specialsts). Look for a big lobbying fight on this.

Back in January, AMA Board chairman Joseph M. Heyman, MD spoke about this. He said, “We are all on the same page when it comes to investing in primary care in this country. We must present a unified front.” He then lays out their agenda on this issue: “The American Medical Association absolutely supports this important investment in primary care. Payments to primary care physicians must increase. The American Medical Association absolutely opposes applying budget-neutrality rules that confine offsets to the physician payment pool. Congress should not rob Dr. Peter, the surgeon, to pay Dr. Paul, the primary care physician.”

HOWEVER: There is a loop hole here. They could shift payments to primary care functions like prevention and management, but not actually address the cost (i.e. avoid brawling with the AMA). Jeff Goldsmith of Health Futures Inc. says that “Rebalancing Medicare can await the huge Deficit Reduction bill Congress will consider after the Congressional elections in 2010.” (Read his post here.) This is pretty sneaky, but politically it could be just what Democratic leadership is looking for.

Solution Three. The HHS has announced $300 million, to expand the National Health Service Corps, which repays student loans for students dedicated to practicing primary care in communities of greatest need.

Solution Four. Expect also to see doctors push back if Obama’s administration moves forward with a suggestion to allow nurse practitioners and physician assistants to carry out some of the same functions as physicians. Who controls what doctors can do now? Doctors of course. Watch out for AMA, the doctor’s union.

Solution Five. Dr. Georges Benjamin, executive director of the American Public Health Association says that another way to expand primary care is to have some specialists provide the equivalent of primary care. For example, he said obstetrician-gynecologists essentially serve as primary care physicians for many women — a model that could be used for patients who rely on other specialists. This does not actually address the problem however, because OB/GYN’s face shortages as well.


~ by Kathryn Bailey on September 22, 2009.

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Google+ photo

You are commenting using your Google+ account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )


Connecting to %s

%d bloggers like this: