Thursday, October 2, 2008

Primary care - Implications of Prmary Care Shortage, as Told to a National Reporter

Implications of the Primary Care Shortage, as Told to a National Reporter

A reporter from a national publication, which shall go unnamed, called to ask what I thought was being done to address the U.S. primary care shortage. We spoke for some time, and she will have her own take on the problem.

Her questions to me were.

• What do you believe is the single greatest factor contributing to the nation’s primary care shortage?

Massive unremitting long-standing frustration and demoralization due to low payments, burdensome paperwork distracting from care, rising malpractice premiums, continuous Congress threats of pay cuts, and relentless pressure to install EMRs. That’s about a simple as I can make it, with the emphasis on frustration and lack of action to correct inequities.

• Is there any data to show where the shortage is greatest?

You bet, and the data all point to greatest shortages in underserved rural, inner cities, and in regions of high proportions of Medicare, Medicaid, and uninsured patients. The root cause of the shortage is, frankly, a business problem, since the overwhelming number of doctors are small businesspersons, with payrolls to meet, staff to retain, and bills to pay. It is reasonable to assume doctors would prefer paying patients on low paying or non-paying patients to meet these obligations.

If Medicare, Medicaid, and health plan payments fail to meet overhead, and the insured and underinsured numbers continue to mount, some doctors will no longer accept new patients from these sectors.

One cannot stay in practice if expenses continually outstrip revenues. That is simply a business reality, and there is no dancing around it. Universal or expanded coverage will worsen the problem because coverage without access to primary care physicians is meaningless. What good is coverage if you can’t find a doctor who is too overloaded and stressed financially to accept new patients.

Keep this in mind: U.S. medical schools produce about 18,500 new graduates each year, and less than 10% are entering primary care residences. That amounts to 1850 new primary care doctors each year, or about 37 new primary care doctors per state, a drop in the bucket of medically underserved regions.

• Are there any promising legislative, regulatory, or private sector solutions that hold promise?

Yes, but you don’t turn around the present shortage, which has been building for 25 years, on a dime. It takes 10 – 12 years to produce a trained competent primary care physician. Graduating medical students are typically $150, 000 in debt, they are smart, they have eyes and ears, and they know specialists make 2 to 3 times more than generalists, have more balanced life styles, work shorter hours, and command greater respect.

Given these countervailing factors, younger doctors will continue to gravitate towards specialties and towards secure hospital employment, and oldcr doctors will continue to leave primary care to become hospitalists, ER doctors, “owned” physicians paid by hospitals, locum doctors, concierge and cash only doctors, and physicians in non-clinical positions.

Legislatively, the hottest thing on the horizon right now are “medical home” programs where doctors are paid more to offer comprehensive, coordinated, and personal care. More than 20 states and 108 bills have initiatives to make these homes a reality, and Medicare is pushing its own medical home pilot projects.

The basic idea to reward primary care doctors more handsomely through payment reforms blending fee-for-service, payments for being responsive to patient email, phone calls, and same day appointments, and P4P.

On the private sector, side, Big Business, led by IBM, has collaborated with the major primary care societies – the American Academy of Family Practice, the American College of Physicians, the American Academy of Pediatrics, and American Osteopathic Association – to form an organization The Patient Centered Primary Care Collaborative to promote Medical Homes. This organization is working with more than 50 major corporations, state medical societies and state government to re-empower primary care.

In a related effort, major corporations are establishing worksite clinics, led by salaried primary care physicians, to provide care at the worksite featuring preventive care, embedded EMRs with best practice guidelines, free generic drugs, and controlled specialty networks. About 7200 coporate worksites, with roughly 1000 employees at each site, can support these clinics, and they are cropping up all over the country.

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Discover What You Think said...

So, You Want To Be A Doctor…..

In recent times, others have appeared to express concern about the apparent shortage of primary care doctors in particular in the United States. Both presently as well as in the years to come, others speculate that the shortage of doctors will continue to progress to even greater absence of PCPs that what exists now. Less than 20 percent of medical school graduates go for primary care as a specialty as a residency program today. Typically, the main reason believed by many is lack of pay compared with other medical specialties. Some anticipate a shortage of 60 thousand or so primary care doctors in the future within the United States. The PCP doctors who practice right now would not recommend their specialty, or their profession, it has been reported.
It is estimated that the U.S. needs presently tens of thousands more primary care physicians to fully satisfy the necessities of those members of the public health. Ironically, PCPs have been determined to be the backbone of the U.S. Health care system, which I believe them to be. For example, PCPs manage the many chronically ill patients, who benefit the most from the much needed coordination and continuity of care that PCPs historically have strived to provide for them. Nearly half of the U.S. population has at least one chronic illness- with many of those having more than one of these types of these illnesses. A good portion of these very ill patients have numerous illnesses that are chronic, and this is responsible for well over 50 percent of the entire Medicare budget, who are largely cared and treated by PCPs.
The shortage of primary care physicians is possibly due to other variables as well- such as administrative hassles that are quite vexing for the physician vocation overall- along with ever increasing patient loads complicated by the progressively increasing cost to provide care for their patients due to decreasing reimbursements from various organizations the doctors receive for the services they provide. For reasons such as this, it is believed that some PCPs are retiring early, or simply seeking an alternative career path. As mentioned earlier, the PCP specialty is not desirable for a late stage medical student, so this is quite concerning to the public health in the United States. The number of medical school graduates entering family practice residencies has decreased by about half over the past decade or so. PCPs also have extensive student loans from their training to complicate their rather excessive workloads as caregivers with decreased pay, comparatively speaking.
Despite the shortage of these doctors, primary care physicians do in fact care for the populations they serve and are dedicated to their welfare, as difficult as it may be for them at times. Studies have shown that mortality rates would decrease due to increased patient outcomes if there were more PCPs to serve those in need of treatment. This specialty would also optimize preventative care more for their patients. Studies have also shown that, if enough PCPs are practicing in a given geographical area, hospital admissions are decreased, as well as visits to emergency rooms. This is due to the ideal continuity in health care these PCPs provide if numbered correctly to serve a given population of citizens. In addition, PCP care has proven to improve the quality of care given to patients, as well as the outcomes for these patients as a result are more favorable. Most importantly, the overall quality of life for their patients is much improved if there are enough PCPs to handle the overwhelming load of responsibility they presently have due to this shortage of their specialty that is suppose to increase mildly if at all in the years to come. The American College of Physicians believes that a patient- centered national health care workforce policy is needed to address these issues that would ideally be of most benefit for the public health. Policymakers should take this into serious consideration.
“In nothing do men more nearly approach the Gods then in giving health to men.” --- Cicero
Dan Abshear (ex-military medic and physician assistant for nearly 20 years)
Author’s note: What has been written has been based upon information and belief of a layperson, yet also the assessments of a patient.