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.