Starting Points: primary care physicians

Showing posts with label primary care physicians. Show all posts

Apr 14, 2010

U.S. Faces Shortage of Doctors - WSJ.com

As Ranks of Insured Expand, Nation Faces Shortage of 150,000 Doctors in 15 Years

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First-year resident Dr. Rachel Seay, third from left, circumcises a newborn in George Washington University Hospital's delivery wing on March 12.

The new federal health-care law has raised the stakes for hospitals and schools already scrambling to train more doctors.

Experts warn there won't be enough doctors to treat the millions of people newly insured under the law. At current graduation and training rates, the nation could face a shortage of as many as 150,000 doctors in the next 15 years, according to the Association of American Medical Colleges.

That shortfall is predicted despite a push by teaching hospitals and medical schools to boost the number of U.S. doctors, which now totals about 954,000.

The greatest demand will be for primary-care physicians. These general practitioners, internists, family physicians and pediatricians will have a larger role under the new law, coordinating care for each patient.

The U.S. has 352,908 primary-care doctors now, and the college association estimates that 45,000 more will be needed by 2020. But the number of medical-school students entering family medicine fell more than a quarter between 2002 and 2007.

A shortage of primary-care and other physicians could mean more-limited access to health care and longer wait times for patients.

Proponents of the new health-care law say it does attempt to address the physician shortage. The law offers sweeteners to encourage more people to enter medical professions, and a 10% Medicare pay boost for primary-care doctors.

Meanwhile, a number of new medical schools have opened around the country recently. As of last October, four new medical schools enrolled a total of about 190 students, and 12 medical schools raised the enrollment of first-year students by a total of 150 slots, according to the AAMC. Some 18,000 students entered U.S. medical schools in the fall of 2009, the AAMC says.

But medical colleges and hospitals warn that these efforts will hit a big bottleneck: There is a shortage of medical resident positions. The residency is the minimum three-year period when medical-school graduates train in hospitals and clinics.

There are about 110,000 resident positions in the U.S., according to the AAMC. Teaching hospitals rely heavily on Medicare funding to pay for these slots. In 1997, Congress imposed a cap on funding for medical residencies, which hospitals say has increasingly hurt their ability to expand the number of positions.

Medicare pays $9.1 billion a year to teaching hospitals, which goes toward resident salaries and direct teaching costs, as well as the higher operating costs associated with teaching hospitals, which tend to see the sickest and most costly patients.

Doctors' groups and medical schools had hoped that the new health-care law, passed in March, would increase the number of funded residency slots, but such a provision didn't make it into the final bill.

"It will probably take 10 years to even make a dent into the number of doctors that we need out there," said Atul Grover, the AAMC's chief advocacy officer.

While doctors trained in other countries could theoretically help the primary-care shortage, they hit the same bottleneck with resident slots, because they must still complete a U.S. residency in order to get a license to practice medicine independently in the U.S. In the 2010 class of residents, some 13% of slots are filled by non-U.S. citizens who completed medical school outside the U.S.

One provision in the law attempts to address residencies. Since some residency slots go unfilled each year, the law will pool the funding for unused slots and redistribute it to other institutions, with the majority of these slots going to primary-care or general-surgery residencies. The slot redistribution, in effect, will create additional residencies, because previously unfilled positions will now be used, according to the Centers for Medicare and Medicaid Services.

Some efforts by educators are focused on boosting the number of primary-care doctors. The University of Arkansas for Medical Sciences anticipates the state will need 350 more primary-care doctors in the next five years. So it raised its class size by 24 students last year, beyond the 150 previous annual admissions.

In addition, the university opened a satellite medical campus in Fayetteville to give six third-year students additional clinical-training opportunities, said Richard Wheeler, executive associate dean for academic affairs. The school asks students to commit to entering rural medicine, and the school has 73 people in the program.

"We've tried to make sure the attitude of students going into primary care has changed," said Dr. Wheeler. "To make sure primary care is a respected specialty to go into."

Montefiore Medical Center, the university hospital for Albert Einstein College of Medicine in New York, has 1,220 residency slots. Since the 1970s, Montefiore has encouraged residents to work a few days a week in community clinics in New York's Bronx borough, where about 64 Montefiore residents a year care for pregnant women, deliver children and provide vaccines. There has been a slight increase in the number of residents who ask to join the program, said Peter Selwyn, chairman of Montefiore's department of family and social medicine.

One is Justin Sanders, a 2007 graduate of the University of Vermont College of Medicine who is a second-year resident at Montefiore. In recent weeks, he has been caring for children he helped deliver. He said more doctors are needed in his area, but acknowledged that "primary-care residencies are not in the sexier end. A lot of these [specialty] fields are a lot sexier to students with high debt burdens."

Mar 3, 2010

The Doctor Won’t See You Now

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A critical shortage of primary-care physicians is yet another symptom of our ailing health-care system.

By Mary Carmichael | NEWSWEEK

Published Feb 26, 2010

From the magazine issue dated Mar 8, 2010

After taking a month to regroup, the White House has put health care back at the top of its agenda, asking Republicans for new ideas and trying to regain momentum for old ones. But last week's summit came down mostly to the same old talking points. And even if the president does manage to get some version of health-insurance reform passed in the next few months, he and the country are still going to be dealing with the related crisis of America's doctor shortage. Primary-care physicians, family docs, general practitioners—whatever you call them, they're the country's first line of defense, the ones responsible for promoting preventive care, finding ways to keep people from getting sick in the first place, and thus bringing down costs throughout the system. If every American went to one of these doctors regularly, health-care costs might come down as much as 5.6 percent a year, saving $67 billion, according to one estimate. Yet we don't have nearly enough doctors to make that happen, and fewer are being produced every year.

The annual number of American medical students who go into primary care has dropped by more than half since 1997. It's hard to get an appointment with the doctors who remain. In some surveys, as many as half of primary-care providers have stopped taking new patients. The other half are increasingly overworked and harried. Clearly we need to find a way to increase their ranks, and both the congressional health-care bills and President Obama's reform proposal make moves in that direction. But those efforts are somewhat limited, and a more comprehensive solution could be thwarted by the same thing that's stalled the rest of health-care reform so far: politics.

The reason behind America's doctor gap is a matter of money. The average income in primary care is somewhere in the mid-$100,000s, which sounds like a lot but is less than half what specialists such as radiologists and dermatologists make. Given that doctors may graduate with as much as $200,000 in med-school debt, it's easy to see why primary care started hemorrhaging recruits more than a decade ago and why radiology and other well-paid, high-tech specialties took off in popularity.

The field has since entered a vicious cycle. As fewer people have entered primary care, the doctors who are left have been forced by tight schedules to shortchange some patients, forgoing the long, meandering chats that used to be a big part of checkups in favor of 15-minute, checklist-style appointments. The close relationships that general practitioners once had with patients drew many idealistic students into the field. Now recruiters face an extra-tough sell: they have to convince bright young would-be docs to pursue a career that won't pay very well and won't be as emotionally fulfilling as it once was.

How can schools entice more aspiring doctors into primary care? The Tufts University School of Medicine, to take one example, offers a $25,000-per-year scholarship for med students who agree to work in primary-care practices in rural Maine for much of their training period. Students on this Maine Track start shadowing doctors on the third day of orientation. This year's program drew 257 applicants for just 36 slots.

The problem with the Maine Track is that it doesn't actually require med students to enter primary care after they graduate. It can't, says Peter Bates, chief medical officer at Maine Medical Center, which jointly administers the program with Tufts. "If you're a bright kid with a great future, being told you have to be a family physician in rural Maine—even if that's what you want to do [now]—might strike you as confining," Bates says. "Why would you close down your opportunities?"

There are dozens of training programs like Tufts's around the country, as well as the National Health Service Corps, which pays back loans and hands out scholarships and stipends in exchange for a few years of service in rural areas, where the shortage of primary-care providers is most acute. Obama and the Senate have both called for an expansion of the program in their proposals for reform, which has already received $200 million in stimulus funds. Several new medical schools, including some that focus on primary care, have also recently opened. But all those changes may not be enough to fill the gap. "We need more than half of doctors in this country doing primary care," says Harris Berman, interim dean of the medical school at Tufts. "It's a bigger problem than we can solve with programs like ours."

So what else can be done? Lately, some policymakers have argued that instead of having a primary-care doctor, more people—especially young, healthy patients with simple medical needs—should see a nurse or physician assistant who administers routine care and kicks more complex problems up to a doctor when they arise. "If you're just coming in to have your blood pressure checked and your pulse taken, you really don't need to see a doctor, and you might not need to see a nurse, either," says David Barrett, president and CEO of the Lahey Clinic in Burlington, Mass. "There are three-stripe military sergeants with two-year degrees who can provide excellent primary care. There's absolutely no reason to force all primary-care providers to have an M.D."

The Lahey Clinic is an "integrated group practice"—one of the teamwork-oriented organizations, like the Mayo Clinic and the Cleveland Clinic, that have been lauded for cutting costs and eliminating waste in the health system. In its primary-care service, a "team captain" physician supervises nurses, PAs, and other health-care professionals who perform tasks like checking blood pressure but don't necessarily make formal diagnoses on their own. The problem with taking this approach nationwide is that nurses and PAs are subject to the same economic forces that drive medical students. Almost half of current nurse practitioners and physician assistants work in specialty practices, where the money is. Then there's the fact that the country already has a nursing shortage. How are nurses going to replace doctors if there aren't enough nurses to begin with?

There's one more group of people, foreign medical graduates, who could theoretically fill in for the missing primary-care providers. The trouble is, they're already doing that. More than a quarter of primary-care doctors currently practicing in the United States have gotten their diplomas abroad. Increasing their numbers would be problematic for both the left (which might object to poaching doctors from developing countries that need them) and the right (which would surely object to recruiting non-Americans to do a job that reliably pulls in six figures, especially when unemployment is high).

Inevitably, then, the solution to the primary-care crisis is going to have to involve something simpler: paying primary-care providers more, so as to draw more bright young physicians into the field. At least it sounds simpler. But even this turns out to be maddeningly complex.

Most primary-care doctors, like all other physicians, are paid bit by bit for each medical task they perform (unless they work somewhere like the Lahey or the Mayo, which pay set annual salaries). Private insurers decide how much they'll reimburse docs for each task partly by looking to Medicare's policies for guidance. Medicare, in turn, makes its decisions by committee. Here is the bad news for primary-care docs: most of the physicians on the committee that sets the reimbursement rates are specialists. Medicare—and, consequently, private insurance—doesn't reimburse primary-care doctors as lavishly as it does their more specialized counterparts. That's why primary-care incomes are relatively low in the first place.

Changing anything about the way primary-care providers are paid will be immensely complicated. For one thing, rural doctors sometimes perform specialized procedures because no one else is available—would they still qualify for a raise? And then, what exactly constitutes a task that should be reimbursed? For a high-tech specialist, this is often clear-cut: each scan or chemical test counts. But what about all the things primary-care doctors do that don't involve technology? "You don't get paid to talk to people and tell them to stop smoking. Nobody values my time to do that," says Joe Gravel, a family physician and chief medical officer at the Greater Lawrence Family Health Center in Massachusetts. "They'll pay for the lung transplants, but they won't pay to prevent 50 people from needing them."

In January, Medicare raised reimbursement rates for some primary-care services by about 4 percent, and its payment committee will call for another small increase this week. That's a good start, says Lori Heim, president of the American Academy of Family Physicians, but "if you're talking about changing the way students view primary care, it needs to be more like 25 percent, and that's on the low side." Both the House and Senate reform bills also include a slight increase in primary-care payments—5 and 10 percent, respectively.

To fund such a pay raise, Congress would either have to spend more money on health care or pinch some from the specialists by lowering their pay rates. The first strategy is clearly controversial—no one wants to increase health-care costs further. The second, budget-neutral strategy is bound to tick off the specialists. Peter Mandell, a spokesman for the American Academy of Orthopaedic Surgeons, sent a clear message last year when the Medicare reimbursement committee suggested a 10 percent shift in payments toward primary-care docs and away from specialists. Telling The New York Times that his group had "a problem" with the idea, Mandell added, "If there's less money for hip and knee replacements, fewer of them will be done for people who need them." It's a short step from his polite, reasonable statement to rallies over the specter of rationing.

So here is the fundamental dilemma of the primary-care crisis: One of the solutions with the best chance of working is politically unpalatable, and even those who support it admit it's a bureaucratic nightmare. But without it,we may be heading for an even bigger disaster that nobody wants. Does this sound familiar? The cure for primary care, it turns out, is ultimately going to be the same thing that's needed to fix the rest of the health-care system: political will.