By Pat Wechsler
Nov. 13 (Bloomberg) -- President Barack Obama’s health overhaul, aiming to add 36 million Americans to the insurance rolls, will worsen a family-doctor shortage, triggering longer waits for office visits and crowded emergency rooms.
“This is already a catastrophic crisis,” said Joseph Stubbs, president of the Philadelphia-based American College of Physicians, the second-largest doctor’s group in the U.S. “Now we’re talking 30 million more people who will want to see a doctor. The supply of doctors just won’t be there for them.”
Underserved areas in the U.S. currently need 16,679 more primary-care physicians to reach a “medically appropriate” target of 1 for every 2,000 residents, U.S. data shows. The health-care overhaul bills before Congress would raise pay for family doctors, increase residency training and forgive school debt to help meet that deficit. Those measures, though, will take years to make a difference, said Stubbs, who also works as an internist in Albany, Georgia.
More family doctors are needed to cut health costs through early diagnosis and prevention, and increase access to medical care, Obama said in a June 15 speech to the American Medical Association meeting in Chicago. The Massachusetts health-care initiative shows what can go wrong if the primary-care system isn’t fixed simultaneously with the start of universal coverage, said Allan Goroll, a professor of medicine at Harvard Medical School in Boston.
Massachusetts passed a law in 2006 that has increased the percentage of insured to 97.4 percent of its population, the highest in the U.S., from 93.6 percent.
Waiting Times Rise
The average waiting time to see a family-medicine doctor in Boston, a city with 14 teaching hospitals, is 63 days, the most among 15 cities in a 2009 surveyby Merritt Hawkins & Associates, a recruiting and research firm in Irving, Texas. People in Los Angeles waited 59 days, while those in Miami saw doctors in 7 days, the survey found.
Boston’s longer wait was “driven in part by the health- care reform initiative,” the report said.
Even before the initiative, there was a shortage of primary care doctors in Massachusetts, said Harvard’s Goroll, who is also an internist atMassachusetts General Hospital in Boston. As many as half of doctors in the state have closed their practices to new patients, forcing many of the newly insured to turn to emergency rooms for care, he said.
“The primary lesson of health-care reform in Massachusetts is that you can’t increase the number of insured unless you have a strong primary-care base in place to receive them,” Goroll said. “Without that foundation of primary care, Massachusetts has ended up with higher costs and people going to emergency rooms when they can’t find a doctor.”
Spending to Double
Per-capita health spending is projected to double in Massachusetts by 2020, according to a June report by the state. Insurance premiums rose 10 percent this year, Massachusetts Health and Human Services Secretary JudyAnn Bigby wrote in an Oct. 21 New England Journal of Medicine article.
There were 303,749 primary-care doctors in the U.S. at the end of 2007, according to data in a 2009 American Medical Association report. That number rose 11 percent from 2000 to 2007, falling behind a 13 percent jump among other doctors, the Chicago-based group said.
The shortage in primary care isn’t uniform across the nation, according to U.S. Health Resources and Services Administration data from all 50 states, which shows 6,215 designated shortage areas. In general, suburban and wealthier urban areas tend to be well stocked with family doctors, and rural areas and inner cities are short.
Underserved Communities
The federal government designates regions as being underserved based on per capita numbers. To be designated, a region needs to have less than one family doctor per 3,500 residents. Using just this ratio, the communities have 7,413 fewer primary-care doctors than they need, the HRSA said.
An adequate level -- established by public health clinicians and staff as affording “appropriate” access to health care -- is 1 for every 2,000 residents, according to the HRSA, which gathers the data. That brings the deficit to 16,679.
In most industrialized nations, including Germany and the U.K., there is one primary-care physician for every specialist, according to the Organization of Economic Cooperation and Development in Paris. The U.S. ratio is closer to one to three, according to the AMA.
The U.S. will need another 35,000 to 46,000 primary-care doctors within 15 years as the population ages, the American College of Physicians said in a 2009 report.
Living Longer
“We are living longer and living more often with chronic disease,” said Cathy Schoen of the health-care research group the Commonwealth Fund in New York. “Someone needs to be in the center of care and know the whole patient if care is to be coordinated and efficient.”
Becoming a family doctor -- once the icon of U.S. medical care, from Norman Rockwell paintings to TV’s Marcus Welby -- has lost its luster over the past decade, primarily because these physicians earn, at most, half of what specialists make, Harvard’s Goroll said.
In the late 1990s, Medicare and Medicaid changed the reimbursement system to compensate medical procedures at a higher rate than management and evaluation of patients, something family doctors focus on in their practices.
The emphasis on procedures and technology led many prospective doctors to choose careers in higher-paying radiology, orthopedic surgery, anesthesiology and dermatology, according to Goroll.
Average Salary
The average salary for family physicians grew 18 percent over five years, or about 3.6 percent annually, according to data from Merritt Hawkins, the recruiting firm. That compares with a 46 percent increase, or 9.3 percent a year, for orthopedic surgeons.
Family practice pays an average of $173,000 a year, a 2009 survey by Merritt Hawkins shows. This compares with $391,000 for a radiologist, $481,000 for an orthopedic surgeon, $344,000 for an anesthesiologist and $297,000 for a dermatologist.
Given that the typical medical student debt is about $140,000, the income disparities prove to be “strong disincentives for younger physicians,” according to a 2009 report from the American College of Physicians.
In a 2008 survey of third-year medical residents, 21 percent said they planned to pursue careers in general internal medicine, the equivalent of primary care, according to the American College of Physicians. That’s down from 54 percent in 1998. The rest were headed to subspecialties, such as oncology, gastroenterology and infectious disease.
Medical-School Changes
Medical schools at Duke University in Durham, North Carolina, and Johns Hopkins University in Baltimore are attempting to change the trend by creating primary-care residency programs that let students work with families outside the hospital setting.
At Duke, a family medicine leadership residency was started three years ago to let students practice “21st-century primary care,” working in outpatient clinics and in communities, said Lloyd Michener, who is the chair of the department of community and family medicine at the medical school.
“It brings in an element of public health since residents are assessing both the needs of the patients and the community they are working in,” said Barbara Sheline, the school’s assistant dean for primary care.
A four-year urban health residency that begins in July 2010 at Hopkins combines medicine and pediatric training at community clinics and in schools.
Students in the Community
Duke also has approved a new primary-care curriculum for its medical students, allowing up to nine to choose work in community clinics during their four years.
The university will offer the program to three or four students this year on a pilot basis, then accept applications for the slots in the 2010-2011 academic year. The program will offer scholarships to give students the option of choosing a career in primary care without worrying about a large educational debt, Sheline said.
“For most of us, primary care is a calling,” Michener said. “But I see medical students turn down the idea of primary care for very thoughtful reasons about wanting a family themselves and not wanting to work all the time.”
Hopkins’ medical school also converted to a curriculum this year emphasizing “individualized medicine, based on genetic makeup and history, environmental influences and lifestyle,” said Charles Wiener, director of Hopkins’ residency programs and vice chairman of the department of medicine.
‘Knowing the Individual’
“Primary care knows the individual best,” Wiener said. “I’m hopeful this will spark more interest among students.”
Health-care overhaul legislation in the U.S. House and Senate offers medical school debt forgiveness for those who choose primary care. The bills also call for a redistribution of unused residency spots to primary care and general surgery.
They also attempt to redress the pay inequity between primary care and specialty medicine by giving family doctors a payment bonus of between 5 and 10 percent annually for at least the next five years. This is on top of a restructuring of Medicare payments beginning in 2010 by the Centers for Medicare & Medicaid Services.
The agency is taking money away from specialists such as cardiologists and radiologists to fund a 6 percent to 8 percent increase in reimbursement for office visits to family physicians phased in over four years. The House version would also provide federal funds to increase Medicaid primary-care payments.
Medicaid Expansion
By allowing those living at 150 percent of the federal poverty level to qualify, the overhaul would expand the ranks of Medicaid by more than 10 million people in 2015.
These are populations that typically don’t have family doctors and frequently have been living with untreated chronic illness, said Lori Heim, president of the Leawood, Kansas-based American Academy of Family Physicians, representing 94,000 doctors and medical students.
Heim, who is also a family doctor at Scotland Memorial Hospital in Laurinburg, North Carolina, said she cared for a man in his 40s with untreated high blood pressure. Although the patient had a full-time job, he had no health insurance and no primary care doctor. He was already suffering from permanent liver and heart damage, and had to be admitted to the intensive care unit, she said.
“Instead of a family doctor putting him on generic blood pressure pills years ago that would have cost less than $100 a year, I had to put him in the ICU, which alone will run several thousand dollars,” Heim said. “Down the road, he may need dialysis. This is a working example of why costs keep going up and what happens when there aren’t enough family physicians.”
To contact the reporters on this story: Pat Wechsler atpwechsler@bloomberg.net.
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