Wednesday, April 29, 2009

Primary Care Shortage makes Times Front Page

On April 27, 2009 the New York Times ran a page 1, right-column piece entitled “Shortage of Doctors Proves Obstacle to Obama Goals” by Robert Pear.[1] This is very interesting in part because this position in the paper is reserved for the most important news of the day; it must have been a slow news day, because this is not news. For example, it has been addressed several times on this blog alone, including most recently in the guest piece by Dr. Patrick Dowling, “The basic law of modern health care” (4/22/09), my own piece “More primary care doctors or just more doctors?” (Apr 3, 2009), “The ten biggest myths regarding primary care in the future” by Dr. Robert Bowman (Jan 15, 2009)and as far back as Dec 11, 2008 (“A quality health system needs more primary care physicians”). So, yes, it is a big problem. However, the comments in Mr. Pear’s articles only sometimes refer to primary care, and sometimes to all doctors, thus confusing the issue. The President says, quite clearly, “We’re not producing enough primary care physicians…The costs of medical education are so high that people feel that they’ve got to specialize.” But Senator Orrin Hatch of Utah is quoted as saying “The work force shortage is reaching crisis proportion,” not clearly about primary care, and Rep. Shelley Berkley includes both: “We don’t have enough doctors in primary care or in any specialty.”

With respect to Rep. Berkley, this last statement is clearly wrong. While, depending upon how we measure it (again see “More primary care doctors or just more doctors?, Apr 3, to see my discussion of Dr. Richard Cooper’s analysis), there may be shortages in some non-primary care specialties, we have plenty of doctors in many others. Probably too many in some. There is an issue of distribution; most doctors are heavily concentrated around major cities and their suburbs and do not “distribute” based upon where the population is located. (Family medicine is the notable exception, as these doctors do distribute to where people are.) It may be politic to say “…or in any specialty” but it does a tremendous disservice to efforts to address the problem. While new medical schools are opening, and others are increasing their class sizes to produce more physicians, there is no evidence that this will increase the number of students choosing family medicine or other primary care specialties. As the article notes (and this blog has described), “Doctors trained in internal medicine have historically been seen as a major source of primary care. But many [correction: most!] of them are now going into subspecialties of internal medicine, like cardiology and oncology.” Even osteopathic medical schools, long high producers of primary care, have been confronting a major movement of their graduates into subspecialty careers.

The economic incentives go the wrong way. According to the Times article, “Senator Max Baucus, a Montana Democrat and chairman of the Finance Committee, said Medicare payments were skewed against primary care doctors...`Primary care doctors are grossly underpaid compared with many specialists’.”
He is proposing an increase in payments to primary care physicians, as is the Medicare Payment Advisory Commission (MedPAC). However, MedPAC feels that “To offset the cost…Congress should reduce payments for other services, an idea that riles many specialists”.

You betcha. “We have no problem with financial incentives for prmary care,” says Dr. Peter J. Mandell of the American Association of Orthopaedic Surgeons, but “We do have a problem with doing it in a budget neutral way”. Because their income will go down. Dr. Mandell states that “If there’s less money for hip and knee replacements, fewer of them will be done for people who need them.” Maybe, but I doubt it. The reimbursement for these procedures could drop a great deal and the surgeons would still be making plenty of money on them, so they will probably not stop doing them.

So there is a great shortage of family physicians and other primary care providers. Something has to be done. One way is to increase the reimbursement of these physicians by Medicare, which will result in other insurers following suit. This can be done in a budget-neutral way, or even in a money-saving way depending upon how much is cut from specialist reimbursement. A way to do this is to only pay for procedures for which there is strong evidence of benefit. Given the current economic situation, the cost of health care, and the enormous incomes of some specialists, it is almost certain that there is no possibility that specialist reimbursement will not decrease, whether or not primary care payments are increased.

Another way to increase the number of students entering primary care is to repay their loans. The Times says that “new doctors typically owe more than $140,000 when they graduate”, and it is frequently much more, even $250,000 for those attending private schools (or public schools as out-of-state students, where the tuition is as high as at private schools) who do not come from wealthy families. This sort of loan repayment is currently done by the National Health Service Corps and the military, but there are not enough positions in the NHSC to supply the nation’s civilian primary care needs. Such programs must be expanded. The Obama administration is continuing the Bush administration’s policy of expanded funding for Community Health Centers, but there are not enough doctors and nurses to fill the positions in primary care.

We need to have a two-pronged effort, to cover everyone in a way that provides quality health care in a cost effective manner (single payer) and incentives for students to enter the specialties of greatest need, primary care and especially family medicine.
Of course, if we continue to hear stuff like Sen. Baucus saying: “Everything BUT single payer is on the table. Single payer if off the table” and Speaker Pelosi: "In our caucus, over and over again, we hear single payer, single payer, single payer. Well, it's not going to be a single payer," we can be pretty sure single payer won’t happen. We’ll get a plan that won’t work and will cost a lot. But maybe we can take heart in Churchill’s optimistic assessment of the American people: “You can always count on Americans to do the right thing—after they’ve tried everything else.”

[1] Pear R, “Shortage of doctors proves obstacle to Obama goals”, NY Times Apr 27 2009.

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