Architects of Healthcare Reform Face Critical Shortage of Primary Care Docs

By Christopher Moraff, The Philadelphia Tribune. Posted July 14, 2009.

"As a quick example, you can do an amputation of a leg for $40,000 but the system will only pay you pennies on the dollar to keep someone from needing an amputation in the first place," he says. "So, what do we get? We get a lot of guys that do amputations on legs."

All About the Benjamins

This paradigm is perhaps most evident in the yawning pay differential that exists between family care doctors and specialists. According to the 2008 Physician Compensation Survey conducted by the American Medical Group Association (AMGA), the median annual salary for a general practitioner is $190,182, while a geriatrics doctor earns just under $180,000. By contrast, the median annual salary for a dermatologist is $344,847; an ophthalmologist, $305,301; and a diagnostic radiologist, $420,858.

According to AAFP, the income gap over a typical physician career amounts to a 256 percent differential in return on investment between primary care doctors and the average medical specialist.  With the typical med student leaving school with upwards of $140,000 of debt, it's not hard to understand why they might shy away from primary care.

"Basically, we're saying to the nation's medical students that primary care is complex work and we're going to pay you less at a time when many are struggling financial themselves," Epperly says.

Dr. Woolhandler says she sees this first-hand. "I do a lot of teaching at Harvard and often students will say ‘I like primary care; I'd love to be able to go into primary care but…,' and it's usually something financial. There's a lot of young people making these life decisions who are also saddled with debt and obligations," she says.

How much a doctor makes is determined largely by a 29-member group called the Relative Value Scale Update Committee, or RUC. The RUC was developed in 1991 to determine the fee schedule for Medicare reimbursements and includes one member from each medical specialty plus three rotating seats.

Although primary care services account for roughly half of all Medicare volume, only four permanent seats on the RUC represent primary care fields; so, when it comes to revaluing reimbursement codes, representatives from high-end specialty fields have the deck stacked. And since Medicare spending is fixed, more money for one specialty means less for another.

"Medicare drives what other insurance companies do, so the other [private] insurance companies all key off of the Medicare rates and so what gets done in Medicare becomes the law of the land in terms of other insurance company valuations," Epperly explains.

Recruitment is Key

Beyond the issue of payment, primary care reform advocates say major American medical schools need to rethink the way they recruit future doctors.

The training of new doctors is especially critical now, as the physician population ages. In Pennsylvania, for instance, more than 50 percent of the physicians represented by the Pennsylvania Medical Society are over the age of 50, and less than eight percent of them are under the age of 35, the group says. If current trends continue, as primary care doctors retire there will be fewer and fewer to take their place.

The shortage is particularly acute in inner city and rural areas, and among minority populations, which is where Epperly says medical schools need to start focusing recruitment efforts.

"What American medical schools do right now is they recruit and train the type of workforce that most meets the needs of academic teaching medical centers and university medical schools, not what they need in inner-city Philadelphia or rural Idaho," he says. "So, we're getting a lot of high-end, white kids coming from privileged families that are bright, but their view of the world is based on a financial model with a very subspecialty orientation."

There is presently a severe deficit of minority students entering medical school. According to the Association of American Medical Colleges (AAMC), as of 2006, 28.8 percent of the U.S. population was Black, Latino, or Native American, yet these groups accounted for only 14.6 percent of medical school graduates. Nationwide, only 6 percent of practicing physicians are members of these groups.

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Christopher Moraff is a writer, journalist and photographer and a frequent contributor to In These Times and The American Prospect Online. He also works as a correspondent for The Philadelphia Tribune and is senior editor of the monthly online political journal Common Sense Magazine. He lives and works in Philadelphia.

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