Architects of Healthcare Reform Face Critical Shortage of Primary Care Docs
This article originally appeared in the July 12 issue of The Philadelphia Tribune
We all know the routine. You call your doctor for appointment, and -- unless you have an acute illness -- you might get one in two weeks, ten days if you're lucky. On the day of your visit you get to the office early only to find three, four, or even five patients in the waiting room who seem to have been given the same appointment time as you.
After about 40 minutes spent flipping through old copies of Sports Illustrated your name is called and you are escorted to an exam room. Okay, you think, here we go. But you're not seeing a doctor yet. Instead, you'll sit in that tiny room staring at the jars of cotton and trays of plasma vials for another 20 minutes before the physician finally comes in. He'll spend, on average, ten minutes with you before scribbling something in your chart and rushing out to the next patient. By the time you leave, your one o'clock consultation has turned into a brief, two o'clock encounter.
At this point it's easy to get frustrated, even angry, and many of us do. But here's a flash: it's not your physician's fault.
America is suffering from a critical shortage of primary care doctors; and with a potential 47 million uninsured people likely to get covered under President Obama's healthcare reform initiative…well, if you think things are bad now, just wait.
The U.S. Department of Health and Human Services says that as of March 31 there were 65 million people – or 21 percent of the U.S. population -- living in Health Professional Shortage Areas (HPSAs), which it defines as geographical areas with one or fewer primary doctors per 3,500 residents. HHS says it would take 16,585 practitioners to meet a minimum requirement for adequate coverage (one practitioner per 2,000 residents). And studies indicate that by 2025 that deficit will grow to 44,000 physicians.
To make matters worse, every year fewer medical students enter general practice, choosing instead the more lucrative specialty fields. By some accounts the number of med students entering office-based primary care is at an all-time low of just seven percent.
The time it takes to see a doctor is one symptom of this problem. According to Merritt Hawkins' annual study on physician wait times for 2009, the average American waits 20 days to get an appointment with their physician. In Boston, which ranked the worst, it takes, on average, 63 days to see a doctor. The study's authors say that's because in 2006 Massachusetts passed a healthcare reform initiative that implemented near universal coverage for all of the State's uninsured. And while opponents of universal healthcare are right to call the Massachusetts scenario a harbinger of things to come under a national plan, most are unwilling to admit that what caused the problem in the first place is the competitive provision model they tend to favor.
Dr. Steffie Woolhandler, an internist, Harvard Medical School professor and cofounder of Physicians for a National Health Care Program, says the primary care shortage is a product of the way we pay for healthcare in America.
"The bigger issue is that the whole orientation of the system is out of whack and all the resources are concentrated in the wrong parts of the system," she says.
According to Dr. Ted Epperly, president of the American Academy of Family Physicians (AAFP), that's because the U.S. for-profit healthcare system is designed to favor expensive, procedure-based medicine over less costly patient-focused preventative care.
"Unfortunately the American healthcare system does not value what primary care does to keep people healthy," Epperly says. "We've got a back-end system that's treating all the disease that if we put the money on the front end of the system in terms of wellness and health promotion we could have prevented it in the first place." He says the reason is simple: like any other business, the healthcare market likes to sell those services that will turn the greatest profit.
"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.
"Study after study shows that students of color are more likely to practice in communities of need and practice in communities similar to those they came from than other students and if we can get more students to do that than we're going to provide access to communities that lack access today," said Charles Terrell, chief diversity officer at AAMC.
Potential Solutions Abound
On June 18, Epperly joined the heads of the American College of Physicians (ACP) and the American Osteopathic Association (AOA) on Capitol Hill to impress upon lawmakers the urgency of the primary care shortage. They say fixing the shortage will require a 30 percent increase in payments to primary care physicians under Medicare over the next five years.
Others have proposed more radical fixes. A 2006 study by the Institute of Medicine (IOM) recommended replacing the current "pay-for-service" fee structure with a "pay-for-performance" model.
"Medicare beneficiaries are not getting the highest possible quality of care because the program's payment system encourages volume rather than efficiency and quality," said Dr. Steven A. Schroeder, chair of the study.
The IOM acknowledged that there is little hard data on the efficacy of such a system, and so it proposes a gradual phase-in of pay-for-performance. For an initial period of three to five years, the committee recommends, Congress should reduce base Medicare payments across the board and use the money to fund rewards for strong performance. Though the plan is not directly intended to increase compensation for general practitioners, since robust primary care has been shown to keep people healthy, it would effectively amount to the same thing.
Meanwhile, lawmakers in both houses of Congress have taken steps to address the problem. In May, Rep. Allyson Schwartz (D-PA) introduced the Preserving Patient Access to Primary Care Act of 2009, which among other things would offer scholarship and loan repayment opportunities and increased Medicare reimbursement for primary care physicians. Schwartz, who has worked as a healthcare administrator and is married to a cardiologist, has made healthcare reform a key part of her agenda.
Also in the House, Rep. Jim McDermott (D-WA), himself a physician, is sponsoring a bill that would provide free tuition to state schools for medical students who agree to enter primary care fields for at least four years after graduation. And companion bills in the Senate and House aim to reduce the physician shortage by increasing the number of Medicare-funded residency training positions by 15,000, offering incentives to hospitals that emphasize filling primary care slots.
Meanwhile, the healthcare reform bill released by the House on June 19 includes a five percent bonus for primary care services and as much as a 10 percent bonus for primary care services provided in a Health Professional Shortage Area. To qualify for the bonuses at least 50 percent of a physician's services must be primary care.
Harvard's Woolhandler says solutions like this are a good start, but will only provide temporary relief without fundamental changes in the U.S. healthcare model.
"It's like putting a Band Aid on the problem, though Band Aids can be useful," she says. "But it's not going to solve the problem if we continue to say healthcare is a business and everyone should just be going out and allocating resources based on where the money is. Healthcare is a public service… we need to run the system the way we run the fire department. No one says we're going to put up a fire department only where people are willing to pay the most."