Doctors urge: Rescue primary care or work force shortage will mount

Making primary care a more attractive specialty must be part of health system reform, physician groups say.

By Brian Hedger , Kevin B. O’Reilly — Posted Dec. 8, 2008

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The lack of access to primary care doctors leads to worse health outcomes and higher costs, according to an American College of Physicians report released in November and aimed at influencing the shape of impending health system reform. As the population ages and demands on health services increase, Americans will find it more difficult to locate primary care physicians to help coordinate care in a fragmented system.

The 63-page ACP white paper reviews more than 100 studies from the last 20 years and concludes that the proportion of primary care doctors in a community is related to population health outcomes and system costs. The number of U.S. medical graduates entering residences in family medicine and internal medicine has dropped by half in the last decade as physicians pursue less time-squeezed and higher-paying specialties, the ACP report said.

The report comes amid signs from Capitol Hill that politicians are taking the work force shortage seriously.

"The timing of the paper is critical," said Robert Doherty, ACP's senior vice president of governmental affairs and public policy. "As Congress and the administration start putting together the pieces of the reform puzzle, we want primary care to be an important piece of the puzzle."

The ACP and groups representing family physicians and pediatricians have called for policies that encourage the patient-centered medical home, restructure primary care physician payment and help primary care doctors with medical school debt.

In November, the AMA adopted policy supporting programs to decrease the educational debt load of physicians who choose primary care practice. The Association also endorsed the medical home concept and pledged to work with medical schools to devise innovative ways to recruit and train primary care physicians.

The work force crisis is due to a "combination of inadequate payment to do the job right and inadequate resources to organize practices to do it right," said Allan H. Goroll, MD, chair of the Massachusetts Coalition for Primary Care Reform, an alliance of local health care organizations testing a new payment model. "You have the primary care doctor as the Lone Ranger -- this isolated person onto whom this huge primary care mission falls, and it's too big for one person."

Dr. Goroll, a professor of medicine at Harvard Medical School, said Massachusetts' experience shows what can happen when expansion of health insurance coverage is not accompanied by efforts to bolster access to primary care.

"The newly insured in Massachusetts have the highest use of nonemergent care in the ER," he said. "It's expensive and inefficient."

Rep. Allyson Y. Schwartz (D, Pa.) agreed, saying that expanding primary care access is "almost a prerequisite" to comprehensive health system reform.

"If we do plan to extend meaningful health insurance coverage to more Americans and seek to reduce costs, we need to make sure Americans have access to primary care," she said.

In September, Schwartz introduced the Patient Access to Primary Care Act to require Medicare to cover practices qualified as patient-centered medical homes, hike pay for evaluation and management services, and offer assistance with medical school debt. The bill does not have a price tag yet, but Schwartz said bolstering primary care will save money over time.

Schwartz will reintroduce her bill in January. Sen. Maria Cantwell (D, Wash.) is likely to introduce a companion bill, the ACP said.

Sen. Max Baucus (D, Mont.), chair of the Senate Finance Committee, introduced a reform plan in November that said primary care should be strengthened "by using federal reimbursement systems and other means to improve the value placed on their work."

Meanwhile, President-elect Barack Obama's plans to support primary care include offering loan help, improving payments and expanding grants for primary care residency training.

Survey says: "Help!"

The call for a rescue plan was reinforced by a survey released in November by the Physicians' Foundation that detailed practicing physicians' frustrations.

The survey, conducted by physician recruiting firm Merritt Hawkins & Associates, was sent to roughly 270,000 primary care doctors and 50,000 specialists. Citing long hours, low pay for primary care, and paperwork hassles associated with Medicare, Medicaid and private insurers, the 11,950 physicians who responded did not paint a pretty picture of being a doctor.

Nearly 60% would not recommend medicine as a career to young people, and 78% believe there is a shortage in primary care. Only about one in four primary care doctors would choose primary care again. About half of all physician respondents said they plan to reduce their patient load or stop practicing within the next three years.

"We wanted to take the temperature of the medical profession, especially primary care doctors. We found there's a fever, and it needs to be treated," said Lou Goodman, PhD, CEO of the Texas Medical Assn. and president of the Physicians' Foundation. It was created in 2003 as part of a class-action settlement among physicians, medical societies and insurer Aetna Inc.

The foundation said an independent analysis found the study had a 1% margin of error. But Ed Salsberg, work force studies director for the Assn. of American Medical Colleges, urged caution, saying the roughly 4% response rate is relatively low and that unhappy doctors were more likely to have responded.

The findings did not surprise Doug Curran, MD, a family physician at Lakeland Medical Associates in Athens, Texas, where he's practiced since 1979.

He remembers a time when he could order tests without paperwork hassles. Now, Dr. Curran and his 10 fellow physicians at Lakeland Medical wrestle with a stack of paperwork and fret about Medicare payment cuts.

"There is no plan to bail out the local doctor," Dr. Curran said. "In fact, there is a plan to kill the local doctor if they don't fix Medicare."

What remains unclear is how politicians' promises to rescue primary care will play out in a likely fierce battle over health system reform. But raising awareness of the crisis is the start of finding a solution, said Ted Epperly, MD, president of the American Academy of Family Physicians.

"This won't be turned around overnight. It will take a decade to get out from under this," Dr. Epperly said. "America's in for a tough go with regard to access and having a sufficient primary care work force to address the needs of the country.

"I'm glad that at least we're diagnosing the problem. The problem is that it's long overdue."

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Impact of primary care

Having more primary care physicians in a community is associated with less use of acute and surgical care, according to a national study of health care utilization. Extrapolating from those data, researchers say a 15% increase in primary care doctors in a given metropolitan area would:

  • Cut emergency department visits by 10.9%.
  • Cut the number of surgeries by 7.2%.
  • Cut inpatient admissions by 5.5%.
  • Cut outpatient visits by 5.0%.

Source: "Health care utilization and the proportion of primary care physicians," American Journal of Medicine, February (link)

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Rethinking a medical career

A survey asked primary care physicians if they had their careers to do over, what would they do?

Choose surgical/diagnostic specialty 41.0%
Choose primary care 27.7%
Choose not to be a physician 26.7%
Choose nonclinical path 4.6%

Note: The survey of 11,950 physicians did not say how many primary care physicians responded to this question.

Source: "The Physicians' Perspective: Medical Practice in 2008," October (link)

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Sour on medicine

More than 4,000 of nearly 12,000 doctors surveyed by the Physicians' Foundation commented about the medical profession. Their anonymous remarks gave several reasons why unhappy physicians are looking to scale back practices or leave medicine entirely. Here is a sample:

  • "If not for a son who I'm working to put through college and a house mortgage, I would quit medicine in a heartbeat! I'm beat, tired and underappreciated. Sometimes I cry myself to sleep -- wondering why I got into all this."
  • "I cannot continue seeing fewer patients for less money and adding more paperwork requirements. I've had one nervous breakdown and would rather not do that again!"
  • "I would invite each government policymaker to spend one day in a primary care office or community clinic to see the current chaos that is American medicine."
  • "I do not see why anyone would go into medicine at this time and very much regret having chosen medicine as a profession. I would never recommend medicine as a profession to anyone."
  • "Can you imagine what would happen if your plumber handed you a bill for $60 and you replied, 'I think I'll just pay $32?' In no other profession are services paid for in such an arbitrary fashion."
  • "Bean-counters have taken over decision-making in health care."
  • "We need more primary care physicians, but students are choosing primary care less often. What is their incentive? Our hours are worse, our pay is less, our hassles are greater and we have a legal system that is out of control. I had to leave private practice because I couldn't make a living. As an employee, however, I have lost all of my autonomy."
  • "With $100,000 in student loans, I do not know how I will ever achieve financial security. Morale is low in general among physicians in our state. I would not choose medicine as a career again."
  • "Paperwork! Paperwork is killing us!"
  • "HELP!"

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External links

"How Is a Shortage of Primary Care Physicians Affecting the Quality and Cost of Medical Care?: A Comprehensive Evidence Review," American College of Physicians, November, in pdf (link)

"The Physicians' Perspective: Medical Practice in 2008," The Physicians' Foundation, November, in pdf (link)

"Perspective Roundtable: Redesigning Primary Care," New England Journal of Medicine, Nov. 12, video (link)

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