March 25th, 2010 by Jon LaPook, M.D. in Better Health Network, Expert Interviews, Health Policy, News, Video
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With the passage of healthcare reform, an estimated thirty two million new patients will try to find primary care doctors. That’s not going to be so easy because we already face a shortage of primary care doctors and about 13,000 more will be needed to take care of those newly eligible for insurance.
According to the American Medical Association, there are about 312,000 primary care doctors practicing in the United States. That includes family medicine, general practice (GP), internal medicine, and pediatrics. (In addition, there are 43,000 ob-gyn’s who also may serve as primary care doctors.) The estimate that another 13,000 will be needed comes from a study done by the Robert Graham Center for Policy Studies in Family Medicine and Primary Care in partnership with the Agency for Healthcare Research and Quality.
Sixty five million Americans already live in areas that don’t have enough primary care doctors. And relief is not on the way anytime soon. It takes 5 to 8 years for a first year medical student to be trained as a primary care doctor. And the trend for budding doctors over the past decade has been away from primary care and towards more lucrative specialties. Read more »
January 21st, 2010 by KevinMD in Better Health Network, Health Policy, Opinion
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It’s no secret that without a stronger primary care foundation, the current reform efforts are unlikely to be successful. If anything, it will only delay the inevitable.
I wrote last month that one discussed solution, adding more residency slots, won’t help: it would simply perpetuate the disproportionate specialist:primary care ratio.
A recent op-ed in The New York Times expands on that theme. The authors suggest that not only does primary care need to be promoted, specialist slots should be limited. Simply building more medical schools, or adding more residency slots, without such restrictions will only add to the number of specialists.
Already, many primary care residency slots go unfilled – what’s the point of adding more?
You have to solve the root cause that shifts more students away from primary care: disproportionately low pay, disrespect that starts early in medical training, and poor working conditions where bureaucracy interferes with the doctor-patient relationship.
Until each of those issues are addressed, simply more spending money to produce more doctors simply isn’t going to work.
*This blog post was originally published at KevinMD.com*
January 11th, 2010 by RyanDuBosar in Better Health Network, News
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ACP Internist’s wrap-up of current events continues with ping-pong for health care reform, how the recession curbed health care spending and how legislation preventing patient-dumping can hurt the physicians required to provide treatment.
Health care reform
Negotiations for health care reform will avoid the formal conference procedure and instead negotiate directly. The “ping-pong” talks, which don’t have to be public, will send the bill back-and-forth between the House and Senate until both chambers agree. C-SPAN wants to televise the negotiations. The goal is to pass the legislation by a State of the Union speech scheduled for February. (Los Angeles Times, C-SPAN, Baltimore Sun)
The recession did what Congress has struggled to do–slow spending for health care. Spending on physicians and services rose by 4.4% in 2008 over the previous year, the slowest increase in 50 years of tracking by the Centers for Medicare and Medicaid Services. Still, spending totaled $2.3 trillion, or more than 16% of the entire economy. The credit freeze in the most recent recession may have dissuaded people from paying large deductibles. (AP, USA Today) Read more »
*This blog post was originally published at ACP Internist*
December 17th, 2008 by Dr. Val Jones in Primary Care Wednesdays
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By Alan Dappen, MD
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Alan Dappen, MD
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Believe it or not, this headline paraphrases the recent lead article from the American Medical News, covering a comprehensive, white paper published by the American College of Physicians (ACP). The article reviews the state of primary care physicians. The conclusion: since primary care doctors are essential to control the spiraling costs of health care, a bailout is necessary to shore up their rapidly shrinking ranks.
To understand why they argue a bailout is needed, we must look at what caused the crisis. Primary care doctors are drowning in red tape, as my partner Steve Simmons mentioned last week. Over the past 20 years have come bureaucracies and regulations with acronyms like OSHA, CLIA, HIPPA, CPT, ICD-9, P4P. Drops led to trickles: more complex certification and increasing malpractice risk. Then trickles formed streams of data that is required of practitioners: quality reporting, management reports, productivity measures, electronic medical record systems, billing reports. Finally, the flood of information needed to stay in compliance with Medicare, Medicaid and insurance regulations swamps primary care providers.
The creative and intellectual focus of primary care physicians has been diverted to understanding this new world order of business contracts, negotiated rates, billing details, payment denials, coding, and non-compensated services. This is no game. It means the difference between medical practices staying afloat or going under. There are now thousands of reasons a doctor can lose money by getting fined, sued, or refused reimbursement.
Family doctors and internists have grown weary. They feel underappreciated by their patients, undervalued by the specialists, underpaid by the insurance company, overworked to meet expenses, and overexposed to malpractice risk. U.S. medical graduates entering family medicine residencies dropped by 50% over 10 years and are now filled mostly by non-US trained physicians. American medical graduates now rush to specialties where they make better money, gain higher status and/or achieve better control of their work schedules. To keep primary care doctors in adequate supply, so the argument goes, system subsidies and readjustments are needed.
Outsiders easily “get” what went wrong the auto and financial industries. These industry execs standing in line for handouts make most of us angry. They refused to do so many things to avoid their plight: innovate, stand up to wrongs, worry about sustainability, take responsibility, invest in a new future, even ”bending the truth” and turning a blind eye was fine as long as there were profits. They say that Americans didn’t want “the truth.” They want us to believe that they are victims of circumstances beyond their control. What should we think of primary care doctors who put themselves on the same playing fields as these execs asking for a bailout?
Internists and family doctors are the backbone of a vibrant healthcare system that is cost-effective [see later blog post to learn why]. But, for far too long we in primary care have piggybacked on the insurance systems, relying on them to pay the bills, even when the costs of administering that is more expensive than the care provided in most cases. This has slowly weakened our doctor-patient relationships and our advocacy for patients, thus compromising our power and professionalism. By casting its lot with third party payers, primary care essentially has announced that it wants someone else to fix the problem of affordable care.
I feel that the solution to primary care is simple. We should not be looking for a bailout. Instead, primary care doctors must step up to initiate change. Personally, I stopped waiting for someone else to rescue me or tell me how to do my job, promising they could make me happy. The restructuring I’m suggesting to revitalize primary care is that patients retain control of the funds they (and their employers) have been giving to the insurance companies for their day-to-day care (which now account for about 30% of total costs), and directly purchase the services they need from doctors who serve them best. Doctors in Oregon (www.greenfieldhealth.com), New York City (www.hellohealth.com) and Northern Virginia (www.doctokr.com) already have set up such practices. These doctors have developed innovative business models that deliver better care to patients at much lower cost. But these will only spread on a large scale if patients understand the value of these new business models, and flock to support them.
More details about the changes needed can be found on our website or by listening to our story with “The Story” on National Public Radio, and in this blog in the coming weeks.
Until then, I remain yours in primary care,
Alan Dappen, MD
November 7th, 2008 by Dr. Val Jones in Expert Interviews, Health Policy
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There is a critical shortage of primary care providers in the United States. The public’s perception is that there is no shortage, and politicians have spent very little time talking about how to address the shortage. The American Academy of Family Physicians has been carefully studying this issue and strongly recommends incentives for physicians who would consider primary care: increased reimbursement for non-procedural work, and medical school debt-forgiveness are two of many.
The universal coverage system in Massachusetts immediately unmasked the problem of the primary care shortage. Newly insured citizens have been astonished to discover that they cannot find a primary care physician even though they want one. Wait times often exceed 6 months, and very few physicians are accepting new patients.
I have had the privilege of listening in to various healthcare reform discussions among politicians and advocacy groups here in Washington. Every time I raise the issue of “what will you do about the primary care shortage?” they offer the same tepid response: all providers will need to “work together” to provide primary care services, and innovative programs like retail clinics and nurse-driven care models will help to fill the gap in physicians.
My friend and fellow blogger, Dr. Rich Fogoros recently wrote an amusing (and cynical) post about how physicians should simply “hand over” primary care to nurses. (The same argument that many politicians seem to be making). The only problem with this reasoning is that nurses may not be willing to provide primary care services for the same reasons that physicians aren’t too keen on it: the pay is low, the workload is grueling, and there are other career options that offer better lifestyle and salary benefits.
I spoke with a group of nurses on a recent podcast about this very issue and their view was that, “we’re not suckers” – primary care is not as appealing as ICU work, for example.
Gina (Code Blog): Not every nurse wants to go back to school for additional years and shell out a lot of money to become a nurse practitioner and then not make a whole lot more than we’re making now. I’ve worked with nurse practitioners who have come back to work in the ICU because they can’t make enough money in primary care to support their families.
Strong One (MyStrongMedicine): We don’t have enough educators to teach nursing at our nursing schools. Nurse educators are paid about a quarter of what they’d make at the bedside. There are long waits to get into nursing school because we don’t have enough instructors to handle the influx. Until that problem is solved we aren’t going to see in increase in nurses entering the market.
Terri Polick (Nurse Ratched’s Place): I have a friend who’s a nurse practitioner and she had to borrow over $100,000 for her education. I’m a three-year diploma nurse so technically I don’t even have a college degree – but I’m making a lot more than nurse practitioners and I don’t have all that debt. Politicians need to know that nurse practitioners can’t just “pick up the slack” from physicians. Nursing and medicine are two different specialties and we’re trained to do different things.
So for those of you out there who may have shrugged at the primary care shortage and figured that when the docs are gone, someone else will just pick up the slack – think again. Any national universal coverage system will simply unmask what many physicians have known all along: equal access to nothing is nothing. Without making primary care a more attractive career option for providers of all stripes, don’t expect an influx of any sort into the field.
Long wait times for basic healthcare will probably become the norm in America.
