Wednesday, April 7, 2010

Wanted - Primary Care Doctors ASAP.

In a few years, every American will be required to have health insurance. As a result, the 32 million people currently uninsured will seek out a personal physician. This role typically is filled by a primary care doctor, like an internist or a family physician.

While passage of the health insurance reform bill affirmed the belief that having health insurance is a right rather than a privilege, the legislation falls short on building a healthcare system capable of absorbing the newly insured. Universal healthcare coverage is not the same as providing universal access to medical care. Having an insurance card doesn't guarantee that individuals can actually get care.

One doesn't need to look any further than the Commonwealth of Massachusetts to see what problems lay ahead. In 2006, the state required everyone to have health insurance. It was believed that having universal coverage would have slowed healthcare costs. Expensive emergency room visits would be averted as newly insured individuals would have a personal doctor who could address the problems sooner and at less cost.

Unfortunately, that scenario never occurred. According to the state medical society over half of internists and about 40 percent of family physicians were not accepting new patients. So the newly insured still didn't have a personal doctor to call upon even though Massachusetts has the most primary care doctors per capita than any other state. Insurance coverage does not mean access to medical care.

If a manageable patient panel per full time primary care doctor is about 2000 patients, then the nation would need an additional 16,000 doctors to care for the newly insured. With some evidence that the nation is expected to be short about 40,000 primary care doctors over the next decade, one should wonder if we are training enough doctors to fill the gap.

The answer is no. With the 2010 residency match, US trained medical students have indicated that primary care is not what they want to do. Of the roughly 2300 positions in family medicine residency programs, only 45 percent were filled by students attending American medical schools. While the American Academy of Family Physicians proclaimed the 2010 Match as the most successful ever with 91% of residency positions filled, the sad reality is obtaining this rate required eliminating 600 positions over a decade. In 1999, there were over 3200 family medicine positions available for medical students to match into.

Internal medicine numbers are better, but won't address the primary care crisis either. Though nearly 5000 students are training in internal medicine, the trend has been to use the three year residency program as a prerequisite for more lucrative medical subspecialties like cardiology, pulmonary, or oncology, to name a few. While in 1998, 54 percent of internal medicine residents planned on becoming primary care doctors after training, by 2003, the number fell to only 27 percent.

Solving the primary care crisis can't be done with ancillary clinicians. As Americans are paying more for healthcare, I don't believe that they would willingly choose to have primary care done by nurse practitioners or physician assistants. That is not to say that there are not plenty of excellent clinicians out there, but adding these physician extenders won't bend the healthcare cost curve. Their costs often are comparable even as their knowledge base is less.

Though the healthcare reform legislation tries to maintain the primary care workforce via increased income for primary care doctors providing Medicaid services as well as increase the numbers with grants for more primary care training and loan repayment for doctors working in underserved communities, the reality is medical students won't be signing up. The specialty's relatively low pay, absence of work-life balance, and low prestige compared to other medical fields doesn't resonate with today's students.

That's too bad because the nation and the public needs more primary care doctors than ever. Not only can primary care doctors decrease costs, but also the amount of time wasted getting to the right specialists. One health plan that focused on using primary care physicians to coordinate care discovered use of specialists fell by 14 percent, emergency room use decreased by 16 percent, and prescriptions declined by 11 percent. When patients self-referred to specialists, about 60 percent went to the wrong specialist. More troubling is that on average $1500 was spent on various tests and diagnostic services over an 11 month period before patients were told that the specialist could not help them.

So having a personal doctor is important and can save you time and money, but more importantly get you feeling better sooner. Too bad the nation won't have enough to go around. Hurry and find a primary care doctor you like and trust because it is possible later on you might find yourself without this indispensable advisor and guide for many years to come. Result to you and implications for the nation? Spending more time and money and not getting any healthier.

Want a crystal ball on how this legislation will affect the country? See what Massachusetts does next.

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