Thursday, October 30, 2008

The big issues the candidates are not addressing: Access to primary care

Access to primary care

Between now and Election Day, I will be inviting your comments about the big health care issues that neither Senator McCain nor Senator Obama are addressing--or at least not emphasizing in the campaign.

Today's topic: the impending collapse of primary care medicine in the United States.

In January 2006, the American College of Physicians warned that primary care was heading for collapse, citing the decline in the numbers of young physicians choosing primary care specialties like general internal medicine, and evidence that general internists were leaving the field in greater numbers than subspecialists. The paper received a lot of favorable comment, but also a fair amount of comment that the word collapse overstates the problem.

Now, few argue the point that the United States is facing a huge shortage of primary care physicians for adults. A study published in Health Affairs estimates a shortage of 35,000 to 44,000 primary care doctors for adults by 2025. The Journal of the American Medical Association reports that only two percent of fourth year medical students plan to go into general IM. The message is getting out to the broader public as well: the November Reader's Digest writes that "soaring office costs demanding insurance companies, low Medicare payments, staggering debt, and politicians who refuse to make hard choices are driving primary care physicians out of business." ACP President-elect Joe Stubbs, a general internist in Albany, Georgia, was quoted by Reader's Digest as calling the primary care issue "an evolving crisis of unprecedented proportion."

Yesterday's Washington Post reported that the experiences in the two states have guided the health care reform proposals of Senators McCain and Obama: Senator Obama has looked to the Massachusetts experience, and Senator McCain has looked to Minnesota. As the Post noted in its article, "the large number of people who have gotten insurance [under the Massachusetts plan] and are suddenly looking for care has aggravated a shortage of family physicians and other primary-care doctors" in the Commonwealth.

So what have the candidates said about primary care? Not too much. As ACP's comparison of the candidate's positions shows, Senator Obama's plan mentions the importance of primary care and the need to reduce medical education debt, but that is about it. Senator McCain's plan does not propose any policies to address the primary care shortage, although the GOP's convention platform mentions its belief "in the importance of primary care specialties and supporting the physician's role in the evaluation and management of disease."

The problem for the next President is in the absence of policies to reverse the collapse of primary care, access and outcomes will be poorer and costs higher. Even if the new President and Congress could agree on a plan to dramatically reduce the number of uninsured, they may find that there aren't enough primary care doctors left to take care of them, just as Massachusetts has found. Giving someone an insurance card doesn't give them access if they can't find a primary care doctor to take care of them.

Today's questions for our readers: Do you agree that primary care is nearing collapse? If so, what should the next President do about it?


Jason said...

Thanks for the opportunity to voice my thoughts and opinions. I think my perspective would be well understood in this forum versus other media outlets. This is my first comment on a blog of this sort.

As an internal medicine resident, I observe and experience the unfortunate setting in which PCP's currently practice. Uninsured illegal immigrants; poor medicare reimbursement (setting the standards for private reimbursement); a high percentage of patient's with primarily psychosocial and/or economic stressors; huge patient panels forcing 7-min encounters and an inordinate amount of sub-specialty referrals. No wonder I can count on one hand the number of my med school (private school with 200 students/year) classmates that planned to become PCPs for adults. One was in the military and the other three, bless their hearts, were brilliant and subbornly altruistic. Granted, there were several that matched in internal medicine, but nearly all were planning on sub-specializing (myself included).

If not for my load of medical school debt (~$200K) and the thankless compensation of primary care (compared to other specialties), I would prefer to practice general internal medicine, inpatient and outpatient. I think it is more satisfying to "own" the complete medical care of a patient. But there's too much baggage as mentioned above. It's not a practical choice for a medical school graduate who is up to his/her nose in debt and a family (current or future) for which to provide.

What should the next president do? If he could somehow undo Medicare, that would be a great start. But that's a fantasy for sure. I think free-thinking, industrious Americans could have figured things out better if government had not mettled in the first place. Putting my conservative/liberal leanings aside, how about debt relief? Not this $20-50K per year of work in underserved areas hocus pocus. I mean total debt relief to all that choose primary care, without contraints on where or how they practice. I think you would get droves of medical students that decide that $90-150K/year without any student debt to pay off is a practical choice. They could follow their altruistic nature without sacrificing "the good life" they/we expected to provide for our families when choosing to become physicians. I really believe that we would see many that go back home and provide needed care to the communities that supported them throughout their formative years.

I'm not sure, I guess. But maybe it would be a good start. If it were an easy question, everyone would know the answer. What does everyone else think?

bdoherty said...

The campaign to support primary care crisis goes global!

John Iglehart has a new post on the Health Affairs blog,, on a new World Health Organization (WHO) report that calls for “a worldwide campaign to underscore the importance of primary care.” While noting that the WHO report “barely mentions the United States,” John reviews evidence that there is beginning to be a glimmer of hope in the United States, including growing support for the concept of a Patient Centered Medical Home, a key part of ACP's advocacy efforts to support general internal medicine and primary care more broadly. I encourage our readers to review John’s important and excellent contribution to the discussion.

DrJHO7 said...

I appreciate jason's point of view, and i think our congressmen should read his account and many more like it. I agree with him that structured loan forgiveness programs should be part of the solution to the challenging problem of rebuilding the medical workforce in the direction of primary care specialties.

I will counterpoint some of his comments, though from the perspective of some one who has practiced GIM for 18 years.
1. Medicare reimbursement is the best reimbursement any specialty (primary vs specialty) sees for E&M in many areas of the country, and based on trends over the past 8 years, is not likely to increase more than 1-2% per year in the foreseeable future. Other insurers use MCR as their benchmark, and in most markets are unlikely to pay more, since docs are willing to work for mcr. Government is unlikely to dismantle and rebuild mcr, but they are likely to continue to modify/improve it.

2. Most of us, myself included, didn't go into this business for "the money". I would venture to say that if primary care salaries went up $20,000/year as of tomorrow, it would not have an impact on the number of young docs choosing primary care careers. The money is in nuclear cardiology, sleep labs, mri, pet, cat scan, frequent endoscopic procedures and cosmetic surgery. There are way too many of the first 5 examples being done now, due to profit incentives, and this is increasing the avg cost of care per person in this country by staggering amounts.
Our economy cannot sustain salaries for most docs that are 2-4 times that of the avg primary doc for any prolonged period of time (see Bob's comments) - the system will fall flat on its face.

3. every medical specialty has baggage - comes in different shapes and sizes, but it is essentially baggage

4. the resurrection of primary care will come from practice innovation: Dr's who want to do it, figuring out for themselves how to make it better for their patients and for themselves (called leadership), ie reasonable retainer fees for pt's that can afford, EMR/better information systems, PCMH models of prctice that receive prospective payment incentives; students and residents being true to their calling will choose primary specialties, aided by tuition reimbursement programs from public or private funding; medicare and insurance payment reforms that close the gap of reimbursement between E&M and other procedures, equalizing incomes somewhat. drjho7

christine.harter said...

I wholeheartedly agree with Jason that I wish that Medicare had never been enacted in the first place, and I think that we are really going down the wrong road with the draconian "reform" that is being proposed. (I'm just 49 years old, by the way, and a former member of Physicians for a National Health Plan.)

Let's use some logic here:
If all of medical care remains tax-financed, do you think either our government OR our beleagured employers can ever pay enough for both an increase in reimbursement for primary care AND a maintenance of the relatively high reimbursements for procedures? Yet do you think that in the political realm that there will ever be a decrease in reimbursements for procedures? Nor SHOULD it be decided on a political level. It should be decided in a free market, where people decide for themselves whether certainly the back surgery that often doesn't work, is worth many times more than primary care.

Medicare has destroyed/is destroying medical care, and anything even close to "Medicare for all" (even the mandated coverage that people are mistakenly assuming is substantially different) will make it a commodity rather than a profession.

I am in primary care (and have been for 20 yrs), but mainly because I am a Christian and I consider this a ministry rather than a job. I suspect that on the large scale, that isn't true for very many physicians. Nor should it be. We don't go into it for the money, but we as a whole are fairly ambitious people, and we do need somewhat of a "career track" to have the POSSIBILITY of earning more money as we go into mid-life.

I think it's obvious that some infusion of private money is where the answer is, but not by the punitive "pay or play" taxation, where those tax dollars will immediately get snatched up by the procedural specialties, but rather the free market choices of things like retainer practices, and as drjho7 has implied, charitable giving toward loan forgiveness. (he said public/private: the government has already mortgaged our children's future and must not add to the deficit, so we should turn to private sector.) The Christian Medical Society has a loan forgiveness program. Many other charities would do the same if private money were not forcefully taken in taxation. And Mr. Obama says, "Let's take more from all the people over $250,000". I think that if we allow private options and not just public, we could achieve much. Just look at what the new Congressman (and ACP member) from Louisiana has accomplished through private means.[see the news item in this issue of ACP Advocacy] Interesting, and somewhat sad, that because we have voted to concentrate more money in Washington, that being in Congress becomes a more effective way of helping the people of Louisiana than if this innovative and altruistic doctor had stayed in Louisiana doing his private work to help people. Government money gives perverse incentives; free market and charitable and "one on one" efforts, though seemingly more inefficient, nonetheless are the only way to actually accomplish what we want and need, including access to primary care.