Shortfall in primary care physicians likely to get worse

By Brian Newsome
http://www.gazette.com

Health insurance and rising medical costs are stars of the political stage this election season, yet a potentially larger crisis looms: a shortage of primary care physicians.

Some doctors use terms such as “collapse” and “disaster” in talking about the state of primary care during the next decade. They say the issue will likely force lawmakers to radically rethink how health care dollars are spent.

Primary care doctors – generally pediatricians, internal medicine doctors and the traditional family physician – are considered the front line of health care, especially for chronic diseases and preventive care. A shortage could translate into costlier and less-efficient health care.

The reality is, there are not enough primary care doctors to see everyone now. Already, some patients, such as those enrolled in Medicare or Medicaid or living in rural areas, are struggling to find a doctor willing to see them. 

By one account, the Pikes Peak region is short about 20 primary care physicians and will be short at least 10 more in the coming years. The figures come from a study done this year by Penrose-St. Francis Health Services, and they’re likely understated, said Dr. Jeff Oram-Smith, chief medical officer for Penrose-St. Francis Health Services. Not every doctor on the rolls, for example, is regularly seeing patients. 

Dr. Randy Bjork, a Colorado Springs neurosurgeon and head of the El Paso County Medical Society, which includes nearly 1,000 local doctors – 353 in primary care – estimates the region is short about 100 primary care physicians. His estimate considers people who travel here from rural areas for care.

Plenty going, few coming 

There’s no magic number for how many physicians a community should have. Factors such as driving distance or the age of the population play a role. 

No one, however, disputes there’s a shortage, and it’s only expected to worsen, for a number of reasons. 

About 35 percent of all physicians in the U.S. are 55 or older and within five or 10 years of retirement. Many of those are primary care doctors. 

As they retire, fewer doctors are in line to take their place, with most grads going into higher-paying specialties. 

In 2006, the American College of Physicians published a report, “The Impending Collapse of Primary Care Medicine and Its Implications for the State of the Nation’s Health Care.” 

The group noted that in 2003, only 27 percent of third-year medical students planned to pursue careers in general medicine compared with 54 percent in 1998. 

New medical school graduates routinely face student loans of at least $200,000. Bjork said a new doctor can tack on $150,000 a year in medical malpractice insurance and about that much a year in other costs associated with a practice: office space, professional organizations and staff members. 

“Primary care isn’t a good business practice anymore,” said BJ Scott, president and chief executive officer of Peak Vista Community Health Centers, which provides primary care for the uninsured and underinsured and employs 22 fulltime primary care physicians.

Bjork said a businesssavvy medical student recognizes that taking an extra year in school for a fellowship in a specialty can mean an additional $50,000 a year in salary and fewer patients to break even.

“Just do the math,” he said. “It doesn’t matter how much you’re making if more is going out.”

The cost of running a practice comes as reimbursements shrink, especially for Medicare and Medicaid. Bjork said doctors recover only 10 percent to 15 percent of their costs from federal programs.

That means doctors take on huge patient loads to cover their costs and have little flexibility to absorb nonpayers or Medicare and Medicaid patients. The pressure on primary care doctors has gotten to a point where an increasing number want out. Many of those who remain are going cash-only or saying no Medicare and Medicaid.

“Very few young physicians are going into primary care,” said the American College of Physicians report, “and those already in practice are under such stress that they are looking for an exit strategy.”

A world without enough doctors

The worsening shortage will exacerbate dysfunctions already present in financing and delivering health care, experts say. 

Family doctors, as a first line of defense against disease, are widely regarded as the most efficient way to handle health care, said Peak Vista’s Scott.

A person who can’t see a primary care doctor for routine management of congestive heart failure, for example, might end up having a long stay in the hospital, said Oram-Smith of Penrose-St. Francis.

“Instead of managing somebody’s disease, the system just treats acute episodes,” he said.

Some people have turned to emergency departments for primary care. Health care providers have long talked about the uninsured turning to emergency departments because they can’t be turned away. Yet many patients, especially those on Medicare, are coming because they can’t find someone to see them in a timely manner, Scott and Oram-Smith said.

“You can’t fault the patient,” Oram-Smith said. “If they try to get a doctor’s appointment and can’t get it, there’s not a whole lot of alternatives for them.”

In its report, the American College of Physicians paints a dire picture of the U.S. health care system if the primary care shortage isn’t addressed.

“Without primary care, the health system will become increasingly fragmented, over-specialized, and inefficient – leading to poorer quality care at higher costs,” the report said.

Health care experts have solutions, but none is likely to make a significant dent during the next 10 years, when the problem is expected to become critical.

For example, medical students entering primary care could be given incentives such as loan forgiveness, but churning out doctors is typically an eight- to 10-year educational process.

Although loan forgiveness might help, it wouldn’t address low reimbursements physicians face when they’re starting out.

Doctors say the most logical solutions will likely be radical, changing the way doctors get reimbursed and rethinking how health care is administered.

Bjork is pushing a plan in which patients and physicians partner in a for-profit self-insurance venture that he says would address reimbursement problems. It has gotten preliminary nods from patients and Colorado insurance regulators but received a cool response from doctors, who could see a drop in pay, he said.

The American College of Physicians is pushing the concept of a “medical home” that would rethink the doctor/patient relationship. Doctors’ roles would go beyond treating illness to acting as consultants and coordinators. The idea is proposed as a pilot project and a group of doctors, patients and employers have rallied behind it. They’ve formed the Patient-Centered Primary Care Collaborative, www.pcpcc.org.

Oram-Smith said sooner or later politicians and the public may have to rethink health care and consider unpopular alternatives that include either significantly more spending or a rationing of care.

“We’ve tried to give everything to everybody, which may not be reasonable to do,” he said.

He gave a hypothetical example of a 95-year-old man who gets a total knee replacement, even if the man will do little walking. The money for the procedure might hold greater value if spent elsewhere. 

Try to sell that idea, though, to the man with the new knee, he said.

CONTACT THE WRITER: 636-0198 or bnewsome@gazette.com

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