The doctor is not in: More patients, fewer doctors drawn to primary care offices

By John P. Kelly
http://www.tauntongazette.com

Behind seven doors, seven patients waited for Dr. Robert Baratz, who paused in front of a hallway whiteboard in South Shore Health Center in Braintree, Mass., and shook his head. Seven more were in the front waiting room.

It was 11:30 in the morning. In a basket near the reception desk, a stack of paperwork was building.

The day before had been worse. Baratz, the clinic’s 62-year-old lone primary-care internist, said he saw 33 of the day’s 50 patients.

“In order to do this, you have to give 15 minutes a patient, no more – how can you give good service that way?� Baratz said.

Six years after opening the practice, Baratz said he dreams of leaving it behind. Like many general practitioners, Baratz believes the primary-care field is buckling under the weight of growing patient loads, onerous insurance regulations, long hours and salaries that fail to make it all worthwhile.

The problem is not unique to Massachusetts. Nationwide, a rift has widened between the number of primary care physicians and the demand for their services.

Yet the issue in Massachusetts is more pronounced since legislators passed the 2006 landmark law requiring all residents to be insured.

The number of insured patients has spiked by more than 350,000. That has contributed to waiting lists at some primary care practices running months long, while other practices have stopped accepting new patients altogether.

Meanwhile, the number of medical students pursuing careers in primary care has fallen steadily for the past decade. The aging population threatens to make the situation more grave in the near future, physicians and policymakers say.

“With the cost of running a practice, the burden of the hours and the paperwork … it’s a bad combination,â€? said Dr. Bruce Auerbach, president of the Massachusetts Medical Society.

Hectic days, less pay

The issue captured considerable attention on Beacon Hill in recent months, where lawmakers debated legislation – championed by Senate President Therese Murray of Plymouth – to control the soaring cost of health care. The final bill, expected to be signed soon by Gov. Deval Patrick, includes several provisions meant to address a shortage of primary care doctors.

Under the bill, students at the state’s medical school would have loans forgiven and get tuition incentives for committing to working at least four years in primary care in Massachusetts. It would also create a Health Care Work Force Center to research additional ways to address work force shortages.

To reduce administrative costs, insurance companies and health care providers would switch to a unified standard of billing and coding – addressing the current system, which many consider inefficient, frustrating and costly.

The hectic lifestyle that often comes with working as a primary care physician is only exacerbated by relatively modest salaries – perhaps as high as $100,000, though small compared to incoming cardiologists, radiologists and other specialists who can earn four times as much, Auerbach said. Earning power can be an especially persuasive factor for medical students, who often shoulder debts of $120,000 or more.

One factor is that insurance reimbursement rates are often drastically lower for physicians in primary care. For example, a physician like Baratz who spends half an hour with a patient is paid roughly one-third what a gastroenterologist earns for performing a colonoscopy in the same amount of time, Auerbach said.

“It’s still a 30-minute intervention (but) one person gets (paid) three-fold,� Auerbach said.

‘The whole patient’

At Boston University Medical Center each year, 45 senior residents graduate from an internal medicine residency program. In the late ’90s, half of them went into primary care. Today, it’s closer to one in 10, said the program’s associate director, Dr. Angela Jackson.

Many students pursue specialized medicine not only for higher pay, but for greater prestige.

But Jackson stresses the rewards of primary care are still alluring to many students, who want personal interaction with patients.

“A lot of times they say they like the relationships and dealing with the whole patient, not the whole organ,� said Jackson, also director of the medical center’s primary care residency training program.

At South Shore Health Center, Dr. Baratz blamed insurance companies for establishing reimbursement scales that provide significantly greater rewards for procedural medicine.

Recently, a female patient came to him with severe stomach pains. After ordering off-site CAT scans, an MRI and other tests, Baratz said he managed to make an early diagnosis of pancreatic cancer. Hours of staff time had been necessary for pre-authorizations from insurers, setting up appointments and reviewing test results.

“The radiologist is the one who really got paid,� Baratz said. “I didn’t.�

He added, “Managed primary care – that’s the kind of care you want – and guess what? Nobody is going into this business, because they don’t pay.�

Patriot Ledger writer John P. Kelly may be reached at jkelly@ledger.com.

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