Why is there a shortage of primary care physicians?

By DR. RALPH K. MESSO
http://www.silive.com

STATEN ISLAND, N.Y. — Americans today are facing a severe shortage of primary care specialists. According to a recent study in the Journal of the American Medical Association (JAMA), only 2 percent of the graduating classes of medical schools are entering residency training in primary care.

Primary care is defined as the practice of internal medicine (the care of adults), pediatrics (the care of infants and children), family practice (the care of all ages), or internal medicine/pediatrics combined (again, the care of all ages). Although OB/GYNs are sometimes thought of as primary caregivers for the female population, it is the previously mentioned specialties that are quoted by the article in JAMA.

It is estimated that there are currently 56 million individuals in this country that are “medically disenfranchised”– having inadequate access to primary care physicians (PCPs).

Among Medicare beneficiaries, 3 percent — or more than 1.3 million people — have difficulty finding a new primary care physician.

So, where have all the PCPs gone? There are many answers to this question. Many older physicians are dying, and not being replaced by new physicians. Many physicians are “throwing in the towel,” and retiring much earlier than they had originally planned. Some have left the stress and demands of private practice, and teach full time.

Some new graduate physicians are choosing a new specialty called “hospitalists.” These are primary care physicians who only care for hospitalized patients. They do not have private practices, alleviating many of the pressures we so often feel.

There is more and more bureaucratic red tape from insurance carriers, more stumbling blocks to get tests ordered, approved and performed. Also, decreased reimbursement from the carriers, and increasing malpractice premiums are other factors in the shortage of PCPs..

Because Medicare and insurers fix fees, the only way primary care physicians can survive is to take on more and more patients. This in turn may mean spending less time with the patient. As a result of this, we often hear patients say, “My doctor doesn’t spend enough time with me.”

A recent American College of Physicians study compared the U.S. health system with those of 12 other countries and analyzed why the latter had better medical outcomes for far less funding. Over and over, the studies prove that systems that have a primary care physician or have what is deemed “medical home,” always fare better.

The overhead in a PCP office runs about 65 percent, of which 40 percent is spent dealing with insurance companies. The earnings of PCPS are approximately half to a third of our colleagues in the more lucrative sub-specialties.

This phenomenon correlates with the matching of residency spots this past year. Only about 42 percent of primary care spots were filled, while in orthopedic surgery, 94 percent of spots were filled.

It goes without saying that graduating medical students who often have at least $150,000 in debt, will chose the more lucrative specialties.

CONCIERGE MEDICINE

There is a new trend evolving in many parts of the country called “concierge medicine.” Although looked upon unfavorably by the American Medical Association, it serves as another option for which PCP physicians can remain in practice, and patients can continue to receive the quality care they so deserve.

Concierge medicine is where the patient pays the PCP a fixed amount of money, ether monthly or yearly. For this, the patient is given “customized care,” such as getting the physician’s home phone number, cell phone number, and usually appointments that last upward of an hour — almost always on the same day the call is placed. This allows the physician to focus on “the patient,” and not on survival.

Too much of the physician’s time is spent taking care of the insurance carrier’s work.

Study after study has proved that those patients who have a PCP often are healthier, and when an illness occurs, it is usually diagnosed at a much earlier stage.

Unfortunately most medical schools in this country favor overspecialization. Many of the “osteopathic” medical schools (schools granting a D.O. degree vs. allopathic which grants an M.D. degree), highly promote the training of primary care physicians.

I am happy to say that there are many efforts to entice medical students to enter primary care on the horizon. Some include loan forgiveness and financial incentives to help get started in practice. I only hope this occurs sooner than later.

This column is provided by the Richmond County Medical Society. Dr. Messo is immediate past-president of the society director of internal medicine/pediatric education at Richmond University Medical Center. He maintains a private practice in Eltingville and is also and adjunct clinical professor at Touro College of Osteopathic Medicine, Harlem. Questions may be sent to the column in care of the Advance.

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