Stanley Feld M.D.,FACP,MACE
Medical students are choosing procedure oriented subspecialties rather than family practice or internal medicine (Primary Care). There has been a 50% decrease between 1997 and 2008. This trend resulted from the fact that it is difficult to make a living in a non procedure oriented practice. Cognitive medical care and positive physician patient relationships have been devalued. The government and the healthcare insurance industry have not adequately compensated cognitive medical care in an attempt to save money.
“Once they discover that she is Dr. Kate, the supplicants line up to approach at dinner parties and ballet recitals. Surely, they suggest to Dr. Katherine J. Atkinson, a family physician here, she might find a way to move them up her lengthy waiting list for new patients.”
Positive patient physician relationships have an important therapeutic effect. The patient physician relationship is disappearing as primary care physicians have less time to relate to their patients. They have to see more patients in a shorter time in order afford their practice overhead.
“Modest reimbursement, medical school debt, an aging population and the prevalence of chronic disease have each played a role in primary care physician ".
The primary care physician shortage widens with increases in population, decreases in the uninsured in Massachusetts, overuse of the healthcare system by first dollar insurance coverage, increases in obesity and subsequently increases in chronic disease and the decrease in reimbursement to the primary care physician.
“Since last year, when the landmark law took effect, about 340,000 of Massachusetts’ estimated 600,000 uninsured have gained coverage. Many are now searching for doctors and scheduling appointments for long-deferred care.”
The result has been an unintended consequence leading to the realization that Massachusetts has a severe primary care physician shortage. It also has resulted in the state’s widening budget deficit. The solution to the problem is to change the approach to care. The primary care physician has to be taught to extend his intellectual property.
“It’s a recipe for disaster,” Dr. Sereno said. “It’s great that people have access to health care, but now we’ve got to find a way to give them access to preventive services. The point of this legislation was not to get people episodic care.”
Dr. Serno is right on target. There are not enough Clinical Endocrinologists to take care of all the patients with Diabetes Mellitus. There are not enough Clinical Cardiologists to take care of all the heart disease patients. There are not enough Clinical Pulmonologists to take care of all the lung disease patients. Primary care physicians have to install systems of care of chronic disease in their practices. They initially see most of the chronic disease patients. The complications of chronic diseases absorbs ninety percent (90%) of the healthcare dollar. These costs can be decreased by at least 50% with effective chronic disease management.
“Whether there is a national shortage of primary care providers is a matter of considerable debate. Some researchers contend the United States has too many doctors, driving overutilization of the system.”
It seems obvious there is a growing shortage of primary care physicians. Politicians always want to do a study. All they have to do is go into a typical physician’s office and observe the demands on the physicians and the problems the physicians have.
“But there is little dispute that the general practice of medicine is under strain at a time when there is bipartisan consensus that better prevention and chronic disease management would not only improve health but also help control costs.”
“With its population aging, the country will need 40 percent more primary care doctors by 2020, according to the American College of Physicians, which represents 125,000 internists, and the 94,000-member American Academy of Family Physicians. Community health centers, bolstered by increases in federal financing during the Bush years, are having particular difficulty finding doctors.”
There are many who say we have more primary care physicians than previously. I believe all of their arguments blur the issue. The truth is every community there is a shortage of primary care physicians.
“I think it’s pretty serious,” said Dr. David C. Dale, president of the American College of Physicians and former dean of the University of Washington’s medical school. “Maybe we’re at the front of the wave, but there are several factors making it harder for the average American, particularly older Americans, to have a good personal physician."
“Studies show that the number of medical school graduates in the United States entering family medicine training programs, or residencies, has dropped by 50 percent since 1997.”
Physicians are not becoming primary care physician because they can not afford to become primary care physicians. The Medicare reimbursement for a half-hour primary care visit in Boston is $103.42 while reimbursement to a gastroenterologist for a colonoscopy requiring roughly the same time would be $449.44.
"Dr. Atkinson, 45, said she paid herself a salary of $110,000 last year. Her insurance reimbursements often do not cover her costs, she said."
“I calculated that every time I have a Medicare patient it’s like handing them a $20 bill when they leave,” she said. “I never went into medicine to get rich, but I never expected to feel as disrespected as I feel. Where is the incentive for a practice like ours?”
The physicians’ goal is to help people get well. They also want to earn a reasonable livelihood for their efforts and intellectual property. Physicians have not done a good job arguing this point.
Organized medicine (AMA,AAFP,ACP) has not done a very good job of defending the physicians’ value.
As time passes the problems with the delivery of healthcare will escalate as the secondary stakeholders, the healthcare insurance industry, the pharmaceutical industry, and hospitals thrive making egregious profits while the primary care physician shortage intensifies.
The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.
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