Health Care Reform: Shortage of Primary Care Physicians is a Vexing Problem

Oh where oh where will those doctors come from, Oh where oh where can they be.  This is a vexing nursery rhyme that is ringing around the debate for healthcare reform.

With the anxiety of Congress and the Obama administration growing over healthcare reform, physicians are taking the stage and asserting their valuable input and experience to the debate. Central to this opinion is that any “reform in our health care system must include a well-educated, caring primary care doctor who is able to manage the health of his or her patients with an eye to using resources optimally to keep costs down.” In fact, if Congress and politicians were to take the time to realize that all many Americans need is a primary care physician a lot of the debate on health care reform could be resolved.

Moreover, while much of the focus on reform is centered on getting millions of people covered, Americans must realize there will not be enough “doctors there to actually provide the health care.” In fact, fewer and fewer medical students are choosing primary care and many primary care doctors are leaving the field,” because reimbursement rates are low, incentives are nonexistent, and the risks and disadvantages far outweigh the benefits. As a result, Dr. Vance Harris, a primary care physician in Redding, California provided CNN with examples from his daily practice of why this trend is taking place.

Dr. Harris sees dozens of chest pain patients each month, and after performing a history and exam as a primary care physician, does not always order an EKG, get a consult, set up nuclear imaging or send for a catheterization. Consequently, he saves the system tens of thousands of dollars for practicing effective medicine. Dr. Harris also has to deal with being late to his appointments with patients and being “chastised by at least six patients before the end of the day,” all for at most $75 for each patient.

When patients come in to Dr. Harris demanding invasive measures, he tries to treat them first with less evasive techniques, and explains to them it is reasonable, even though patients are never happy. And over the past 20 years, the cost savings to the system he has provided is thousands of dollars each and every time he is willing to make the call and go with the treatment. His “reward is about $55 from Medicare and private health insurers.”

Other constant problems such as low back pain he treats with regular physical exams and history to reassure patients there is no need for MRI’s or to operate, and that the risk of missing anything is low. Instead of wasting his time explaining an MRI of minimal significance, Dr. Harris sets “realistic expectations on recovery and avoids needless imaging, which helps saves the system thousands of dollars.” Again he is only rewarded another $55.

Another constant frustration he deals with is diabetics, and getting patients, and teenagers to take care of themselves and check their blood sugar. Once again is reward for years of struggle that seem wasted “is a few hundred dollars at best, while the savings to society for my hard work and never-give-up attitude is in the tens of thousands of dollars.”

For Dr. Harris, today he is in his 22nd year in practice, now caring for 3,600 patients. Although he has saved hundreds of thousands of dollars each and every year, today he makes less than “half what he did 20 years ago.” What kind of financial incentive is that for primary care doctors “to hang in there and work harder?”

While many physicians like Dr. Harris, went into medicine to serve mankind out of “a sense of love and compassion,” the revelation of such financial discrepancy and lack of motivation and rewards have forced many physicians out of primary care, leaving the rest to “wonder how long they can continue to work like this? In fact, it is not because physicians like Dr. Harris do not want to practice; it is because they “can no longer afford to work as a physician.”

What should scare Americans even more is that if 45 million uninsured are added to an already dwindling primary care provider list the result will be catastrophic: physician assistants will be providing the safety net with two years of training; newly trained physicians will be even more disincentivized go into primary care once they see the salaries, and internal medicine could become almost nonexistent in practice.

With the American Academy of Family Physicians projecting a shortage of primary care specialists to be short 39,000 by 2020 under the current system, no one seems to be asking how we get more money to physicians. Furthermore, “the Physicians' Foundation have said that over the next three years they plan to reduce the number of patients they see or stop practicing entirely,” which only increases the amount of patients per doctor (or lack thereof).

The key here is that Congress must focus on community health centers (CHCs) and the funding they receive through the government, as well as their support through medical training programs and residencies. If Congress and medical schools work together to open up more slots in medical school for primary care, as well as residencies, and more incentives like loan forgiveness, qualified applicants will follow.   Also Medical Schools need to be careful on the conflict of interest policies which in some instances reduce the number of residency slots by preventing corporate support for those slots.  Until then, next time you see your primary care physician (if you even can get to one), ask them how many patients they are seeing, and what would happen if 45 million more patients were added to their workload.    I think you will find the answer illuminating.