Shortage of primary care physicians and health insurance

[Guest guest]

In search of primary care physicians

By DR. RICHARD FELDMAN, South Bend Tribune.

Unfortunately, the national discussion regarding how to provide health insurance

for the more than 45 million uninsured largely ignores a smoldering crisis that

must be corrected before any model of expanded coverage could become

operational: Although there is a projected shortage of all physicians, there is

a critical lack of family physicians and other primary-care physicians to

provide the care necessary if significantly more Americans were insured.

Because of years of congressional inaction since the defeat of the Hillary

Clinton plan more than 10 years ago, some states forged ahead with health care

reform. Massachusetts, the best known of these newly established plans, mandates

that nearly all individuals must obtain health insurance.

The program is running into various problems, including the fact that the state

has insufficient primary care physicians to care for the influx of more than

400,000 previously uninsured people. Many people can't find a doctor and, if

they do, it may take many weeks and even months to get an appointment. Patients

continue to seek expensive fragmented care in emergency rooms and urgent-care

centers. Some doctors are crowding their schedules to accommodate the need, but

many are not willing to accept new patients. Unfortunately, what Massachusetts

learned about the lack of primary care physicians is reflective of the nation as

a whole. And it's going to get worse.

Our population is aging with 76 million baby boomers loaded with chronic

diseases about to enter the Medicare system. It is estimated that up to

one-third of primary care physicians will retire in the next decade. Half of new

physicians are women, many of whom will work part time as they balance

child-rearing with career.

But here's the biggest problem: Only a small fraction of medical school

graduates are choosing careers in primary care fields including family medicine.

Since 1997, the number choosing family medicine has dropped by 50 percent

despite the fact that we will need 40 percent more primary care physicians by

the year 2020. Utilizing physician extenders such as nurse practitioners can

help, but is not the solution.

We have created an inflationary system with fee-for-service reimbursement that

values and encourages specialist and procedural care rather than the

time-intensive services provided by primary care physicians. I don't see the

current health care reform bills in Congress changing this situation.

Primary care physicians, faced with high overhead and modest payments, work

longer hours and increasingly see more patients to maintain their incomes. There

is no reward for spending the time necessary with patients for the provision of

the " medical home. " The primary care medical home provides continuous,

comprehensive care, ongoing relationship with a personal physician, care

coordination, chronic disease management, preventive services, patient advocacy

and many tasks that fall outside face-to-face encounters which are not

reimbursed by the fee-for-service system.

The result: primary-care physicians are the lowest paid of all physicians, yet

their educational debt after medical school easily averages over $150,000. Why

not choose a higher paid specialty with that type of financial burden?

Primary care will form the essential foundation of any well-performing future

health care system. Unarguably, a robust primary care base creates the best

quality and cost-effective health care system with the best health outcomes and

the lowest mortality rates. It reduces unnecessary and redundant care, reduces

gaps in services, and matches health care resources and expensive procedures and

technology with patient needs.

Massachusetts as well as congressional health care reform bills have proposed

modest financial incentives to promote primary care. It won't be enough to solve

the shortage problem. Our health care system and its payment structure must be

completely redesigned to truly value primary care medicine and the benefits it

can bring.

True health care reform is unachievable until the fundamental problem of a lack

of primary care physicians is corrected.

Dr. D. Feldman is a former South Bend resident who now lives in

Indianapolis. He is chairman of the board of directors of the Indiana Academy of

Family Physicians and is former commissioner of the Indiana Department of

Health.

http://www.southbendtribune.com/article/20100128/Opinion/1280356/-1/googleNews