Re: WSJ.com - Primary Health Care Needs Fixing Before Universal Care Can Work

[Guest guest]

Ben,

Great editorial (as

usual). Thanks for continuing to

fight the good fight!!

WSJ.com - Primary Health Care Needs Fixing Before Universal Care Can Work

Good thoughts in the article.

Not sure if the graph is correct.

Surely the Peds Primary isn't filled

with 43 US Seniors.

I think the interesting thing is

that the whole healthcare system is not following supply and demand...not that

it has in a long time, but...

If we go to a national Medicare

system -- will fees continue to down, thus FP #'s go down -- shouldn't the fees

go up as supply goes down?

Next 5 years should be interesting.

Locke, MD

http://online.wsj.com/article_email/SB120647936859463451-lMyQjAxMDI4MDI2NjQyNzY5Wj.html

Return to

Web Version

Graph 5

Comparison of Primary Care Positions Filled with US

Seniors in March (1997-2008)

2008 NRMP Results

Download graph as PDF (136 KB).

THE DOCTOR'S OFFICE

By BENJAMIN BREWER, M.D.

Primary Health Care Needs Fixing Before Universal Care Can Work March 26, 2008

Who will take care of the estimated

47 million uninsured Americans if they get health coverage promised by

politicians?

Few people seem concerned about

whether the supply of primary care doctors is up to the task. But they should

be.

Even without health-care reform,

the demand for family physicians is expected to surge by 2020, when the nation

will need 140,000 family physicians, according to the American Academy of

Family Physician's 2006 Physician Workforce Report. That's a 40% increase over

the 100,000 family doctors at work in 2006.

Low payments to primary care

doctors are discouraging those of us in practice and are dissuading new doctors

from entering the field. Medicare's proposed 0.5% fee increase to family

doctors like me for the remainder of 2008 is well below inflation. None of my

office expenses will rise less than 0.5% this year.

To me, universal coverage looks

like an empty promise. Just nationalizing health insurance by declaring

Medicare for all isn't going to get the job done. Medical insurance coverage

without a doctor to see is another big health problem -- not a solution.

An expanded insurance program based

on Medicare or state Medicaid, another stingy payer, will prompt many doctors

to opt out if they can. If doctors are forced to participate in a program with fees

lower than their cost of doing business, I expect primary care doctors in

private practices like mine will close up shop.

Once displaced, they'll probably

work in ERs, continuing to provide high-cost care for diseases that a properly

designed and financed health system would have prevented or nipped earlier and

more cheaply.

Massachusetts, the state with

mandated insurance coverage most like Sen. Hillary Clinton's health plan, has

suffered a painful shortage of family doctors the last two years. More

people signed up than predicted and higher costs have led to premium increases.

It's apparent to me there is no increased access to care with this plan in many

areas and no cost savings have materialized.

That tells me that physicians in

any universal coverage program will have to weigh the personal and financial

risk of an access crunch. When a bad outcome arises, I expect lawyers will come

after the overburdened primary care docs instead of the politicians who

promised more than could be delivered.

We won't see better health outcomes

or any cost savings from improvements in quality unless there are broadly

trained primary care doctors available and willing to practice where they're

needed. Some would advocate using nurse practitioners or physician assistants

to fill this role, but I don't see that working as well. A family doctor's set

of skills is much broader. In this case, you get what you pay for.

If we add large numbers of patients

to the underfunded, understaffed primary care system we have now, things won't

improve. That approach will look good on TV for 15 minutes and then health care

as most Americans experience it will continue to stink, just more expensively.

Until we adequately fund primary

care, we're not going to get the health system Americans expect.

Right now the U.S. is graduating

about half the family physicians we'll need in the coming years, and the government

proposes to cut funding to train more. The 2009 federal budget would abolish

funding for training programs under Title VII of the Public Health Service Act,

including Section 747 of the act, which provides the only federal grants for

training primary care physicians.

To fill the primary care gap, we

could flood the U.S. with foreign trained doctors. In fact, we're pretty much

already doing that in our training programs. Fifty-six percent of doctors

starting family medicine residencies this summer are foreign graduates. Foreign

grads practice mainly in larger cities so that doesn't help overall

distribution of doctors to smaller communities.

Only 65 more U.S. medical students

chose family medicine for their residency this year than last year for a total

of 1,172. (See a chart on the primary care trends here.) Compared with the bleak decline of the last 10

years, a 2% increase in family practice residents is cause for celebration

among family doctors. " We're extremely pleased with this year's

match, " said AAFP President Jim King, M.D., of Selmer, Tenn.

Still, I would be happier if every

one of those doctors had a sustainable practice to grow into. The fact is that

costs are too high for an economically viable practice in many areas. Payments

from the government and large insurance companies don't adequately cover

expenses and the burden of educational debt. The cost of malpractice insurance

to practice the full range of primary care medicine, including obstetrics, is

untenable for most.

How can anyone rationally expect to

build up the nation's health on that crumbling foundation?

Family physicians could meet the

needs of the uninsured, the underinsured and the baby boomers, but not without

some fundamental changes in the way they are paid.

Due to his

schedule and the volume of email he receives, Dr. Brewer may not be able to

respond to all reader email. He does participate in his forum, where readers

are urged to post. His email address is thedoctorsofficewsj.

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[Guest guest]

a definite improvement over the $2 medical home.i would love to see ben write a piece which specifically addresses the value of what we do, and to wonder how much that is worth.at the risk of a hipaa violation, let me be more specific.within the last week, i have seen two patients, both having gotten involved with drugs. because i have established relationships with both the patients and their families (oh, gee, isn't that what we do as family doctors?), because i am able to spend the necessary time when it's needed to find out what's going in their lives and to ask the deeper probing questions (oh, gee, that's IMP-style practice), to wait for the answers to them, and to actually listen to and evaluate the answers (oh, gee, that's because i don't have a waiting room full of patients, and if someone is waiting, they know that i will spend the appropriate time with them, too), i can actually find out what's going on with them, get to the root causes of their

problems, figure out solutions with them, hopefully make a difference, prevent further adverse health effects, avoid potential harm to others, help prevent adverse potential legal consequences, thereby keeping their options open and preventing further societal cost, ie, prison and potential poverty, and requiring state aid. let's not forget early and unwanted pregnancy.what's that worth?put a dollar amount on that one, will ya? and it's not just how we're paid, it's what we're paid, too.and while you're at it, figure out how come that which is necessary is so undervalued, while that which is a luxury is regarded as a necessity.i want some answers, i'm thinking about moving to new zealand or going back to residency and specializing in something really expensive.LLLL" Brady, MD" wrote: Ben, Great editorial (as usual). Thanks for continuing to fight the good fight!! WSJ.com - Primary Health Care Needs Fixing Before Universal Care Can

Work Good thoughts in the article. Not sure if the graph is correct. Surely the Peds Primary isn't filled with 43 US Seniors. I think the interesting thing is that the whole healthcare system is not following supply and demand...not that it has in a long time, but... If we go to a national Medicare system -- will fees continue to down, thus FP #'s go down -- shouldn't the fees go up as supply goes down? Next 5 years should be interesting. Locke, MD http://online.wsj.com/article_email/SB120647936859463451-lMyQjAxMDI4MDI2NjQyNzY5Wj.html Return to Web Version Graph 5 Comparison of Primary Care Positions Filled with US Seniors in March (1997-2008) 2008 NRMP Results Download graph as PDF (136 KB). THE DOCTOR'S OFFICE By BENJAMIN BREWER, M.D.

Primary Health Care Needs Fixing Before Universal Care Can Work March 26, 2008 Who will take care of the estimated 47 million uninsured Americans if they get health coverage promised by politicians? Few people seem concerned about whether the supply of primary care doctors is up to the task. But they should be. Even without health-care reform, the demand for

family physicians is expected to surge by 2020, when the nation will need 140,000 family physicians, according to the American Academy of Family Physician's 2006 Physician Workforce Report. That's a 40% increase over the 100,000 family doctors at work in 2006. Low payments to primary care doctors are discouraging those of us in practice and are dissuading new doctors from entering the field. Medicare's proposed 0.5% fee increase to family doctors like me for the remainder of 2008 is well below inflation. None of my office expenses will rise less than 0.5% this year. To me, universal coverage looks like an empty promise. Just nationalizing health insurance by declaring Medicare for all isn't going to get the job done. Medical insurance coverage without a doctor to see is another big health problem -- not a solution. An expanded insurance program based on Medicare or state Medicaid, another stingy payer, will prompt many doctors to opt out if they can. If doctors are forced to participate in a program with fees lower than their cost of doing business, I expect primary care doctors in private practices like mine will close up shop. Once displaced, they'll probably work in ERs, continuing to provide high-cost care for diseases that a properly

designed and financed health system would have prevented or nipped earlier and more cheaply. Massachusetts, the state with mandated insurance coverage most like Sen. Hillary Clinton's health plan, has suffered a painful shortage of family doctors the last two years. More people signed up than predicted and higher costs have led to premium increases. It's apparent to me there is no increased access to care with this plan in many areas and no cost savings have materialized. That tells me that physicians in any universal coverage program will have to weigh the personal and financial risk

of an access crunch. When a bad outcome arises, I expect lawyers will come after the overburdened primary care docs instead of the politicians who promised more than could be delivered. We won't see better health outcomes or any cost savings from improvements in quality unless there are broadly trained primary care doctors available and willing to practice where they're needed. Some would advocate using nurse practitioners or physician assistants to fill this role, but I don't see that working as well. A family doctor's set of skills is much broader. In this case, you get what you pay for. If we add large numbers of patients to the underfunded, understaffed primary care system we have now, things won't improve. That

approach will look good on TV for 15 minutes and then health care as most Americans experience it will continue to stink, just more expensively. Until we adequately fund primary care, we're not going to get the health system Americans expect. Right now the U.S. is graduating about half the family physicians we'll need in the coming years, and the government proposes to cut funding to train more. The 2009 federal budget would abolish funding for training programs under Title VII of the Public Health Service Act, including Section 747 of the act, which provides the only federal grants for training primary care physicians. To fill the primary care gap, we could flood the U.S. with foreign trained doctors. In fact, we're pretty much already doing that in our training programs. Fifty-six percent of doctors starting family medicine residencies this summer are foreign graduates. Foreign grads practice mainly in larger cities so that doesn't help overall distribution of doctors to smaller communities. Only 65 more U.S. medical students chose family medicine for their residency this year than last year for a total of 1,172. (See a chart on the primary care trends here.) Compared with the bleak decline of the last 10 years, a 2% increase in family practice residents is cause for celebration among family doctors. "We're extremely pleased with this year's

match," said AAFP President Jim King, M.D., of Selmer, Tenn. Still, I would be happier if every one of those doctors had a sustainable practice to grow into. The fact is that costs are too high for an economically viable practice in many areas. Payments from the government and large insurance companies don't adequately cover expenses and the burden of educational debt. The cost of malpractice insurance to practice the full range of primary care medicine, including obstetrics, is untenable for most. How can anyone rationally expect to build up the nation's health on that crumbling foundation? Family physicians could meet the needs of the uninsured, the underinsured and the baby boomers, but not without some fundamental changes in the way they are paid. Due to his schedule and the volume of email he receives, Dr. Brewer may not be able to respond to all reader email. He does participate in his forum, where readers are urged to post. His email address is thedoctorsofficewsj. Powered by * Please note, the sender's email address has not been verified. This guy agrees with you Click the following to access the sent link: WSJ.com - Primary Health Care Needs Fixing Before Universal Care Can Work* This article will be available to non-subscribers of the Online Journal for up to seven days after it is e-mailed. Get your

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Be a better friend, newshound, and know-it-all with Yahoo! Mobile. Try it now.

[Guest guest]

My comments on this article - physician demand and supply is tricky to

determine. I've seen numerous analyses turn out to be flat wrong.

When I was in medical school (early 1990s), the mantra was to go into

primary care, because the HMO model would take over heath care and

specialists would be on the soup lines out of work while the primary

doc gatekeepers would rule the system.

Look how that turned out.

My prediction is that physicians from the baby-boom generation will

not retire like we're predicting. This may lead to an adequate supply

of docs, or even an oversupply if physicians don't retire like we're

predicting.

What's the basis of my prediction? Older docs are grandfathered out of

recertification, allowing fewer barriers to continued practice. Cost

of retirement is rising, forcing even docs to consider working extra

years, and generational work ethics of the baby boom generation

emphasizing work over retirement.

We'll see how it works out, but I don't think we'll see huge shortages

of physicians like some are predicting.

Rahul Patel, MD

>

> Good thoughts in the article.

>

> Not sure if the graph is correct.

> Surely the Peds Primary isn't filled with 43 US Seniors.

>

> I think the interesting thing is that the whole healthcare system is not

> following supply and demand...not that it has in a long time, but...

>

> If we go to a national Medicare system -- will fees continue to

down, thus

> FP #'s go down -- shouldn't the fees go up as supply goes down?

>

> Next 5 years should be interesting.

>

> Locke, MD

>

>

http://online.wsj.com/article_email/SB120647936859463451-lMyQjAxMDI4MDI2NjQy

> NzY5Wj.html

>

>

> <http://www.aafp.org/online/en/home/residents/match/graph5.html>

Return to

> Web Version

>

> Graph 5

>

>

> Comparison of Primary Care Positions Filled with US Seniors in March

> (1997-2008)

>

>

>

> graph <http://www.aafp.org/match2008/graph5.jpg>

>

> 2008 NRMP Results

>

>

> PDF <http://www.aafp.org/match2007/pdf-icon.jpg>

> <http://www.aafp.org/match2008/graph5.pdf> Download graph as PDF

(136 KB).

>

>

>

<http://www.aafp.org/online/en/home/aboutus/theaafp/about/permissions.html>

>

>

>

>

>

> THE DOCTOR'S OFFICE

> By BENJAMIN BREWER, M.D. <http://online.wsj.com/img/colhed_brewer.jpg>

>

>

>

>

>

>

>

> Primary Health Care Needs Fixing Before Universal Care Can Work

March 26,

> 2008

>

>

> Who will take care of the estimated 47 million uninsured Americans

if they

> get health coverage promised by politicians?

>

> Few people seem concerned about whether the supply of primary care

doctors

> is up to the task. But they should be.

>

> Even without health-care reform, the demand for family physicians is

> expected to surge by 2020, when the nation will need 140,000 family

> physicians, according to the American Academy of Family Physician's

>

<http://www.aafp.org/online/etc/medialib/aafp_org/documents/about/congress/2

>

006/bd-rpts/brdrptp.Par.0001.File.dat/Board%20Report%20P%20on%20Physician%20

> Workforce%20Reform.pdf> 2006 Physician Workforce Report. That's a 40%

> increase over the 100,000 family doctors at work in 2006.

>

> Low payments to primary care doctors are discouraging those of us in

> practice and are dissuading new doctors from entering the field.

Medicare's

> proposed 0.5% fee increase to family doctors like me for the

remainder of

> 2008 is well below inflation. None of my office expenses will rise

less than

> 0.5% this year.

>

> To me, universal coverage looks like an empty promise. Just

nationalizing

> health insurance by declaring Medicare for all isn't going to get

the job

> done. Medical insurance coverage without a doctor to see is another big

> health problem -- not a solution.

>

> An expanded insurance program based on Medicare or state Medicaid,

another

> stingy payer, will prompt many doctors to opt out if they can. If

doctors

> are forced to participate in a program with fees lower than their

cost of

> doing business, I expect primary care doctors in private practices

like mine

> will close up shop.

>

> Once displaced, they'll probably work in ERs, continuing to provide

> high-cost care for diseases that a properly designed and financed health

> system would have prevented or nipped earlier and more cheaply.

>

> Massachusetts, the state with mandated insurance coverage most like Sen.

> Hillary Clinton's health plan, has suffered a

>

<http://www.aafp.org/online/en/home/publications/news/news-now/professional-

> issues/20070802massfpshortage.html> painful shortage of family

doctors the

> last two years. More people signed up than predicted and higher

costs have

> led to premium increases. It's apparent to me there is no increased

access

> to care with this plan in many areas and no cost savings have

materialized.

>

> That tells me that physicians in any universal coverage program will

have to

> weigh the personal and financial risk of an access crunch. When a bad

> outcome arises, I expect lawyers will come after the overburdened

primary

> care docs instead of the politicians who promised more than could be

> delivered.

>

> We won't see better health outcomes or any cost savings from

improvements in

> quality unless there are broadly trained primary care doctors

available and

> willing to practice where they're needed. Some would advocate using

nurse

> practitioners or physician assistants to fill this role, but I don't see

> that working as well. A family doctor's set of skills is much

broader. In

> this case, you get what you pay for.

>

> If we add large numbers of patients to the underfunded, understaffed

primary

> care system we have now, things won't improve. That approach will

look good

> on TV for 15 minutes and then health care as most Americans

experience it

> will continue to stink, just more expensively.

>

> Until we adequately fund primary care, we're not going to get the health

> system Americans expect.

>

> Right now the U.S. is graduating about half the family physicians

we'll need

> in the coming years, and the government proposes to cut funding to train

> more. The 2009 federal budget would abolish funding for training

programs

> under Title VII of the Public Health Service Act, including Section

747 of

> the act, which provides the only federal grants for training primary

care

> physicians.

>

> To fill the primary care gap, we could flood the U.S. with foreign

trained

> doctors. In fact, we're pretty much already doing that in our training

> programs. Fifty-six percent of doctors starting family medicine

residencies

> this summer are foreign graduates. Foreign grads practice mainly in

larger

> cities so that doesn't help overall distribution of doctors to smaller

> communities.

>

> Only 65 more U.S. medical students chose family medicine for their

residency

> this year than last year for a total of 1,172. (See a chart on the

primary

> care trends

> <http://www.aafp.org/online/en/home/residents/match/graph5.html> here.)

> Compared with the bleak decline of the last 10 years, a 2% increase in

> family practice residents is cause for celebration among family doctors.

> " We're extremely pleased with this year's match, " said AAFP

President Jim

> King, M.D., of Selmer, Tenn.

>

> Still, I would be happier if every one of those doctors had a

sustainable

> practice to grow into. The fact is that costs are too high for an

> economically viable practice in many areas. Payments from the

government and

> large insurance companies don't adequately cover expenses and the

burden of

> educational debt. The cost of malpractice insurance to practice the full

> range of primary care medicine, including obstetrics, is untenable

for most.

>

> How can anyone rationally expect to build up the nation's health on that

> crumbling foundation?

>

> Family physicians could meet the needs of the uninsured, the

underinsured

> and the baby boomers, but not without some fundamental changes in

the way

> they are paid.

>

> Due to his schedule and the volume of email he receives, Dr. Brewer

may not

> be able to respond to all reader email. He does participate in his

forum,

> where readers are urged to post. His email address is

> thedoctorsoffice@...

>

>

>

>

> <http://s.clickability.com/s?19=40004 & 7=150 & 38=979910849>

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[Guest guest]

Rahul,

I hope you’re right, but I’m

not seeing it. Most of the colleagues I know >55 years old desire to get out

of the business of medicine as soon as possible. Many are selling out to

hospitals and going to work at urgent care clinics. Many are leaving medicine

altogether. So as far as I can tell about the baby boomers,

they may still be practicing, but it will not likely be in the same role.

Also, remember that the number one factor in satisfaction is autonomy. As

pressures for stupid admin stuff goes up, the number of docs wanting to

continue to practice goes down. The admin stuff lately has been going crazy

(look at the other threads on this serve in the past 48 hours). If that

continues to increase, I’ll even want to retire (and I’m way to

young to be a baby boomer J).

Re: WSJ.com - Primary Health Care Needs Fixing Before Universal Care Can Work

My comments on this article - physician demand and supply is tricky to

determine. I've seen numerous analyses turn out to be flat wrong.

When I was in medical school (early 1990s), the mantra was to go into

primary care, because the HMO model would take over heath care and

specialists would be on the soup lines out of work while the primary

doc gatekeepers would rule the system.

Look how that turned out.

My prediction is that physicians from the baby-boom generation will

not retire like we're predicting. This may lead to an adequate supply

of docs, or even an oversupply if physicians don't retire like we're

predicting.

What's the basis of my prediction? Older docs are grandfathered out of

recertification, allowing fewer barriers to continued practice. Cost

of retirement is rising, forcing even docs to consider working extra

years, and generational work ethics of the baby boom generation

emphasizing work over retirement.

We'll see how it works out, but I don't think we'll see huge shortages

of physicians like some are predicting.

Rahul Patel, MD

>

> Good thoughts in the article.

>

> Not sure if the graph is correct.

> Surely the Peds Primary isn't filled with 43 US Seniors.

>

> I think the interesting thing is that the whole healthcare system is not

> following supply and demand...not that it has in a long time, but...

>

> If we go to a national Medicare system -- will fees continue to

down, thus

> FP #'s go down -- shouldn't the fees go up as supply goes down?

>

> Next 5 years should be interesting.

>

> Locke, MD

>

>

http://online.wsj.com/article_email/SB120647936859463451-lMyQjAxMDI4MDI2NjQy

> NzY5Wj.html

>

>

> <http://www.aafp.org/online/en/home/residents/match/graph5.html>

Return to

> Web Version

>

> Graph 5

>

>

> Comparison of Primary Care Positions Filled with US Seniors in March

> (1997-2008)

>

>

>

> graph <http://www.aafp.org/match2008/graph5.jpg>

>

> 2008 NRMP Results

>

>

> PDF <http://www.aafp.org/match2007/pdf-icon.jpg>

> <http://www.aafp.org/match2008/graph5.pdf>

Download graph as PDF

(136 KB).

>

>

>

<http://www.aafp.org/online/en/home/aboutus/theaafp/about/permissions.html>

>

>

>

>

>

> THE DOCTOR'S OFFICE

> By BENJAMIN BREWER, M.D. <http://online.wsj.com/img/colhed_brewer.jpg>

>

>

>

>

>

>

>

> Primary Health Care Needs Fixing Before Universal Care Can Work

March 26,

> 2008

>

>

> Who will take care of the estimated 47 million uninsured Americans

if they

> get health coverage promised by politicians?

>

> Few people seem concerned about whether the supply of primary care

doctors

> is up to the task. But they should be.

>

> Even without health-care reform, the demand for family physicians is

> expected to surge by 2020, when the nation will need 140,000 family

> physicians, according to the American Academy of Family Physician's

>

<http://www.aafp.org/online/etc/medialib/aafp_org/documents/about/congress/2

>

006/bd-rpts/brdrptp.Par.0001.File.dat/Board%20Report%20P%20on%20Physician%20

> Workforce%20Reform.pdf> 2006 Physician Workforce Report. That's a

40%

> increase over the 100,000 family doctors at work in 2006.

>

> Low payments to primary care doctors are discouraging those of us in

> practice and are dissuading new doctors from entering the field.

Medicare's

> proposed 0.5% fee increase to family doctors like me for the

remainder of

> 2008 is well below inflation. None of my office expenses will rise

less than

> 0.5% this year.

>

> To me, universal coverage looks like an empty promise. Just

nationalizing

> health insurance by declaring Medicare for all isn't going to get

the job

> done. Medical insurance coverage without a doctor to see is another big

> health problem -- not a solution.

>

> An expanded insurance program based on Medicare or state Medicaid,

another

> stingy payer, will prompt many doctors to opt out if they can. If

doctors

> are forced to participate in a program with fees lower than their

cost of

> doing business, I expect primary care doctors in private practices

like mine

> will close up shop.

>

> Once displaced, they'll probably work in ERs, continuing to provide

> high-cost care for diseases that a properly designed and financed health

> system would have prevented or nipped earlier and more cheaply.

>

> Massachusetts, the state with mandated insurance coverage most like Sen.

> Hillary Clinton's health plan, has suffered a

>

<http://www.aafp.org/online/en/home/publications/news/news-now/professional-

> issues/20070802massfpshortage.html> painful shortage of

family

doctors the

> last two years. More people signed up than predicted and higher

costs have

> led to premium increases. It's apparent to me there is no increased

access

> to care with this plan in many areas and no cost savings have

materialized.

>

> That tells me that physicians in any universal coverage program will

have to

> weigh the personal and financial risk of an access crunch. When a bad

> outcome arises, I expect lawyers will come after the overburdened

primary

> care docs instead of the politicians who promised more than could be

> delivered.

>

> We won't see better health outcomes or any cost savings from

improvements in

> quality unless there are broadly trained primary care doctors

available and

> willing to practice where they're needed. Some would advocate using

nurse

> practitioners or physician assistants to fill this role, but I don't see

> that working as well. A family doctor's set of skills is much

broader. In

> this case, you get what you pay for.

>

> If we add large numbers of patients to the underfunded, understaffed

primary

> care system we have now, things won't improve. That approach will

look good

> on TV for 15 minutes and then health care as most Americans

experience it

> will continue to stink, just more expensively.

>

> Until we adequately fund primary care, we're not going to get the health

> system Americans expect.

>

> Right now the U.S. is graduating about half the family physicians

we'll need

> in the coming years, and the government proposes to cut funding to train

> more. The 2009 federal budget would abolish funding for training

programs

> under Title VII of the Public Health Service Act, including Section

747 of

> the act, which provides the only federal grants for training primary

care

> physicians.

>

> To fill the primary care gap, we could flood the U.S. with foreign

trained

> doctors. In fact, we're pretty much already doing that in our training

> programs. Fifty-six percent of doctors starting family medicine

residencies

> this summer are foreign graduates. Foreign grads practice mainly in

larger

> cities so that doesn't help overall distribution of doctors to smaller

> communities.

>

> Only 65 more U.S. medical students chose family medicine for their

residency

> this year than last year for a total of 1,172. (See a chart on the

primary

> care trends

> <http://www.aafp.org/online/en/home/residents/match/graph5.html>

here.)

> Compared with the bleak decline of the last 10 years, a 2% increase in

> family practice residents is cause for celebration among family doctors.

> " We're extremely pleased with this year's match, " said AAFP

President Jim

> King, M.D., of Selmer, Tenn.

>

> Still, I would be happier if every one of those doctors had a

sustainable

> practice to grow into. The fact is that costs are too high for an

> economically viable practice in many areas. Payments from the

government and

> large insurance companies don't adequately cover expenses and the

burden of

> educational debt. The cost of malpractice insurance to practice the full

> range of primary care medicine, including obstetrics, is untenable

for most.

>

> How can anyone rationally expect to build up the nation's health on that

> crumbling foundation?

>

> Family physicians could meet the needs of the uninsured, the

underinsured

> and the baby boomers, but not without some fundamental changes in

the way

> they are paid.

>

> Due to his schedule and the volume of email he receives, Dr. Brewer

may not

> be able to respond to all reader email. He does participate in his

forum,

> where readers are urged to post. His email address is

> thedoctorsoffice@...

>

>

>

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WSJ.com -

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[Guest guest]

shouldn't the fees go up as supply goes down?

>

> Next 5 years should be interesting.

>

> Locke, MD

>

In a free market yes but Medicare is not a free market. Actually, in a

free market, the fewer FP's, the more expensive they become, right ?

What happens in a state regulated system : they find a cheaper

version, like the NP (see the UK situation

http://nhsblogdoc.blogspot.com/).

ly, I don't think that Medicare will increase fees for PCP's, I

think that as the baby boomers get older, they will continue to drop

the fees. Medicare pays from a fixed pool of money, if they pay us

more, they will have to pay somebody else less. They will probably

start rationing more (like needing a PA for every CT - I am surprised

they did not do that yet) and they will increase the out of pocket.

[Guest guest]

I rather liked the $2 medical home piece, but I appreciate your comments.  The total cost of providing a medical home and all associated visits emails and whatnot is obviously higher than $2-3 per person per month, but what would be a reasonable figure?  $15? $25-30?Whatever your price point might be I would suggest it would probably seem low to those paying multiple hundreds in premiums for insurance.  The bottom line in my opinion is that good primary care is not as expensive as many people have been led to believe.  We are separated economically from the value we create.  I wholeheartedly agree.Redefining Healthcare, a book by some Harvard gurus (http://www.hbs.edu/rhc/index.html) talks quite a bit about the value cycle in healthcare and how the value created by primary care is largely invisible and difficult to account for.  Their answer seems to be that we should measure many, many things like a factory does to prove our contribution to the value cycle.  To do this would require the hospitals and our colleagues to price the global cost of care for each episode and agree amongst ourselves how we would split it based on performance metrics.  Much of what they discussed seems logistically very, very difficult.  It seems geared very much toward the pervasive idea that bigger healthcare entities are better because they have better metrics.  What is the value of timely intervention for the patients Lawrence mentions, or the patient with critical CAD saved by recognition of some vague symptoms and timely evaluation?  A heck of a lot more than a level 3 office visit, but proving is going to take some serious effort.The reality is we're saving people major trouble all the time but we're going to be judged on what our patient's A1c levels rather than how many dollars we saved the system.  As long as we're stuck at the minutiae level of A1c measurement as a surrogate of our abilities instead of our total contribution to the patient's care we'll be struggling over the scraps

of the healthcare dollar.One the preauthorization theme -  I did do a piece on being rejected for Lantus insulin by Illinois Medicaid about 2 years ago.  Ben Brewer M.D. [Practiceimprovemen t1] WSJ.com - Primary Health Care Needs Fixing Before Universal Care Can

Work   Good thoughts in the article.   Not sure if the graph is correct. Surely the Peds Primary isn't filled with 43 US Seniors.   I think the interesting thing is that the whole healthcare system is not following supply and demand...not that it has in a long time, but...   If we go to a national Medicare system -- will fees continue to down, thus FP #'s go down -- shouldn't the fees go up as supply goes down?   Next 5 years should be interesting.   Locke, MD   http://online. wsj.com/article_ email/SB12064793 6859463451- lMyQjAxMDI4MDI2N jQyNzY5Wj. html     Return to Web Version Graph 5 Comparison of Primary Care Positions Filled with US Seniors in March (1997-2008)   2008 NRMP Results Download graph as PDF (136 KB).   THE DOCTOR'S OFFICE By BENJAMIN BREWER, M.D.

          Primary Health Care Needs Fixing Before Universal Care Can Work March 26, 2008 Who will take care of the estimated 47 million uninsured Americans if they get health coverage promised by politicians? Few people seem concerned about whether the supply of primary care doctors is up to the task. But they should be. Even without health-care reform, the demand for

family physicians is expected to surge by 2020, when the nation will need 140,000 family physicians, according to the American Academy of Family Physician's 2006 Physician Workforce Report. That's a 40% increase over the 100,000 family doctors at work in 2006. Low payments to primary care doctors are discouraging those of us in practice and are dissuading new doctors from entering the field. Medicare's proposed 0.5% fee increase to family doctors like me for the remainder of 2008 is well below inflation. None of my office expenses will rise less than 0.5% this year. To me, universal coverage looks like an empty promise. Just nationalizing health insurance by declaring Medicare for all isn't going to get the job done. Medical insurance coverage without a doctor to see is another big health problem -- not a solution. An expanded insurance program based on Medicare or state Medicaid, another stingy payer, will prompt many doctors to opt out if they can. If doctors are forced to participate in a program with fees lower than their cost of doing business, I expect primary care doctors in private practices like mine will close up shop. Once displaced, they'll probably work in ERs, continuing to provide high-cost care

for diseases that a properly

designed and financed health system would have prevented or nipped earlier and more cheaply. Massachusetts, the state with mandated insurance coverage most like Sen. Hillary Clinton's health plan, has suffered a painful shortage of family doctors the last two years. More people signed up than predicted and higher costs have led to premium increases. It's apparent to me there is no increased access to care with this plan in many areas and no cost savings have materialized. That tells me that physicians in any universal coverage program will have to weigh the personal and

financial risk

of an access crunch. When a bad outcome arises, I expect lawyers will come after the overburdened primary care docs instead of the politicians who promised more than could be delivered. We won't see better health outcomes or any cost savings from improvements in quality unless there are broadly trained primary care doctors available and willing to practice where they're needed. Some would advocate using nurse practitioners or physician assistants to fill this role, but I don't see that working as well. A family doctor's set of skills is much broader. In this case, you get what you pay for. If we add large numbers of patients to the underfunded, understaffed primary care system we have now, things won't improve. That

approach will look good on TV for 15 minutes and then health care as most Americans experience it will continue to stink, just more expensively. Until we adequately fund primary care, we're not going to get the health system Americans expect. Right now the U.S. is graduating about half the family physicians we'll need in the coming years, and the government proposes to cut funding to train more. The 2009 federal budget would abolish funding for training programs under Title VII of the Public Health Service Act, including Section 747 of the act, which provides the only federal grants for training primary care physicians. To fill the primary care gap, we could flood the U.S. with foreign trained doctors. In fact, we're pretty much already doing that in our training programs. Fifty-six percent of doctors starting family medicine residencies this summer are foreign graduates. Foreign grads practice mainly in larger cities so that doesn't help overall distribution of doctors to smaller communities. Only 65 more U.S. medical students chose family medicine for their residency this year than last year for a total of 1,172. (See a chart on the primary care trends here.) Compared with the bleak decline of the last 10 years, a 2% increase in family practice residents is cause for celebration among family doctors. "We're

extremely pleased with this year's

match," said AAFP President Jim King, M.D., of Selmer, Tenn. Still, I would be happier if every one of those doctors had a sustainable practice to grow into. The fact is that costs are too high for an economically viable practice in many areas. Payments from the government and large insurance companies don't adequately cover expenses and the burden of educational debt. The cost of malpractice insurance to practice the full range of primary care medicine, including obstetrics, is untenable for most. How can anyone rationally expect to build up the nation's health on that crumbling foundation? Family physicians could meet the needs of the uninsured, the underinsured and the baby boomers, but not without some fundamental changes in the way they are paid. Due to his schedule and the volume of email he receives, Dr. Brewer may not be able to respond to all reader email. He does participate in his forum, where readers are urged to post. His email address is thedoctorsoffice@ wsj.com.       Powered by    * Please note, the sender's email address has not been verified.       This guy agrees with you             Click the following to access the sent link:       WSJ.com - Primary Health Care Needs Fixing Before Universal Care Can Work* This article will be available to non-subscribers of the Online Journal for up to seven days after it is e-mailed.                       Get your

EMAIL THIS Browser Button and use it to email content from any Web site. Click here for more information.               *This article can also be accessed if you copy and paste the entire address below into your web browser. http://online. wsj.com/wsjgate? subURI=%2Farticl e%2FSB1206479368 59463451- email.html & nonsubURI=%2Farticl e_email%2FSB1206 47936859463451- lMyQjAxMDI4MDI2N jQyNzY5Wj. html Be a better friend, newshound, and know-it-all with Yahoo! Mobile. Try it now.

Looking for last minute shopping deals? Find them fast with Yahoo! Search.

[Guest guest]

Many specialists are hurting. I believe we have educated too many. If we continue, the subspecilists may need to retrain in primary care. PS A local GI begged me today for referrals. He said, "If I don't start sending everyone, then when I need him he won't be here." He said it was they same for the cardiologists and others locally.valeazinelor wrote: shouldn't the fees go up as supply goes down?> > Next 5 years should be interesting.> > Locke, MD> In a free market yes but Medicare is not a free market. Actually, in afree market, the fewer FP's, the more expensive they become, right ?What happens in a state regulated system : they find a cheaperversion, like the NP (see the UK situationhttp://nhsblogdoc.blogspot.com/). ly, I don't think that Medicare will increase fees for PCP's, Ithink that as the baby boomers get older, they will continue to dropthe fees. Medicare pays from a fixed pool of money, if they pay usmore, they will have to pay somebody else less. They will probablystart rationing more (like needing a PA for

every CT - I am surprisedthey did not do that yet) and they will increase the out of pocket.

Looking for last minute shopping deals? Find them fast with Yahoo! Search.

[Guest guest]

>

> Many specialists are hurting. I believe we have educated too many. If we

continue, the

subspecilists may need to retrain in primary care.

>

>

>

> PS A local GI begged me today for referrals. He said, " If I don't start

sending everyone,

then when I need him he won't be here. " He said it was they same for the

cardiologists and

others locally.

>

Yes, they start to feel the crunch. Maybe they will start going into

micropractice.

[Guest guest]

the 2 big gurus at Harvard are Porter and Regina

Herzlinger. I have read both of their books and I think they are

pretty much clueless as to how healthcare really runs on the local

level. They think that some type of amazing competition between

large groups is going to solve this problem. I would recommend " Rx

for health care reform " by Ken Terry a former editor of medical

economics. An excellent book.

>

> Ben,

> Great editorial (as usual). Thanks for continuing to fight the

good fight!!

>

>

> [Practiceimprovemen t1] WSJ.com - Primary Health Care

Needs Fixing Before Universal Care Can Work

>

> Good thoughts in the article.

>

> Not sure if the graph is correct.

> Surely the Peds Primary isn't filled with 43 US Seniors.

>

> I think the interesting thing is that the whole healthcare

system is not following supply and demand...not that it has in a

long time, but...

>

> If we go to a national Medicare system -- will fees continue to

down, thus FP #'s go down -- shouldn't the fees go up as supply goes

down?

>

> Next 5 years should be interesting.

>

> Locke, MD

>

> http://online. wsj.com/article_ email/SB12064793 6859463451-

lMyQjAxMDI4MDI2N jQyNzY5Wj. html

>

>

> Return to Web Version

>

> Graph 5 Comparison of Primary Care Positions Filled

with US Seniors in March (1997-2008)

>

>

>

>

> 2008 NRMP Results Download graph as PDF (136 KB).

>

>

>

>

>

>

>

>

>

>

>

>

> THE DOCTOR'S OFFICE

>

> By BENJAMIN BREWER, M.D.

>

>

>

>

>

>

>

>

> Primary Health Care Needs Fixing Before Universal Care Can

Work March 26, 2008 Who will take care of the estimated 47 million

uninsured Americans if they get health coverage promised by

politicians?

> Few people seem concerned about whether the supply of primary

care doctors is up to the task. But they should be.

> Even without health-care reform, the demand for family

physicians is expected to surge by 2020, when the nation will need

140,000 family physicians, according to the American Academy of

Family Physician's 2006 Physician Workforce Report. That's a 40%

increase over the 100,000 family doctors at work in 2006.

> Low payments to primary care doctors are discouraging those of

us in practice and are dissuading new doctors from entering the

field. Medicare's proposed 0.5% fee increase to family doctors like

me for the remainder of 2008 is well below inflation. None of my

office expenses will rise less than 0.5% this year.

> To me, universal coverage looks like an empty promise. Just

nationalizing health insurance by declaring Medicare for all isn't

going to get the job done. Medical insurance coverage without a

doctor to see is another big health problem -- not a solution.

> An expanded insurance program based on Medicare or state

Medicaid, another stingy payer, will prompt many doctors to opt out

if they can. If doctors are forced to participate in a program with

fees lower than their cost of doing business, I expect primary care

doctors in private practices like mine will close up shop.

> Once displaced, they'll probably work in ERs, continuing to

provide high-cost care for diseases that a properly

> designed and financed health system would have prevented or

nipped earlier and more cheaply.

> Massachusetts, the state with mandated insurance coverage most

like Sen. Hillary Clinton's health plan, has suffered a painful

shortage of family doctors the last two years. More people signed up

than predicted and higher costs have led to premium increases. It's

apparent to me there is no increased access to care with this plan

in many areas and no cost savings have materialized.

> That tells me that physicians in any universal coverage program

will have to weigh the personal and financial risk

> of an access crunch. When a bad outcome arises, I expect lawyers

will come after the overburdened primary care docs instead of the

politicians who promised more than could be delivered.

> We won't see better health outcomes or any cost savings from

improvements in quality unless there are broadly trained primary

care doctors available and willing to practice where they're needed.

Some would advocate using nurse practitioners or physician

assistants to fill this role, but I don't see that working as well.

A family doctor's set of skills is much broader. In this case, you

get what you pay for.

> If we add large numbers of patients to the underfunded,

understaffed primary care system we have now, things won't improve.

That

> approach will look good on TV for 15 minutes and then health care

as most Americans experience it will continue to stink, just more

expensively.

> Until we adequately fund primary care, we're not going to get

the health system Americans expect.

> Right now the U.S. is graduating about half the family

physicians we'll need in the coming years, and the government

proposes to cut funding to train more. The 2009 federal budget would

abolish funding for training programs under Title VII of the Public

Health Service Act, including Section 747 of the act, which provides

the only federal grants for training primary care physicians.

> To fill the primary care gap, we could flood the U.S. with

foreign trained doctors. In fact, we're pretty much already doing

that in our training programs. Fifty-six percent of doctors starting

family medicine residencies this summer are foreign graduates.

Foreign grads practice mainly in larger cities so that doesn't help

overall distribution of doctors to smaller communities.

> Only 65 more U.S. medical students chose family medicine for

their residency this year than last year for a total of 1,172. (See

a chart on the primary care trends here.) Compared with the bleak

decline of the last 10 years, a 2% increase in family practice

residents is cause for celebration among family doctors. " We're

extremely pleased with this year's match, " said AAFP President Jim

King, M.D., of Selmer, Tenn.

> Still, I would be happier if every one of those doctors had a

sustainable practice to grow into. The fact is that costs are too

high for an economically viable practice in many areas. Payments

from the government and large insurance companies don't adequately

cover expenses and the burden of educational debt. The cost of

malpractice insurance to practice the full range of primary care

medicine, including obstetrics, is untenable for most.

> How can anyone rationally expect to build up the nation's health

on that crumbling foundation?

> Family physicians could meet the needs of the uninsured, the

underinsured and the baby boomers, but not without some fundamental

changes in the way they are paid.

> Due to his schedule and the volume of email he receives, Dr.

Brewer may not be able to respond to all reader email. He does

participate in his forum, where readers are urged to post. His email

address is thedoctorsoffice@ wsj.com.

>

>

>

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Care Needs Fixing Before Universal Care Can Work* This article

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