If you don't think that the health care system in the United States is already in crisis, there are several signs that indicate that it soon will be. Two challenges often identified as exacerbating health care challenges in America are rising costs and a growing shortage of general/family practice physicians. According to a recent program on National Public Radio, "There's already a shortage of primary care physicians nationwide. And with the new health care law, there will be tens of millions of new patients." ["More Patients Find Doctor Is Not In," Neal Conan and Julie Rovner, NPR, 30 August 2010]. Shrinking supply and growing demand means that patients can expect longer waits at the doctor's office and probably higher costs for services rendered. Rovner explains why there is a growing shortage of general practice physicians.
"A lot of [it is] pretty simple economics. It's expensive to go to medical school. And when you get out, you've got to you usually have big loans, and primary care doctors get paid less than specialists. So you're looking at big loans to pay off. And if you want to pay off those loans, you get paid a lot more if you become a specialist. Plus, it's hard to be a primary care doctor. The hours are long. The work is difficult. It's ... emotionally draining. Plus, there's more and more hassle, if you will, from insurers and bureaucrats and everything else. So a lot of students go to medical school [...] thinking they're going to become primary care doctors and then [end up concluding ...] why bother if I can get paid twice as much to be some kind of specialist."
Neal Conan responded to Rovner's explanation this way: "So no shortage of cardiologists, say, in New York or Charlotte, but primary care physicians in Kentucky, that's a problem?" Interesting enough, a report out of Kentucky demonstrates that Conan got it right ["Concierge model provides high-end doctor's visit," by Mary Meehan, Lexington-Herald Leader, 6 September 2010]. Meehan reports:
"More and more 'concierge' doctors in Central Kentucky are offering ... top-flight services for a price — ranging from $1,500 to $4,200 a person annually on top of insurance premiums. Doctors leaving a traditional general practice say decreasing payments from insurance and shrinking Medicaid and Medicare reimbursements mean they have to take on more and more patients to stay afloat. That results, the physicians contend, in stressed doctors and a reduced quality of care. So a small number are opting out of that system in favor of concierge services in which patients pay an upfront fee, and the number of patients served by a practice is capped in the hundreds rather than the 1,500 to 2,000 in a typical practice. The trend, which has been building across the country for about 15 years, is gaining traction in Central Kentucky, with two practices opening in Lexington and one expected to open soon in Versailles. There also are two in Louisville and at least 12 in Cincinnati. ... Dr. Michael Karpf, executive vice president for health affairs for UKHealthCare, said there is real pressure on general practitioners. In fact, Kentucky could use about 600 more general practitioners to serve 900,000 to 1.2 million underserved patients. It makes sense that doctors can feel overwhelmed and patients can feel underserved."
According to another article, the public shouldn't be looking to the educational system to solve the problem ["Primary-Care Doctors: Saying No to $191,000 a Year," by Ruchika Tulshyan, Time, 22 August 2010]. Tulshyan writes:
"Last year, America spent over $2 trillion on health care, the most of any OECD country. Still, with all that money going out the door there is a worsening income crisis among primary-care physicians that, if unaddressed, will lead to an acute shortage of these doctors in the years ahead, when retiring baby boomers will need them most. The education pipeline offers no hint of improvement. Less than 2% of current medical students are interested in general internal medicine and 4.9% in family-care practice, says a study by Dr. Karen Hauer, published in the Journal of the American Medical Association. While a growing concern, it's no mystery as to why the general practitioner (GP) is a dying breed. Rising medical-school costs — up between 4% and 7% from last year, according to American Association of Medical Colleges (AAMC) data — and a continually widening gap between general-practitioner and specialist salaries make the career choice for medical students a fairly easy one: get a specialty. ... In 2009, primary-care doctors earned a median salary of $191,401, according to the Medical Group Management Association's 2010 physician-compensation report. Cardiologists earned a median of $457,310 and dermatologists made $385,088 — doctors who owned their practices earned much more, on average."
A lot of people during these difficult economic times are probably thinking that $191,000 sounds like a lot of money. Tulshyan, however, reports, "The average medical-school student graduates with $200,000 in loans, according to the American Academy of Family Physicians (AAFP). This doesn't include their debt related to four years of undergraduate study. For some students the total debt burden can reach nearly $500,000 — a daunting sum that puts many of them off family medicine." Add to that normal expenses experienced by any family (e.g., mortgage, food, clothing, car, insurance, etc.) and you start to get a sense of why there is a growing shortage of GPs. Before returning to some suggestions that have been made to alleviate this shortage, I'd like to examine how the shortage has affected hospital emergency rooms. "In a snapshot of systemic waste, researchers have calculated that more than half of the 354 million doctor visits made each year for acute medical care, like for fevers, stomachaches and coughs, are not with a patient’s primary physician, and that more than a quarter take place in hospital emergency rooms." ["Health Care Wastefulness Is Detailed in Studies," by Kevin Sack, New York Times, 7 September 2010]. Sack continues:
"The authors of the study, which was published ... in the journal Health Affairs, said it highlighted a significant question about the new federal health care law: can access to primary care be maintained, much less improved, when an already inadequate and inefficient system takes on an expected 32 million newly insured customers? The study is the first to quantify the problem, according to Dr. Stephen R. Pitts, the lead author and an associate professor of emergency medicine at Emory University. Examining records of acute care visits from 2001 to 2004, the researchers concluded that 28 percent took place in emergency rooms, including almost all of the visits made on weekends and after office hours. More than half of acute care visits made by patients without health insurance were to emergency rooms, which are required by federal law to screen any patient who arrives there and treat those deemed in serious jeopardy. Not only does that pose a heavy workload and financial burden on hospitals, but it means that basic care is being provided in a needlessly expensive setting, often after long waits and with little access to follow-up treatment."
Enterra Solutions is looking to work with several hospitals to see if new ways of using social media and analytics can help relieve some of the pressure on emergency rooms. As a side note, Sack points out that another significant source of waste in the health care system is the result of excessive insurance costs and defensive medical practices aimed at mitigating the cost of litigation. He writes:
"Three Harvard professors and a colleague at the University of Melbourne in Australia estimates that the medical-liability system added $55.6 billion to the cost of American medicine in 2008, equal to 2.4 percent of total health spending. More than 8 of every 10 of those dollars — $45.6 billion — was attributed to defensive medicine by physicians who order unnecessary tests and procedures to protect themselves from malpractice claims."
Getting back to growing shortage of general practitioners and the impact that is having on the health care system, Julie Rovner suggests that some of care offered by GPs could be taken over by physician assistants or nurse practitioners.
"One of the ways ... of perhaps fixing this problem is making it more attractive for doctors to become primary care practitioners or making it more attractive for doctors who are primary care doctors to stay primary care doctors, perhaps not having them retire early. ... [One idea is called] the medical home, where a doctor would [be the] quarterback of a health care team. ... The doctor would offload some of the things that makes doctors crazy now, some of the paperwork, some of the things that perhaps doctors don't need as much training to do, that they could have a nurse or a nurse practitioner or even a social worker do instead. It would be better care for the patient, the patient could get different types of care, perhaps, at the doctor's office. The doctor would be freer to do things that only the doctor can do and perhaps have a more sane lifestyle. That's the idea behind the medical home."
Rovner explains that physician assistants are individuals with two-years of specialized medical school training instead of four and that nurse practitioners are basically nurses with master's degrees. Increasing the number of PAs and NPs would go a long ways towards decreasing the growing shortage in the least amount of time. Obviously, there are no real quick fixes to the problem. In the end, medical students will follow the money. Make it profitable to become a family practice doctor, especially in rural areas, and you'll see some self-correction take place within the medical community itself.
