Doctor shortage imperils Obama's health care reform

by Lesley Politi on December 23, 2008

Doctor shortage imperils Obama’s health care reform

Sunday, December 21, 2008

There are plenty of surgeons and other medical specialists in America – more than enough, perhaps. And specialized institutionalized care of high quality is available for people who are seriously ill. But primary care – the continuing personal supervision of a family’s overall health, with emphasis on prevention and early treatment of illness – is sadly lacking for the urban poor, for most rural residents and for millions of middle-class people, too.

President-elect Barack Obama has promised to expand health insurance coverage for everybody. But fulfilling this promise will require enough doctors on the firing line – internists, family doctors, pediatricians, gerontologists and others – to treat the additional people covered. Primary care is a part of the total healthcare system, and the Obama administration must craft a national health manpower policy to provide resources and reverse primary care’s decline.

Studies show that the number of medical students choosing training in internal medicine, family medicine and geriatrics is down, and many physicians now in practice are leaving the field. Reasons cited include long working hours, the complexity of dealing with chronically ill patients, paperwork, insurance issues and reduced reimbursement by insurers and Medicare.

A total of 56 million Americans – roughly 1 in 5 – lack adequate primary care coverage because of a shortage of physicians in their communities, according to the National Association of Community Health Centers. When large numbers of people cannot get basic preventive care or early treatment for conditions before they become serious, costs go up, and everybody ends up paying higher insurance premiums and suffering reduced access to care.

Conservative estimates by the University of Missouri and the federal Health Resources and Services Administration suggest that Obama’s health plan will increase the workload of existing primary care physicians by 29 percent between now and the next 15 years. By the same period, the supply of primary care physicians will rise by only 7 percent, leading to a shortfall of 35,000 to 44,000 primary care physicians who treat adults. Overall population growth and a growing elderly population are driving the projected shortfall.

Increasing the number of medical school graduates is one obvious solution. Expanding existing residency training programs in internal medicine and other primary care specialties is another, but any change would be painful and require major shifts in training priorities of medical schools, curricular reform, legislative relief from early student loan payment, and fixing the way doctors are paid across specialties.

Primary care doctors spend more time talking to patients to help them cope with ailments that are chronic and incurable than they spend performing tests and procedures. But talking to patients is not compensated under our perverse reimbursement arrangements that reward specialists who perform procedures.

The Medical Group Management Association, which conducts surveys of physician compensation, found that for primary care, the median pretax income increased by 21.4 percent from 1995 to 2004 compared with a 37.5 percent increase for other specialties. Fifty percent of family doctors made below $156,000 in 2004, while half of all radiologists earned above $407,000 that year.

The complexity of making the needs of patients compatible with the needs of health care institutions, and producing primary care services is almost overwhelming, but an essential part of healthcare reform. To use an architectural analogy, primary care is considered the keystone of the arch of personal health care. Without it, the system has no stability. The other components of the arch cannot serve their functions effectively, and the personal health care system will remain distorted, costing too much, delivering too little, satisfying too few.

Correcting the imbalance between the primary care practitioner and the specialist should be a top priority.

Spyros Andreopoulos is director emeritus in the Office of Communication, and Public Affairs at Stanford Medical Center. He is the editor and contributor to the 1975 book “Primary Care: Where Medicine Fails.” The article represents his opinion

Source: sfgate.com

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