Will the lack of primary care doctors make universal coverage useless?

It appears that one source of agreement among health reformers is that there isn’t enough primary care doctors.

The New York Times wrote a front-page piece on this issue last month, which I had commented on.  Now, an article in the Washington Post re-iterates the same theme:

As the debate on overhauling the nation’s health-care system exploded into partisan squabbling this week, virtually everyone still agreed on one point: There are not enough primary-care doctors to meet current needs, and providing health insurance to 46 million more people would threaten to overwhelm the system.

As I previously mentioned, the proposed solutions being discussed, like increasing funding to the National Health Service Corps and decreasing the amount of medical school debt, will have very little impact. The combination of Baby Boomers entering Medicare with the potential influx of newly insured patients have the potential to deal the killing blow to our health system.

And even without these obstacles on the horizon, the Post’s piece already paints a grim picture for patients:

Evidence that demand already exceeds the supply of primary-care doctors ripples through the system as patients increasingly have trouble finding a new doctor, then wait weeks or months for an appointment, spend more time in the waiting room than in the examining room, encounter physicians who refuse to take any form of insurance, and discover emergency rooms packed with sick people who cannot find a doctor anywhere else.

Increasing the number of mid-level providers won’t be enough, as their numbers are already accounted for in these dire projections. One way to provide immediate relief would be to entice specialists to shoulder more of the primary care burden, perhaps by providing the financial incentives for them to take on more preventive care responsibilities.

Update:
For those who recognize similarities between this post and the comments I made at the National Press Club on July 17th, you’re right.  This post served as a jumping off point to my remarks at Health Care Reform: Putting Patients First, but here are some additional thoughts from after the event.

Shadowfax, an ER doctor whose progressive-leaning viewpoints I highly respect, says the following:

I agree with the sentiment, but I think you have your sequencing backwards.

We can do universal insurance coverage today. It will not be easy, but it is possible, whereas previous attempts have failed over the last 60 years.

Fixing primary care is something we can start today, but even the best efforts won’t show dividends for several years at the very best. That’s optimistically assuming that primary care reforms would even work.

By your thinking, we should allow the 50 million uninsured to languish without any access to health care for another decade until we see if primary care improves?

Both universal coverage and primary care reforms are necessary, but it is not an either-or proposition. Both must proceed on parallel tracks.

Providing universal coverage is an imperative moral obligation, but one that must be accompanied by forceful cost control. Again, I point to the Massachusetts model as the example of what happens when universal coverage takes precedent above all else.

It was recently announced that, because of fiscal strain their health coverage law is placing on the state’s budget, Massachusetts will have to eliminate coverage for 30,000 legal immigrants. So, without considering costs, it is impossible to sustain universal coverage.

I don’t pretend to have an easy answer, and it’s clear that there are passionate opinions on both sides claiming to solve this difficult problem. But I do know that taking the politically expedient route, by promising universal coverage without strengthening the underlying primary care infrastructure first, will be doomed to failure.

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  • k

    Payment for primary care physicians requires reform in order to attract more medical students to the specialty. The health care legislation in progress must address this, and IMHO overhaul or scrap the Medicare/Medicaid reimbursement system. As long as we’re at it, how about getting rid of the AMA monopoly on CPT codes, or is this addressed by ICD-10-CM/ICD-10-PC?

  • http://www.motionphr.com Jeff Brandt

    The problem is there regardless of Universal care. This is the golden age of innovation in healthcare and the need for as many Primary care doctors in the US may actually reduce. Mid-levels will take up the majority of the slack. With innovation in health technology and implementation of tools such as e-Health, decision support, telemedicine and the many more to come the landscape for medical care will change dramatically in the next few years.

    The problem with the lack of enough mid-levels is the need for more education facility. There are many people that are trying to get into nursing school but are unable to because the schools are not taking more students. There is also the issue of low pay for teacher. Correct this and we will have the educators we need to produce the graduates.

    It will be an exciting and turbulent time in healthcare in the near future. Failure will only occur if we stand still and refuse to adapt to our environment. But with problems comes opportunities and solutions.

    Jeff Brandt CTO motionPHR for the iPhone

  • Matt

    “By your thinking, we should allow the 50 million uninsured to languish without any access to health care for another decade until we see if primary care improves”

    This only makes sense if you assume uninsured=no access to health care. I’m insured, and I’ve been to a doctor 2 times in a decade. Once for a lingering stomach pain, and once for an ear infection. Neither of which even got close to my deductible. If you’re single, 20-45, employed, lower middle class or above, it’s unlikely you rarely see a physician anyway.

    You need to know more about the demographics of these uninsured before you can say because we have 50 million more people we need X number more of physicians.

    “Providing universal coverage is an imperative moral obligation”

    Slow down, sparky. You may believe this, and that’s fine, but that is not a universally agreed proposition. You are dangerously close to declaring healthcare a right. Although that may be where you’re headed given your support of single payer.

    What’s more, it’s an easy sentiment since you don’t clarify what that “universal coverage” covers. If it’s only catastrophic events, how does that equate for the need for more PCPs? You’re starting to devolve into politician speak, where you declare we need all these wonderful things, but never clarify what exactly they are or what exactly they will cost.

  • http://thehappyhospitalist.blogspot.com/2009/06/do-internists-have-confidence-in-their.html Happy Hospitalist

    If we have a moral obligation to have universal health care, do ED docs every where have a moral obligation to stop ordering head CTs on drug overdoses and alcoholics “just in case” they have a head bleed”, in order to pay for this moral obligation. Do they have a moral obligation not to call the hospitalist with social admits because they don’t know how else to get them out of their ER? Do they have a moral obligation not to practice reflex medicine? Do they have a moral obligation to assume responsibility to control their most expensive weapon, the pen?

    While you claim that this country has a moral obligation to provide universal care, I claim that this country has a moral obligation not to bankrupt itself. Now, is your moral obligation more important than mine?

  • SmartDoc

    The basic point is being totally ignored by, well, everyone.

    Diminished access to care IS the basic cost control in this and every other “universal” of “free” totalitarian system.

    How on earth could Canada or Zimbabwe or Obama provide universal quality family medical care? The demand is limitless.

  • http://www.motionphr.com Jeff Brandt

    SmartDoc What are you speaking to. First, people have already lost control. The Universal or Free system is not even being proposed. The people that I know in countries that have plans such as Canada, England and Argentina like there system and think the US system is absurd.

    I think one of our main problem here is looking at the past failures in systems like the VA, Medicare and Medicaid. We have to look forward and make changes together.

  • Okulus

    So when everyone has bought insurance, it will be required, after all, can we then abolish EMTALA?

  • http://www.motionphr.com Jeff Brandt

    tonsillectomies statement, This is the type of rhetoric that is so counter productive by a person that will afraid to use his real name.

    Please join in with your real name and help to find a solution instead of being part of the problem.

    There is a lot of waste out there and we all know it. Like ordering a MRI when a Ultra sound will provide the same results in detecting Fatty Liver (NAFLD), just one example

    Kevin great forum

  • Rezmed09

    Yesterday, CNN referenced a poll claiming that a majority of Americans believe control of costs is more (much more) important than universal coverage.
    I agree that controlling cost should be our priority before opening up more entitlements. President Obama has spoken on ways to control costs, but it is usually vague. The hard part for Congress will be to mandate cost controls via whatever mechanism and whatever rhetoric: Rationing, reduced payments, red tape (most likely), tort reform (very unlikely). In the end Primary Care will be the blunt tool used to limit care, and this will only make this career path less appealing.

  • http://www.motionphr.com Jeff Brandt

    “One reason that European medicine is more affordable than U.S. care is that patients receive far more primary care, and see many fewer specialists. But in the U.S., thanks in large part to low reimbursements, we have too few family practitioners, and so patients wind up seeing a specialist—or land in an ER—because they cannot secure an appointment with a primary care doctor. ” by Maggie Mahar
    http://bit.ly/qiOuF

  • Tom

    I profoundly disagree that universal health care will spark a revival in primary care. If anything, it will put the final nail in the coffin.

    Let’s explore the reasons:
    1. With universal health care, think Medicare and Medicaid paperwork for every patient. Also throw in the fact that if you, with best intentions,code wrongly, per a review, you are liable for that and will pay a penalty, up to and including jail time.

    2. Vastly increased patient load, with more chronic conditions coming in, and a mandate to control costs, will ensure that fewer of these patients will be approved for appropriate treatment. Nothing burns worse than doing your best to do right by a patient, and having it shot down by another party when you and the patient have no recourse.

    3. Reimbursement will remain the same or go down, despite the increased patient load. No-where in the bill do I see anything regarding paying primary care doctors what they are worth.

    So, to recap, increased, more onerous paperwork, more frustration in getting appropriate care for patients, all for the same, or less, pay. Sounds like a field I would shun like the plague. Universal healthcare WILL stand between a doctor-patient relationship, more so than an insurance company does today. With the insurance company, you can appeal, if necessary in a court of law. To whom do bring an appeal to against a government healthcare system? The government?

    Good luck, Shadowfax and Kevin. Look very carefully at what you’re supporting. It’s not what you think.

    On the upside, concierge doctors should do well, so that’s nice.

  • http://www.motionphr.com Jeff Brandt

    H1B visas, healthcare could be next: In 1999 I was the president of a very successful engineering consulting firm that provided e-commerce services to large companies such as Warner Bros and EDS. At that time, there was a shortage of good engineers in this space until lobbyist hired by big business pressed for more H1Bs. I envision that healthcare may be the next victim of this type of invasion.

    You can not fight this type of change, there is to much a stake, you can only postpone it. If there are not enough PCP and nurses, the US will import them. There are plenty of healthcare professional in the world that would love to work in the US. What you can do is except that this change is going to happen and join in to help set the stage in your favor.

    Something to think about.

    Jeff Brandt

  • Tom

    Jeff,
    We already are bringing in foreign medical grads, and they don’t want to do primary care either. Significantly, patient satisfaction is also generally down with foreign medical grads.

    Regarding this: “What you can do is except (sic) that this change is going to happen and join in to help set the stage in your favor.”

    So, you’d like us to embrace our impending catastrophe, rather than fight it. Um, no thanks. I understand why you might feel differently, but for some of us, this is, with little exaggeration, our lives. Dump on us enough, take away all reward from our profession, and rest assured, we will leave.

    You think there will be a long line to replace us, don’t you? I think you’re wrong in that assumption, and losing 10-40 years of experience per retiring physician is not insignificant. Think about the possibility that you could be wrong.

  • Family Doc

    Happy, thank you for pointing out the ways the culture of medicine too must change in order to make health care available to everyone. We *must* stop ordering head CTs on every little old lady who feels weak and has already had multiple scans to try to figure out why. We can’t continue to do screening colonoscopies on 90 year olds (of course, with exceptions based on their life expectancy). I took care of a 101-year old patient last week who is pegged, trached, and chronically on a vent! This is lunacy. I really think if we change the culture within medicine (and it would absolutely have to be with the support of the government and the public to neither demand unnecessary services nor expect us to order every test in the world to avoid missing that one chance in a million diagnosis) and start to value wellness more that technology, we could go a long way towards improving everyone’s health. Pay physicians to take care of people rather than do things to people, and most of us will be happier too.

    The problem with the current plan is that the only way they propose to save money is by decreasing physician reimbursement, coupled with the unproven (and arguably disproven) theory that more access to preventive care will save money. I’m frustrated that physicians aren’t truly represented in these negotiations. It’s all about the insurance companies, PhRMA, etc.

  • http://www.pankajkaranmd.blogspot.com Pankaj Karan,MD

    There has been discussions on several front how to save money from simply medicare and medicaid namely:
    1.By one account 30% of medicare cost is due to unnecessary produres,duplicatioons and frauds.
    2.Susidies to HMO ( unbelievable) to take care of medicare advantage patients which amounts to 100 billions dollars every 7-10 yrs.
    3.Cutting payments for all specialities and radiological servises,DME realted servies,Home healthcare and Hospice care services.
    4.Enticing ptoactive preventive care by PCP by increasing PCP increment in fees charged ( 8% already approved last week by Obama Admin.)bringing the wages of PCP closed to speciality care.
    5.By lowering to cost insurance and bringing more people to insurance pool so that more pts will be available to be seen by PCP or Mid Level providers.
    Not having enough PCPs etc to handle all the supposed to be new pts with new healthplan if pasees is just a lame excuse. Realty is that all of the PCPs in my communites are looking foword to work harder and longer for hte proposed new changes.In fact some speacility like surgergeons and Obgyn are also willing to strat practicing as PCP because they are burnt out by high cost of insurance and spending too many hours in hospitals.
    When there is will,there is way. and we have a leader who is willing to listen waht american people want.
    At last AMA,AFP,ACP,AARP,Nurses assocaition haev all joined to OBAMA plan, not Phrama industry or Insurance industry ‘s lies and deceptions.

  • twaw

    Dr. Karan
    Just an observation: That the AMA, AAFP, ACP, AARP and ANA are aboard with the proposal is the single best reason for me to oppose it.
    These are the same organizations which have been acting on our collective behalf for the last 20+ years. Their collective incompetancies and indifference to their members over that time period is a major reason primary care is where it is today. Past performance is the best predictor of future performance.

  • TrenchDoc

    For PCPs to stay in the game we have to level the playing field in terms of :
    1. Reimbursement – as they say the check from Obama is “in the mail”. An 8 percent raise is not going to help me if I have to increase my overhead 8 percent or greater to meet all the new regulations that will certainly be required.
    2. Decrease the hassel factor by simplfying forms. Every government form is now 2 pages or longer and require that I give a “narrative summary”. What do they think my dictated chart notes are? BTW the dictation costs me 10 cents per line.
    3 Tort reform is a must but I don’t hear anything from Obama about this. Now that every patient willl have a PCP , every PCP will be sued. Because the PCP will be resposible and accountable for everything. But who do you think will have the power?
    4. Bargining power. PCPs are still the largest number of docs in terms of training but we do not have equal representation for our interests by the AMA or any other society. This will force PCPs into larger groups in order to survive.

  • Andy

    If the government forgives student loan debt for Primary care doctors this would increase the amount of pcp’s .This needs to be done for prospective doctors and those already in practice.I know the programs are in place in each state ( for underserved areas )Tort Reform is so obvious I feel funny even mentioning it but the liberals won’t go near it.

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  • Anonymous

    We have been thinking of health care reform only because it is getting too expensive and we can no longer afford it but health care cost has been driven by its economics, if doctors make more money doing angioplasties and stents, who would want to focus his practice in preventing coronary artery disease? If you make more money doing hip replacements, why would more drs. do research and treatment on fracture prevention? These are only two examples, if we want meaning health care reform, we have to rethink the way we are reimbursing health care givers.

    A system that thinks of the welfare of everyone except those who are going to provide it will eventually fail.

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  • http://www.motionphr.com Jeff Brandt

    FYI Here is an article about importing PCP
    In Miami, Cuban Docs Fill Primary Care Void

    http://blogs.wsj.com/health/2009/08/04/in-miami-cuban-docs-fill-primary-care-void/

  • mom

    Doctors are already overloaded. Where is the tort reform? My sons want to be doctors when they grow up. I say no way should they go to medical school now, if Obamacare goes through. Why should they then go through all of the hard work for nothing. Government needs to stay out of healthcare! The AMA does NOT represent all doctors, only a minority of doctors belong to the AMA! No to HR3200!

  • http://www.motionphr.com Jeff Brandt

    There are a lot of professional worker from engineers to lawyers in the USA that have been replace over time by technology, outsourcing, and H1B Visas. Not always better, just always cheaper. The medical field has been shielded from this but this to is now changing. You all know this, we have had coder in Africa for years and labs being evaluated in the southern hemisphere. Remember that a system that does not adapt to change will cease to exist.

    I understand what doctors are fearing because I was in a similar position myself several years ago when most of my company’s work was sent overseas and I had to layoff most of my employees. I saw the writing on the wall several years before and tried to convenience some of my principles that we needed to change strategies and work within the new boundaries but it fell on deaf ear.

    The medical paradigm shift that doctors are facing is going to be difficult and take some time to adjust. What I am saying and trying to warn you about; is to control your future by understanding the upcoming change so it doesn’t control you.

    Jeff Brandt
    http://www.comsi.com