Primary care shortage solutions after health care reform

The new reform law which is called the Patient Protection and Affordable Care Act (PPACA) will be a huge disappointment to the millions of previously uninsured people who finally purchase insurance policies when they try to find a doctor.

Primary care physicians are already in short supply and the most popular ones have closed practices or long waits for new patients. Imagine when 2014 hits and all of those patients come calling. Who is going to be available to treat them?

Primary care shortage solutions after health care reform

Primary care shortage solutions after health care reform

It takes 8-10 years for an under supply of physicians to be corrected because physicians have to go through medical school and residency. There has been no up swing in physicians choosing primary care specialties for years and, in fact, the shortage is predicted to be 46,000 full time physicians by 2025 (Association of American Medical Colleges). Now add millions of new patients, baby boomers reaching Medicare and you have a disaster in the making.

I have been sounding this alarm for at least 10 years as I saw what our lack of policy and attention has done to primary care. Comprehensive Internal Medicine is one of the hardest lines of medicine. Patients are complicated, the work is long and arduous and primary care doctors save the “system” millions of dollars. Why it has not been recognized and rewarded in the United States is a mystery, especially when every other industrialized nation has build their health care policy on primary care.

When thousands of new primary care doctors are needed to care for our population, doesn’t it seem foolish to cut residency training slots and pay specialists 2 to 4 times as much? Some suggestions at this late hour are to use nurses or physician assistants to fill the gaps. Others have suggested shortening the residency time. Both are terrible ideas for our population as medicine is becoming more complicated, not less.

I watched as Anesthesiology and Radiology became the most sought after residencies. I don’t think there was a sudden interest in putting patients to sleep or reading X-rays in the dark all day. When I was a senior resident an anesthesiology friend encouraged me to switch immediately to Anesthesiology. He said “You’ll work 1/2 the time and make 4 X the money.” He was right and I saw what happened in the years to follow.

What can we do today?

* Increase primary care residency program slots effective 2011 at teaching hospitals and pay more for those programs to increase.

* Enact forgivable loans for all medical students who choose primary care and practice it for at least 5 years. You can’t enslave people forever.

* Raise the Medicare reimbursement by 40%. Even that may not be enough to turn this ship around. The inequities are just too large.

* Allow even higher reimbursement for primary care doctors who practice in rural communities or under served areas. The pressures in those areas are magnified and should be rewarded.

* Develop true systems of care where physicians treat the most complicated patients and nurse practitioners handle routine care.

It is time to quite admiring the problem and get to work solving it.

Toni Brayer is an internal medicine physician who blogs at EverythingHealth.

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  • Doc99

    The specter of Doctor Nurse looms larger.

  • Mark

    I agree with many of these points. I would say the 40% raise should be across the board, not just Medicare. More like 200%. In order to fix this fast you have to drastically increase pay. You literally have to make Derm and Radiology and PMR and Rad Onc, etc etc etc be equal to primary care. Watch how many students suddenly lose interest in treating acne. It will be astounding.

  • Dr. Mary Johnson

    If you are going to recomment putting more people into government-sponsored indentured servitude in order to service primary care . . .

    . . . POLICE THE *&^%$#@! PROGRAMS!!!

    It ain’t happening now.

  • LizNP

    The NP and PA can treat so many common conditions; acne, URI, etc. Any physician who has worked with a competent NP would know that — It doesn’t take a JET pilot to pilot every plane.

    • Anonymous

      Your right!!

  • jsmith

    Since the money ain’t right, the problem will get worse.
    Welcome to the age of Dr. Nurse.

  • csmith

    The solution is really not that difficult. You need to adequately capitalize primary care and get away from the fee for service model. I like the idea of taxing health plans 10 % and setting aside 7-8% for vouchers for patients to purchase primary care and use the other 2-3% for preventive services. In a capitated model like this you would have on average $500-600/patient/year which is much more than you have now. Practices would avidly compete for patients and provide more services. The competition would spur more innovation. Niche primary care models would evolve. The creativity and enhanced income would attract young physicians. Evisits, Emails, phone calls and health IT would be embraced as cost-effective since the provider no longer has to have office visits to drive revenue. Most health plans currently only pay out about 78% of premiums for care. Primary care gets about 3%. An additional 7% would amount to 85% of premiums being paid for actual care.

  • The Notwithstanding Blog

    The solutions that you propose are intuitively appealing, but most of them pre-suppose an entrenchment of the current system in which prices and pay are set in a top-down fashion, and primary care physicians continue to be bound by the strictures of the third-party payment system.

    I feel that much progress could be made if primary care physicians stopped accepting direct insurance payments and switched to direct-pay or retainer models. Their overhead would be reduced, their dependence on Congress to “fix” their pay formula every year would be broken, and physicians in rural/underserved areas would be able to charge higher prices to reflect their relative scarcity. This move would free physicians to experiment with new and innovative practice models (varying reliance on NPs, etc.) as they see fit to better serve their patients, without needing to worry about how it will fit into someone else’s set of regulations.

    Allowing physicians and patients to vote with their feet and their dollars will do much to improve everyone’s satisfaction and control over their lives and livelihoods.

  • David Allen, MD

    So this is where we are. Obama Care is the law of the land, now let’s just get used to the idea and fiddle with ‘how doctors are paid’.

    This is crap and many people know it. This new monstrosity of a law must be fought at all levels and, if possible, overturned. It is moving in exactly the wrong direction. There are many common sense reforms which move in the correct direction; some are explained here: (

    But to go further, neither a residency program nor a state nor a federal program should be able to control who wants to treat whom for what amount of money. That should be up to the individuals involved. Medicine has become a bureaucracy at ever level. This includes the training (which is outrageously long, by the way), the licensing, the oversight, the hospitals, the state control of insurance companies, Medicare, Medicaid, etc.,etc.. We have become so entangled by rules and regulations that we can’t even imagine what it would be like to be so unencumbered.

    If you believe in such control and central planning, then there are plenty of countries that may inspire you: Cuba, old Soviet Russia, China. I assure you they have (or at least started with) the same motivations as you. But if you want the innovations and progress that come from a free economy – then – FREE THE MEDICAL ECONOMY!

  • TrenchDoc

    The money is certainly the main issue but the hassel factor is a close second. For example today I got a faxed for to respond to a home health alert that the patient fell outside the parameters because her weight was 170.8 pounds. The upper limits were 170 pounds. My response was to have the patient lose 0.8 pound ASAP.

  • imdoc

    Regarding the comment by “Notwithstanding”: All of what you say is quite obvious and some cash based practices do exist but they exist in pockets of the country in which individuals can afford them. It isn’t to say more ordinary citizens couldn’t afford to pay directly, but the mentality is that care is already paid for by either employer or government. Hence, the majority will not pay around it. If we had school vouchers there would be many more private schools. If there was a big movement toward such a model, one can be sure the regulators would step in to re-establish the status quo. No public official is going to see Medicare patients locked out of the system.

    • The Notwithstanding Blog

      You’re absolutely right that the “zero-or-low marginal cost” mentality is well-entrenched in the minds of most patients when it comes to primary care and routine care. It’s understandable that they should want it that way, too.

      What I don’t understand is why physicians should try to entrench that model even further when it clearly isn’t working for them, and isn’t really working for patients either. Instead of lobbying for “more of the same, but different” proposals mentioned in the original post, I think that _physicians_ should embrace and lobby for alternate models en masse. Instead of begging and pleading for tweaks to a top-down formula, lobby for “primary care vouchers,” or something similar. If Medicare patients are locked out of the system, then reform Medicare to conform to the system that works; don’t contort the system into the arbitrary regulations imposed by Medicare! The medical community is letting its proposals for improvement be unduly limited by the unfortunate but *unnecessary* reality of the present.

      I know I’m talking “should, could, and would” when the reality is probably closer to “can’t.” But it would be nice, wouldn’t it?

  • hawk

    the problem with a medical home vs pay for service is that it leaves a lot of specialists in the lurch. for example, I work in the ER, how would Ibe compensated under a ‘medical home’ model. Typically, I have brief, but life saving interventions in patient care. I get paid for the things that I do. I dontthink that my heroic efforts on a patient behalf, already poorly compensated, should be lowered because the patient fell outside the medical home.

    I love my job, but I expect to get paid for what I do.

  • conciergemd

    There is one solution that a lot of people CAN and COULD afford that might be overlooked by a lot of people. “Concierge Medicine.” According to a survey by Concierge Medicine Today and The Concierge Medicine Research Collective, almost 60% of concierge medicine or “membership medicine” plans cost less than $135.00/mo. Most in this category between $50-80/mo.

  • Toni Brayer, MD

    conciergemd: I have nothing against concierge medicine and it is a patient and doctor pleaser. But the rates of membership plans you mention can only cover primary care. The patient still needs expensive insurance for other health costs, surgery, labs, emergencies, disasters, chronic diseases. It works for those who are sophisticated and have $$. It doesn’t work for the population as a whole.

    My favorite Internal Medicine concierge physician charges $15K annually (a bargain $22K for husband and wife). He limits his practice to 100 patients. You do the math. He has a long waiting list.

    • conciergemd

      I completely agree, Dr. Brayer. While a concierge plan from a good PCP can help people receive the majority of their health care needs throughout the year, a catastrophic plan for hospitalizations, etc., should be part of their budget. Great point! I’m familiar with many physicians who charge those high rates for their care, but they represent a minority of concierge doctors (maybe not in CA or FL). smile. Unfortunately, Royal Pains hasn’t done the public perception of this type of practice model any favors either…smile. Thanks for the great feedback! I look forward to many more discussions with you.

  • Paul MD

    @Dr. Allen

    Thank you. I couldn’t agree with you more.

  • Primary Care Internist

    Whenever I see these types of blog posts, inevitably I can expect frantic suggestions to adopt a concierge model. And that’s fine, if the question is “how can i maximize my income and minimize the hassle factor in my practice” as a physician.

    But the larger question is what will those patients who can’t afford such a practice ie. the VAST MAJORITY of medicare patients, do? Ultimately we all pay the price for their care, and someone needs to come up with a way, quickly, to see that hypertensives, diabetics, chf patients etc. are cared for properly, as outpatients, before their problems get out of hand and wind up being treated as inpatients, which is 20-fold more expensive, for everyone.

    So Dr. Brayer, your suggestions are just so obvious, only our politicians could ignore them. Pay primary care more? duh. I think to make a dent, Obama and company would have to

    a) DOUBLE medicare payments for E&M codes tomorrow;

    b) eliminate fear of malpractice, particularly in geriatrics, when families want their 90-yr-old with a creatinine creeping up to 4.0 but happily demented, referred to nephrology to start dialysis planning, etc.;

    c) choose a universal EMR and GIVE IT AWAY to all doctors seeing medicare patients. This way there’s no unnecessary duplication of tests or hindrance to communication between pcp and specialist;

    d) did i mention doubling medicare payments?

    Even if all these things were implemented tomorrow, the effect on producing enough doctors willing to see 20 medicare patients/day in the office with 8 meds a piece, to meet the wave of demand with the boomers and the new obamacare bill, well that process will still take at least 3-5 years.

    CMS should start to view medicare the way many doctors are starting to view it, as CHARITY CARE, the same way most view medicaid. In other words, they should make it as easy as possible for docs to justify giving away their services. Unfortunately I fear it will turn out like medicaid in NY – primary care invariably in hospital ERs at tremendous expense to the taxpayers.

  • imdoc

    Notwithstanding: Believe me when I tell you that most primary care doctors would love to be able to break out of the existing payment system. That, however requires much more political clout. Economic theory is one thing. Reality is these things require lots of capital and a wealthy patient base. Most doctors find that with financial need and school debt, they are in poor position to bargain. To your question about why we don’t lobby for alternate models; the answer is we have leaders with limited imagination, vision, and courage. Also, hospitals and surgeons benefit greatly from the status quo. If you can design a method to restore free trade, I sincerely hope you make a billion doing it. I am firmly convinced that restoration of a free market would spur innovation and drop costs, but don’t underestimate the power of the political elite whose goal is control.

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