Op-ed: Shortage of primary care threatens health care system

The following op-ed was published on March 13th, 2008 in the USA Today.

Crippling health care bills, long emergency room waits and the inability to find a primary care physician just scratch the surface of the problems that patients face daily.

Surveys suggest that health care is a top domestic priority in the presidential election, and there is no lack of ideas on how to fix our system. Republicans favor using market forces and increasing the burden of health care costs on patients. Democrats, however, focus on covering the uninsured. Sadly, the candidates are missing the bigger picture. We need to address the fundamental issue at the root of our problems: the primary care shortage.

Primary care should be the backbone of any health care system. Countries with appropriate primary care resources score highly when it comes to health outcomes and cost. The United States takes the opposite approach by emphasizing the specialist rather than the primary care physician.

Fragmented care

A recent study from The New England Journal of Medicine analyzed the providers who treat Medicare beneficiaries. The startling finding was that the average Medicare patient saw a total of seven doctors “” two primary care physicians and five specialists “” in a given year. Contrary to popular belief, the more physicians taking care of you does not guarantee better care. In fact, studies show that increasing fragmentation of care results in a corresponding rise in cost and medical errors.

How did we let primary care slip so far? The key is how doctors are paid. Known as “fee for service,” most physicians are paid whenever they perform a medical service. The more a physician does, regardless of quality or outcome, the better he’s reimbursed. Moreover, the amount a physician receives is heavily skewed toward medical or surgical procedures. A specialist who performs a procedure in a 30-minute visit can be paid three times more than a primary care physician using that same 30 minutes to discuss a patient’s hypertension, diabetes or heart disease. Combine this fact with annual government threats to indiscriminately cut reimbursements despite rising office and malpractice costs, physicians are faced with no choice but to increase quantity to maintain financial viability.

Driven from the field

Primary care physicians who refuse to compromise quality are either driven out of business or to cash-only concierge practices, further contributing to primary care’s decline.

Medical students are not blind to this scenario. They see how heavily the reimbursement deck is stacked against primary care. Whether they opt to become a specialist or a primary care physician, they graduate with the same $140,000 of medical school debt. The recent numbers show that since 1997, newly graduated U.S. medical students who choose primary care as a career have declined by 50%. This trend results in emergency rooms being overwhelmed with patients without regular doctors.

Furthermore, if the Democrats’ universal health care proposals come to fruition, the primary care system will be inundated with at least 45 million newly insured patients. As Massachusetts is finding out in its pioneering attempt to provide universal coverage, our system is not ready for this burden. Universal coverage is useless without primary care access.

How do we fix this problem?

It starts with reforming the physician reimbursement system. Remove the pressure for primary care physicians to squeeze in more patients per hour, and reward them for spending time with patients, optimally managing their diseases and practicing evidence-based medicine. Make primary care more attractive to medical students by forgiving student loans for those who choose primary care as a career and reconciling the marked disparity between specialist and primary care physician salaries.

We are at a point where primary care is needed more than ever. Within a few years, the first wave of the 76 million Baby Boomers will become eligible for Medicare. Patients older than 85, who are in the most need of chronic care, will rise by 50% this decade.

Who will be there to treat them?