How the primary care doctor shortage threatens Obama’s health reform plan

Top story in The New York Times.


There’s hope that maybe, just maybe, we’re getting through to the decision makers in Washington.

The article itself is old news to regular readers of this blog, and regurgitates many of the arguments impeding health reform, as well as the problems in solving them.

“Obama administration officials, alarmed at doctor shortages, are looking for ways to increase the supply of physicians to meet the needs of an aging population and millions of uninsured people who would gain coverage under legislation championed by the president.”

It doesn’t take a genius to see that Obama’s plan, which will likely replicate the approach taken in Massachusetts, is doomed to fail if there are not enough primary care doctors to see the influx of newly insured patients. Without access to physicians, these patients will further crowd emergency departments, and health care costs will continue to spiral upwards. And since, as the piece notes, “the ratio of primary care doctors to population is higher in Massachusetts than in other states,” I shudder to think of the disaster waiting to happen on a national scale.

It appears that both parties appear to understand the gravity of the problem, since the primary care shortage is one of the few points they agree on.

The proposed solutions are not new: “One would increase enrollment in medical schools and residency training programs. Another would encourage greater use of nurse practitioners and physician assistants. A third would expand the National Health Service Corps, which deploys doctors and nurses in rural areas and poor neighborhoods.”

None of these options will work. Increasing medical school enrollment will simply produce more specialists if the current physician payment system, which incentivizes students to pursue procedural care, remains. Greater use of mid-levels won’t have an impact either because, i) they too are drawn to specialty care, and, ii) even when including nurse practitioners and physician assistants, studies show that there still won’t be enough providers to meet the generalist demand. Finally, paying off medical school debt is not a good enough reason to dissuade students from becoming specialists, especially with the salary differential of several hundred thousand dollars per year, in some cases.

If politicians are serious about solving the issue, the easiest, and most direct, solution would be to increase Medicare reimbursement for primary care office visits by 20 percent. With the government making such a bold move, private insurers will likely follow. But whether or not it’s done in a “budget-neutral” way will be a point of vicious contention. Specialists will not like the fact that they may have to take a pay cut, and will fight any such proposal to the bitter end. A civil war among physicians seems inevitable.

As I mentioned, none of these topics are new. But it’s good to see prominent light shed on the topic, and perhaps, politicians are starting to realize this issue can single-handedly derail successful health reform.

Now that they’ve identified the problem, let’s see what they do about it.

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