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Primary care crisis is HERE

I recently heard from a UCSF physician who was flabbergasted when he sought an
appointment in our general medicine practice and was told it was “closed.” Turns out we’re not alone: there are also no new PCP slots available at Mass General. The primary care crisis has truly arrived.

I’ve written about the roots of the problem previously, and won’t restate the sad tale of woe. But I hope you’ll take the time to listen to two very powerful NPR reports on the topic – the first, a WBUR special by healthcare journalist Rachel Gotbaum called “The Doctor Can’t See You Now,” is the best reporting on this looming disaster I’ve heard (here is the MP3 and the show’s website). The piece is long (50 minutes), so I’ll summarize a few of its moments that really hit home.

First, it is true – MGH is not accepting any new primary care patients. Like UCSF, therefore, getting “a regular doctor” at MGH now takes the combination of cajoling, pleading, and knowing somebody generally referred to as “working the system.” In other words, the process of finding a primary care doc is now like getting a great table in a trendy restaurant. Obviously, this is horrible for patients, but it is also no fun for doctors. For example, in the NPR special, MGH’s director of Emergency Medicine laments:

“If you really want to give me heartburn, you can say, excuse me but I know you work at Mass General and I would like a primary care physician please.”

As someone who gets requests like that about once a week, I can empathize. Of course, things are far worse for the patients. One woman described her efforts to find a primary care doc this way:

“Yeah, I asked people who had really good doctors that they would put a word in for me and it was almost like writing a personal ad: ‘Hi, interesting woman who’ll talk to you, gives good history…’  ‘Gives good history,’ that would be a really good thing to say!” [she laughs]

The report also makes clear that providing more “access” through expanded insurance coverage won’t do the trick. Massachusetts, you’ll recall, markedly expanded its coverage a couple of years ago (in legislation proposed by that ex-liberal, Mitt Romney). Scott Jasbon, a 47 year-old contractor/bartender, thought he was all set when he enrolled in one of Massachusetts’ subsidized health plans. He was wrong.

“I received a card with my doctor’s name on it and I was told that was my primary care physician. I called the office. They told me that they no longer took the insurance. So then I went through every list of doctors in Sandwich, in the book, called each doctor, and each doctor told me the new plan that I received, they, no one took the insurance… I knew that there was something wrong with me, and I was explaining to each doctor actually as I called them, ‘I’m having problems urinating.’ Hot flushes, I was hot all the time. I knew something was wrong, and I couldn’t get anybody to take care of me.”

Jaspon ended up in an ED, where he was diagnosed with diabetes and hypertension. The ED staff helpfully suggested that he should think about getting a PCP.

What’s happening is old news. The combination of 15 minute visits to see patients bearing both complex medical problems and 20 pages of internet printouts to discuss, the loneliness of a small group practitioner, the lack of prestige, the woefully low pay (the income of the average PCP is less than half of that of many specialties, including dermatology and radiology) in an era in which the average medical student finishes school more than $100,000 in debt, and the sensibilities of Generation Y trainees –- who now are looking for reasonable “lifestyles” and incomes without the need for martyrdom –- have combined to push all but the most unusual medical student and resident away from primary care careers. At Mass General, one out of the 50 graduating internal medicine residents last year was planning to become a PCP; at UCSF, our numbers are only slightly higher.

Some primary care educators used to say that the problem was that students didn’t have opportunities to see the real practice of primary care docs –- if they did, they’d recognize the subtle satisfactions and be more inclined to enter the field. But an upcoming paper by UCSF’s Karen Hauer and others demonstrates that such exposure actually discourages trainees from choosing primary care. Primary care docs are frustrated and demoralized, and most of them are honest enough to share their angst with their students. In other words, It’s The Practice, Stupid.

The dwindling number of PCPs who remain in practice are being far more discriminating about the patients –- and insurance payments –- they will accept. With Medicare reimbursement tightening (Congress just overrode the Prez’s veto of a proposed 10% Medicare pay cut, but you can bet that the proposal will be back again next year), Medicaid reimbursement near Starbucks barista levels, and states proudly providing subsidized insurance at Medicaid-like reimbursement rates, the result is primary care “access” that sounds good in a press conference but is not real.

You might ask, won’t the existing PCPs need to accept even these low insurance payments? After all, they need to see some patients to generate an income. Well, as it turns out, no.

The remaining PCPs are in such demand (not only because so few people are entering the field, but because so many are leaving it –- an ABIM study found that 10 years after initial board certification, approximately 21% of general internists were no longer in the practice of general medicine [vs. 5% of subspecialists leaving their field]) that they can afford to limit their practice to patients with better paying commercial insurance. A few, of course, are limiting their practices even further –- to well-heeled patients willing to provide an up-front stipend of several thousand.

And, for big academic practices like UCSF’s and MGH, opening up new primary care practices involves substantial subsidies, which most academic medical centers are increasingly unwilling to provide. The 1990s theory that you needed a big primary care base to feed your neurosurgery and liver transplant programs has not materialized. Many academic hospitals (including ours) are packed to the gills; with managed care de-fanged, most patients can get to us without necessarily receiving primary care in our system. The result: more “Closed To New Patients” signs.

Won’t the market and the political process work this problem out? Not so much. Even though everybody recognizes the crisis at hand, bumping Medicare’s primary care reimbursement presently involves changing the formula used to calculate reimbursements to all physicians. This is handled by a Secret Society known as the "RUC": the RBRVS Update Committee. In a 2007 JAMA article, Harvard’s John Goodson described the RUC’s membership:

“The RUC has 30 members (the chair only votes in case of a tie) with 23 of its members appointed by ‘national medical specialty societies.’ Meetings are closed to outside observation except by invitation of the chair. Only 3 of the seats rotate on a 2-year basis. Other members have no term limits. Seventeen of the permanent seats on the RUC are assigned to a variety of AMA-recognized specialty societies, including those that account for a very small portion of all professional Medicare billing, such as neurosurgery, plastic surgery, pathology, and otolaryngology.”

In other words, representation on the RUC is like the Senate rather than the House, and in this case, Montana isn’t very excited about turning its money over to California. And since the dollars available for physician payments are capped (at best), bumping primary care reimbursement significantly can only be accomplished if dollars are freed up through lower payments to radiologists, plastic surgeons, and other specialists (and guess who has the better lobbyists). (A percentage or two won’t help because the increases needed to change the dynamics are on the order of 20-40%.)

For more details on the RUC, check out Roy Poses’ blog, which has made a cause out of exposing the committee’s biases and secrecy, and Maggie Mahar’s terrific description of the RUC’s history and inner workings.

The state of primary care is not only sad, it is incredibly stupid. Mountains of research have demonstrated that primary care-based care is less expensive. Without access to primary care doctors, patients get their basic care in emergency rooms, or from subspecialists, or not at all. In any case, care is fragmented, technology over-intensive, and wickedly expensive.

The second NPR report I liked described primary care in the Netherlands, where the cost of health care is far less than that of the U.S… and the doctors make house calls! How do dey do dat? Easy. They’ve determined that providing superb access to primary care, even in patients’ homes, is not only humane and effective, but probably saves money by preventing unnecessary ED visits and hospitalizations. Just one more reminder of how dumb our present system is.

The forces of inertia getting in the way of solving the primary care crisis are so strong that only a very powerful implosion will create the political wherewithal to overcome them. Specialists don’t want to forgo income, medical students will continue to vote with their feet, existing primary care docs have resigned themselves to more of the same and are hunkering down for retirement, and many patients are perfectly happy bypassing primary care docs to get their care from hordes of subspecialists. The patients who take the biggest hit, of course, are poor and middle class folks with chronic diseases – even those with insurance, who can’t find a PCP and can’t afford a VIP doctor, and who therefore live in perpetual fear of the next crisis.

When insiders like medical school faculty members can’t find a regular doctor, though, you know that this dysfunctional and unsustainable situation is now coming to a head. Once gas prices and the mortgage meltdown begin receding from the headlines, expect that the primary care crisis will become a Page One issue.

It’s about time.

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  1. 5:06 Nets center Andre Blatche hits a jumper to make the score 62 57, and Pacers announcer Chris Denari mentions that like in Boston, Kevin Garnett has to come out early in the first and third quarters. This reminded me of the Pacers pregame show I was listening too on 1070 The Fan when Austin Croshere mentioned that he doesn fully buy in to this Brooklyn squad to be a top seeded team. Basically Croshere believes that with the years of basketball mileage on their body, Garnett and Pierce could perhaps reach their full potential if they played once every three games. Throw in the fact that Pierce, Garnett, and Jason Terry combined for 8 23 from the field, 21 points, and nine turnovers, I now wonder how Sports Illustrated picked this squad to be the number three seed over the course of an 82 game season.

  2. Primary Health care centers of the National Guard Health Affairs have access to Family Medicine back up on the campus and in the Hospital. The Department is sharing a significant work load by classifying patients in routine management and specialty referrals. Pre-employment check up, and annual evidence based screening services are the key provisions., to learn more please enter her

  3. I suppose physicians are like the Obama administration in that they have difficulty in getting the general public to understand major underlying issues when it comes to healthcare.
    Let’s take the $70 per patient payment as just mentioned. The doctor works 7 hours and sees 10 patients. That becomes $700 a day or $100 per hour. Now let’s double the number of patients to 20. This now gives us a total of $1400 a day. That’s twice as much as some people think an over paid doctor should make. Wow $1400 a day or $336,000/year!
    Now let’s say the doctor is running lean and mean and has only 3 full time employees. Let’s say that the doctor is able to find good high school educated people to work for him and they make $18.00/hr, $15.00/hr, and 13.00/hr. That becomes $46.00/hr in the average persons mind of how much the doctor is paying in salary. Now let’s add in another $5.00/hr for employee expenses such as social security, Medicare, unemployment insurance, workers comp insurance that the employer has to make in addition to the base salary. Don’t forget another $1.00/hr for employee benefits such as health insurance, uniform allowance, continuing education, etc. Not bad, that $200.00/hr that people think doctors make has been reduced to $148/hour. Very good money! Now how about rent. Let’s low ball it again at $18.00 per sq ft in a decent area. And let’s make it a small office, say 1000 sq ft. That’s $11.00/hr. We need a phone with no yellow page advertisement. That’s $2.00/hr. How about supplies. That comes to about $11.00/hr. Computer system service agreements $3.50/hr. Utilities $3.00/hr. Office equipment leases $15.00/hr. Accounting fees $1.50/hr. Malpractice insurance $17.00/hr. Let’s stop here and do a sub total. $64/hr! Now we are down to $84/hr from a start of $200/hr. Do you want me to factor in advertisement costs, business insurance, custodial costs, billing fees, patient account defaults and every other miscellaneous item for ~$30.00/hr. This leaves the most efficient physician with $54.00/hr which is $90,720/year if he never misses a day from work and can consistently see 20 patient’s a day. This is a far cry from the $336,000 number that gets tossed around if he had no expenses and took every dollar home.

  4. Hello,
    If Medicare pays a doctor 70.00 a visit for example. IF the doctor sees ten patients a day isn’t he making at least 700 dollars plus you know he’s making money more on other insurances. I am just wondering if doctors just want a bigger pay hike and how much of an issue is this really? I believe other issues exist. My doctors make over 100 a visit. Are their lifestyles just demanding more money or is this really an issue? Most doctors i see live very nicely. How are they affording that? Many are in 6 figures working in so called poverty hospitals. What if shared their income with some other doctors? Is it reasonable to not live on half million a year and settle for half of that? I have heard of insurance rates. How much do they really pay for these things out of pocket? I have known doctors with over a million in the bank.
    connie sans.

  5. as a primary care physician, i’m grateful to read this article. many of us did not go into primary care for the money, needless to say, but we did because we love what primary care was about–knowing the whole patient, and caring for the whole patient. i feel this is taken for granted. i don’t think many specialists can appreciate how hard it is to manage seeing 20-30 patients a day who have 5-10 concerns, ranging from the mundane to life-threatening. it’s a challenge to be able to translate their problems into medical language–to make it fit in the framework in which we think disease–to decide what problems can be dealt with simply, what problems require specialst help, and at the same time being able to tailor your care to the patient’s own education level, literacy, financial/transportation resources, insurance restraints, values, litigousness, etc. it’s a skill that requires being able to read people and have good communication skills. at the end of the day, i look at my notes and seem alarmed at how simple everything looks, but i realize all i document is simply the bottom line of the problems discussed. what isn’t seen is how difficult it was to get to that bottom line. While it may not seem to be as disease-oriented and cerebral as other fields, I feel what we do is equally important and just as, if not more, emotionally taxing. It’s really hard for me to believe that some specialists work less hours that me (i work at least 60 a week) and make twice as much. I don’t want to quit, because i still believe in primary care, but at the same time, I wish there was a way to cut back on my hours so that I could have a normal life and take care of my family.

  6. Who do you suppose CMS went to for advice on how to pay for a medical home? That’s right, the RUC, who came up with a ridiculous scheme that no one in their right mind would sign on to.
    Primary care is now the career of choice for the discerning student who, after residency, can set up a cash only practice in this wide open field, cherry pick patients and net 3x the average salary of an FP.
    After years of being undercompensated by third party payers through the auspices or the RUC, I became cash only and this year will earn over $500k taking care of about 700 highly complient, cash paying patients. I don’t like being part of the problem but there is simply no other way to practice value based cognitive care in this country and earn enough to justify the 14 years I spent in higher education.
    No lectures please, I simply refuse to be undervalued at the behest of proceduralists. The citizenry which should prize my skill in providing cost effective care has instead made it clear they believe a cardiac cath is 48 times more valuable that a 25 min visit consisting of health counselling (based on RBVs). Actions…consequences. Something is only worth what someone is willing to pay for it and the market has set the value of my services quite appropriately.
    No reimbursement scheme will work as long as compensation formulae have to be cleared through the proceduralist dominated RUC. As long as medical care is reimbursed based on the resources used rather than the value provided, we will get more cost and less value.

  7. I go to a state medical school(UCLA) and my student budget is $48k annually. Multiply by four and $125k is not the number you come up with. Its more like $200+ interest. Before getting accepted at UCLA, I was planning on going to USC whose current cost per student is in the $66k range. Realistically if you average out the public and private medical institutions my guess is $250k is a reasonable debt expectation at graduation. This debt continues through residency while you make $35k/yr.
    Honest question as a medical student though, is it that specialists make too much at $300k or that primary care docs make too little at $100k? I will grant that PCPs are underpaid, but society seems willing to let this happen. More and more primary care is being run by PAs and NPs and medicare seems unwilling to increase PCP reimbursement. So why should I go into Family Medicine/Generalist practice? Please provide a convincing, cogent argument that stands more firm as a career and business investment than “because I love to treat patients.” If I want to see patients I’ll do Emergency medicine where I have a life or Cardiology where I will have no life but at least will receive a specialist’s income.(not my actual choices mind you)… You are right though as a group medical students vote with our minds and feet and everything is pointing towards the death of PCPs being trained at US medical schools. Perhaps we will import enough from abroad and promote NPs and PAs to fill vacuum of primary care our society will need.

  8. In Canada medical students pay approx $15,000 per year tuition. Average debt on exit is $ 125, 000 which is on par with the US. We are still able to get 40% of students to choose family medicine. My belief is that there is a better culture of valuing the primary care specialist. As an example 7 of the 17 medical schools in Canada have family physicians as Deans of Medicine! All schools have departments of family medicine (http://www.carms.ca/eng). There is also a national concerted effort to move more funding and residency positions into family medicine.
    While it is tempting to blame debt on specialty choices, a few studies in recent years have suggested that debt load had no impact on specialty of choice in Canada(Dhalla, CMAJ). Rather, it seems to be lifestyle control issues that is driving students away from family med, peds, ob-gyn. Students accept that they will be able to pay off their debt. They also accept that entering the workforce 2-3 years earlier than their specialist friend if they choose family med will offset any reduction in pay scale.
    I don’t think we have it all right in Canada but I think that our primary care training seems much more palatable to the average Canadian medical student.
    Tom Lacroix

  9. @DP:
    Harvard has no department of family medicine…this is about as close as it gets, I believe: a Tufts residency in a hospital that happens to also have a Harvard affiliation.
    http://www.tuftsfmr.org/curriculum/academic_affiliates.shtml
    But that isn’t to say Harvard trains no primary care physicians. Harvard-affiliated hospitals do train a small number of general internists and pediatricians (as well as a handful of med-peds docs). But Harvard still isn’t a significant source of primary care physicians. Very few of its students or even the residents of its primary care programs actually go into full-time primary care. Hospitalist practice, with higher salary for fewer hours of work and a more manageable lifestyle (at least in Boston), has been a significant draw.
    These problems are probably not unique to Harvard. Most of the research-oriented medical schools have similar statistics. Their graduates have options, and they follow the money. There’s also a not-so-subtle bias against generalism among the faculty (e.g., “why would you waste your intelligence on primary care?”).
    Of course, the folks who say this have only a superficial understanding of what family practice is or how to provide high-quality primary care. They’re way too focused on doing “everything possible,” for end-stage and acutely ill patients…who just happen to have problems for which richly reimbursed tests and procedures can be provided.
    Now there will be some who say “Fine…but why should Harvard be training PCPs? Why not have other, less-selective medical schools train the primary care workforce?” The reason is that we don’t just need more PCPs. We need more of the best minds in medicine to practice primary care (recognizing that there are “best minds” at many medical schools…and plenty of lemons at Harvard).
    Actually doing a good job providing primary care is the most intellectually demanding job in medicine. It’s far easier to subspecialize: see a narrower range of diseases, order a standard battery of tests, do a few procedures, and refer any condition you don’t feel comfortable with to the primary care doc (or worse yet, to another specialist). We need a complete reversal of the training and payment hierarchy: diagnostic skill and comprehensive care management (the true province of primary care) at the top, and technical skill at the bottom, with most procedures being performed by hyper-specialized non-physician technologists.

  10. This is an issue that is also extensive to areas such as endocrinology and diabetes treatment. In its most recent issue, the diaTribe newsletter touched on the numbers of medical students planning on pursuing endocrinology with an emphasis on diabetes as their area of focus and the results were pretty scary… decreasing numbers of specialists for one of the fastest growing chronic conditions there is in the US.

  11. The Future of Family Medicine (FFM) report documents the current crisis in the U.S. health care system and how family physicians are uniquely positioned to address it.
    One of the few bright spots to come out of the report is the TransforMED http://www.transformed.com/index.cfm initiative which is a 24 month National demonstration project to transform family practice in the US. The American Academy of Family Physicians (AAFP) took a leadership role in creating a new, not-for-profit initiative, TransforMED, to put the FFM recommendations into action. It includes projects at 14 medical schools to transform the content and structure of their residency training programs in family medicine as well.
    (I am not affiliated in any way with it)

  12. jd, Does any other nation force as much debt on all college students? I’d be in favor using free schooling to create more primary care but it should come with some payback strings. I’d also use this carrot to attract students from low income and “rural” communities. No free ed for specialists though.

  13. Another post that speaks the truth – completely unheard by our legislators. Point out that the Emergency Departments can’t handle the load and that, also, is not heard by our legislators.
    Let’s hope that we don’t force any physician to participate in government medicine because then a black market will form – however I doubt that or legislators will hear that reality either.
    My legislators don’t respond when I approach them about this subject.

  14. Does any other nation force those who go to medical school to pay $100,000 or more?
    My hunch is that despite all the complaints about pay, if this huge obstacle to bringing new people into primary care were eliminated, we would see a surge of new PCPs. It would open up the profession to motivated people from families in the lower 60% of the income scale.
    That’s not to say we don’t need to fix the reimbursement system. We do.

  15. No PCPs at Brigham and Women’s are taking new patients either. Yet Massachusetts introduced legislation mandating coverage for 200K+ people who haven’t seen a doctor in years. Perhaps they should have considered the primary care infrastructure before guaranteeing everyone health care.

  16. The ugly and brutal truth is that specialists in this U.S. are radically overpaid in comparison to their counterparts in any country in the industrialized regardless of the health insurance system. Until someone with enough clout stands up to the ridiculous notion that a specialist making $300k-$400k annually is underpaid, things won’t change.

  17. This is an important issue to raise. It is interesting that in the mainstream media, the focus on “access to care” centers on insurance coverage. But just as insurance portability is not an issue in isolation, neither is the shortage of primary care physicians. For example, there is not just a shortage in primary care MDs, but a projected shortage of physicians in general (http://www.aamc.org/workforce/). This shortage cannot be simply explained by low salaries. Forbes recently listed the top 25 highest paying jobs. The top nine places are occupied by various sorts of medical specialists, including primary care physicians. (http://www.forbes.com/2008/05/15/jobs-careers-compensation-lead-careers-cx_pm_0515jobs.html). Clearly, there are multiple distortions in the health care system place that prevent normal market corrections.

  18. One of the scariest aspects of the PCP shortage in the US is the lack of educational infrastructure for primary care reform.
    Consider the following.
    Currently, Canada produces more family physicians than the US in a given year. Per capita, Canada produces nearly 8 times the number of family physicians. Even if you factor in that Internists, Ob-Gyn and Pediatricians are considered primary care, the gap remains very large.
    In spite of Canada’s production of 40% of all grads entering family medicine, we think we will fall short. We are looking at alternate care providers (like PA’s, nurse practitioners) and IMG’s to fill the gaps.
    One of my greatest concerns is that in the face of rapid change in the healthcare system, relying on providers with a more limited training may lead to less flexibility in response to profound medical/healthcare delivery advances that are coming.
    Robert Bowman’s work on physician maldistribution in the US also warns about reliance on allied health who seem to distribute less than family physicians.
    Tom Lacroix, MDCM, FRCPC Pediatrics
    Assistant Dean Rural Regional
    Schulich School of Medicine & Dentistry
    The University of Western Ontario

  19. It’s obvious what has to happen: Medicare needs to pay PCP’s more money to practice general internal medicine and family practice, and thus force the private payers to follow. This should be the real purpose of the “medical home”: to pay PCP’s a living wage w/o drowning them in new paperwork. And it has to be paid for some other way than taking it from specialists, who will stop it cold.
    So many of the “appointments” we cannot get are for getting questions answered that if we had a relationship with them, we could get answered by phone, text or eamil. So Medicare needs to pay for relationships with PCP’s, not for visits, or emails, or lab tests, or whatever. When I called my internist for a routine H+P, the wait was for four months.
    It isn’t just money that PCP’s lack, but respect. So just paying more may not be enough. A lot of the reason why young internists do not enter general practice can be traced not only to a lack of money, but a lack of respect in med. school/teaching hospital peer culture. A lot of medical school faculty believe that primary care is simply unnecessary, in part because they triage themselves, so see no need for this function for the rest of us. Perhaps as with $4 gasoline, we won’t take this problem seriously until enough of us experience the inconvenience of not being able to see a primary doc. This is a huge problem. Good post, brother Wachter.

  20. My view of primary care service in a hospital setting is that by the time you get to hospital you’re past primary care. I would think support of PCPs should be in the community. I’m also not surprized that hospitals (in this country) don’t support PC as it doesn’t bring in enough dollars. Hospitals can’t afford docs that tell patients they don’t need a specialist with lots of expensive testing. I would also like to know why Jaspon could not get a PCP in MA. Could he have before the new plan? Is it because the supposed reduced premiums there under the new “Mitt” plan are partly on the backs of PCPs incomes and not on efficiency “competition” between insurance companies? The cracks they are appearing.

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