Solving Primary Care Shortage Requires More Than New Healthcare Reform Law

April 26, 2010

April 26, 2010 — Imagine, for a moment, the sound of ringing telephones in physician offices in 2014, the first year most Americans are required to carry health insurance under historic healthcare reform legislation enacted last month.

Millions of previously uninsured and undertreated individuals have just purchased policies, many with the help of tax credits, and now they are trying to make appointments with internists and family physicians to treat their migraine headaches, high blood pressure, and constipation.

However, receptionists and schedulers who answer their calls do not have encouraging words. "The first appointment we can give you is 2 months out," they say over and over. "We’re just swamped."

Does this sound like reform?

The new reform law, called the Patient Protection and Affordable Care Act (PPACA), attempts to avoid access scenarios like this by increasing the number of primary care physicians, who are already in short supply. The nation currently needs an additional 17,000 physicians in primary care shortage areas where 65 million Americans live, according to the US Department of Health and Human Services.

Before the passage of healthcare reform, the Association of American Medical Colleges (AAMC) was already predicting a shortfall of 46,000 full-time equivalent primary care physicians by the year 2025 and an overall shortage of 124,000, not counting residents — that was its conservative calculation. The undersupply across the board testifies to the increased specialty needs and primary care needs of an aging population and its Baby Boom cohort in particular. Think cancer, worn-out knees, and leaky hearts.

"A silver tsunami is coming," AAMC chief advocacy officer Atul Grover, MD, PhD, told Medscape Medical News.

The PPACA only stands to worsen the predicted shortage by increasing demand for physician services. The legislation will extend insurance coverage to 32 million additional Americans by 2019, with 19 million entering the pipeline in 2014.

Medical societies and authorities on workforce issues say the PPACA is a promising first step toward mitigating the primary care shortage, but improving the ability to make a quick appointment will require many steps more.

"Newly insured patients can anticipate difficulties gaining access to primary care," writes Robert Doherty, senior vice president of governmental affairs and public policy for the American College of Physicians, in the April 8 issue of the Annals of Internal Medicine. "PPACA will not solve the primary care crisis."

It is widely agreed that in addition to sweetening financial aid to medical students bound for primary care and offering them more attractive pay once they are practicing, healthcare reformers need to eliminate a bottleneck in between — residency training. No matter how many medical students choose primary care, the nation will not have enough physicians in this field unless it markedly increases the number of residency positions for them, experts say.

Primary Care Bonus Should Be Bigger, Some Contend

With medical school debt driving many students into lucrative surgical specialties, the authors of the PPACA wanted to even the odds for medical students choosing primary care. Accordingly, the law expands funding for scholarships and loan repayment for primary care physicians practicing in underserved areas through the National Health Service Corps.

The new law also attempts to narrow the compensation gap between primary care and surgical specialists. Primary care physicians and general surgeons in medically underserved areas will receive a 10% Medicare bonus from 2011 to 2015. In addition, Medicaid reimbursement for family physicians general internists, and pediatricians will increase to Medicare levels in 2013 and 2014 when it comes to evaluation and management services and vaccine administration.

Lori Heim, MD, president of the American Academy of Family Physicians (AAFP), said the 10% Medicare bonus for primary care is a "great start" but not enough to persuade a medical student worried about his or her future earning power to choose this field.

"The bonus needs to be at least 25%," Dr. Heim told Medscape Medical News.

Another believer in higher pay for primary care is hematologist Richard Cooper, MD, a professor at the Leonard Davis Institute of Health Economics at the University of Pennsylvania, Philadelphia. However, Dr. Cooper, a controversial scholar on medical workforce issues, argues that to make primary care financially attractive, clinicians should receive hefty pay hikes just for complex patient care as opposed to across-the-board raises.

"Primary care physicians are rewarded too much for simple things, like taking care of sniffles, and rewarded too little for complicated things, like taking care of congestive heart failure," said Dr. Cooper.

His solution? Hand off the sniffles to lower-paid nurse practitioners and physician assistants and double what primary care physicians receive for managing congestive heart failure and the like. "If they’re practicing in the inner city, triple it," said Dr. Cooper.

Such an arrangement, he said, would lessen the number of patients that primary care physicians need to see each day to earn a living, which would further enhance their field.

Residency Expansion Does Not Go Far Enough, Experts Say

Another way in which the PPACA tries to enlarge the primary care workforce is by increasing the number of residency training slots for such clinicians at the nation’s teaching hospitals. Like more generous compensation, this solution has a Medicare tie-in, because the federal program partially funds about two-thirds of the nation’s residency positions, which totaled 121,000 in 2008-2009, according to the Accreditation Council for Graduate Medical Education. Of these slots, 109,000 were filled.

The PPACA concentrates on slots supported by Medicare. Under the law, two-thirds of these slots that have been vacant for 3 years — now about 1300, according to the AAMC — will be redistributed to residency programs that could fill them. Of these reshuffled slots, at least 75% must be dedicated to primary care or general surgery. When Dr. Grover does the math, he expects to see anywhere from 500 to 900 additional primary care trainees, yielding several hundred or so who will enter practice each year.

However, workforce experts like Dr. Grover say that this increase does not go far enough. To relieve the shortage not only in primary care but also in all of medicine, they say, the nation needs not hundreds but thousands of new trainee positions.

One impediment to this kind of expansion is the Balanced Budget Act of 1997, which froze the number of Medicare-funded residency slots at 1996 levels. That law reflected the conventional wisdom at the time that said medicine faced an oversupply of specialists in the frugal age of managed care.

"They were planning for a world that never happened," said Dr. Grover. The number of slots has increased since then partly because lawmakers enacted loopholes to benefit rural hospitals and partly because some teaching hospitals have continued to add positions without Medicare dollars.

Last year lawmakers in the US House of Representatives and the US Senate introduced legislation that would break through the Balanced Budget Act cap and increase the number of Medicare-funded slots by 15,000. Most would be reserved for training programs in primary care, general surgery, and community settings. Such an increase, said Dr. Grover, would allow training programs that have been turning out between 25,000 and 27,000 practitioners each year to boost that number by 4000 or 5000.

"That won't meet all of our shortages, but it will give us time to figure out what to do next," said Dr. Grover.

Neither bill, however, went anywhere. Dr. Grover said there has been reluctance in some quarters to create slots on a massive scale for fear that "more doctors will just create more demand for healthcare," running up costs. In addition, the legislation’s price tag — estimated at $12 to $15 billion during 10 years — also spooked Democratic lawmakers who were trying to make healthcare reform as inexpensive as possible, he said.

Increase in Medical Schools Affected by Residency Bottleneck

One trend that bodes well for matching physician supply to patient demand is a wave of new allopathic medical schools.

Last year, 2 schools in Florida, and 1 each in Texas and Pennsylvania opened their doors to charter classes. Another new medical school in Virginia plans to follow suit this fall, whereas a school in Michigan is scheduled to debut next year. These 6 bring the count of allopathic schools in the United States to 132.

Meanwhile, 8 other allopathic schools are in various stages of the startup process, said Dr. Grover, although not every school may get launched. This expansion reflects the goal of the AAMC, announced in 2006, to boost medical school enrollment 30% by 2015.

In addition, first-year enrollment in osteopathic medical schools is expected to increase by at least 23% between now and 2015, according to the American Association of Colleges of Osteopathic Medicine.

However, there still remains the residency training bottleneck. Unless it is widened, more medical school graduates will not necessarily translate into more practicing physicians. Instead, graduates with MD and DO degrees minted by US schools will simply take the place of international medical graduates in residency programs, notes Dr. Cooper.

Even if medicine had all the residency slots it wanted, it faces another obstacle in alleviating primary care shortages that healthcare reform will exacerbate. That obstacle is time.

"It takes 4 years of medical school and 3 years of residency training to produce a family physician," said AAFP President Dr. Heim.

The medical education timetable is at odds with the timetable for healthcare reform. Consider a college graduate who enters medical school this fall and plans to pursue a family medicine career because of more generous financial aid and the promise of improved reimbursement under the reform law. He or she would not graduate until the spring of 2014. Tack on another 3 years of residency training and that new family physician would not be on Main Street, ready to give an appointment, until 2017.

Meanwhile, the Congressional Budget Office projects that 19 million patients will gain insurance coverage as required by the PPACA in 2014. Presumably, they will take advantage of it and seek more medical care.

This misalignment of supply and demand prompts physicians such as Dr. Heim to seek more help from the US Congress.

"We've been pointing to the workforce shortage for years," said Dr. Heim. "Now we're getting some action in that direction, but it’s not enough.

"The new law is only a platform for us to build on."

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