Primary care physicians (PCPs) are
becoming extinct. It’s true. Not many medical
students choose primary care as their career path. Older PCPs are retiring
early. Many others are closing their practices or seeking employment at the
local hospital. And there has always been a shortage of primary care physicians
in rural and urban poor areas. Today only 30% of all physicians practice
primary care (compared to about 70% in most other developed countries and about
70% in the United States fifty years ago) and this percentage is shrinking at a
steady rate.
This
my third post in this continuing series
Estimates in the Annals of Family Medicine indicate that America, which today has about 210,000
primary care physicians in active practice, will need an additional 52,000 PCPs
by 2025. Good luck. This is based on growth of the population (requiring 33,000
added PCPs), the aging of the population (10,000) and the added number of
individuals that will have health insurance as a result of the Affordable Care
Act (8000). The number needed almost undoubtedly is substantially higher. And
if you accept my premise to be detailed in a later post that a primary care
physician (or nurse practitioner or physician assistant) should be caring for
only about 500-1000 individuals rather than the current typical 2,500+, then
the need is truly much, much greater.
About 25,000 new graduates enter medical practice
each year. This represents an increase of about 3% per year while the general
population has been growing about 1% per year. Today there are about 29
physicians for every 10,000 population although they are not necessarily
distributed evenly across all population areas or groups.
With these numbers one could argue that there is no
shortage of doctors. Indeed with the opening of new medical schools and many
others increasing class sizes, there should be another 3000 added to the
graduating class each year rising to 5000 by the end of the decade. But most
graduates enter specialty care rather than primary care training driving the
ratio of PCPs to specialists of 30%-70% ever wider. Adding further to the
specialist roles (except those with known shortages like general surgery) will
only add to health care costs rather than increase quality.
There is good data to support the notion that a
primary care-based delivery system increases quality of care and decreases
costs compared to our current specialist-based delivery system.
Critical to how many PCPs are trained are two key
factors. One is how many trainee (residency) slots are available to train
primary care physicians. Medicare pays hospitals to train medical school
graduates during their residency. Currently, Medicare pays teaching hospitals
$9.5 billion each year to subsidize the training of the next generation of
physicians with residency programs that range from three to seven or even more
years after medical school graduation. Medicare has kept these “slots” it will
cover flat since 1997 and has given no indication of raising this as of yet.
But even more importantly are the absolute numbers of PCP vs. specialist slots
available. There are simply many many more specialist slots available. Medical
centers want to train specialists. They represent assistance to the faculty or
staff physicians and they bring an aura of quality to the hospital. No good
professor and chief of, say, neurosurgery at an academic hospital would not
want to have his or her own training program. It is a matter of pride. Absent a
training program, the best will not chose to work for that medical center and
will choose to practice elsewhere. This is a serious conundrum for the medical
center that needs the specialty program to drive more revenue. And Medicare has
been willing to pay for these specialty training programs over the years while
not increasing funding for primary care training.
There is a recent
study covering 2006-2008 residency training and Medicare
payments. Lin, commenting on the article on KevinMD,
noted by separating out those 20 hospitals that trained the most and the 20
that trained the least PCPs, respectively, among all teaching hospitals in the
USA, “the top primary care producing sites graduated 1,658 primary care
graduates out of a total of 4,044 graduates of their hospitals (41%) and
received $292.1 million in total Medicare graduate medical education (GME)
payments. The bottom 20 graduated 684 primary care graduates out of a total of
10,937 graduates from their hospitals (6.3%) and received $842.4 million.” In other words, the hospitals that got the
most money trained a larger proportion of specialists; perfectly logical if
that is where the money is. But this makes little sense in an era of serious
primary care physician shortages that will certainly worsen in coming years.
The other problem is that primary care is not seen
as a desirable career path today. There are multiple reasons. Primary care
physicians earn about one half of what a specialist earns. Specialists are
generally seen to have a higher level of prestige in the community – “I was
sent to Dr Jones, the surgeon.” Most
medical school graduates have large debt loads so earning more means paying it
off sooner. And with a large debt, it is harder and scarier to take out a loan
to start a practice that brings in fewer dollars. But the primary reason is
that medical students realize that PCPs are in a non-sustainable business
model, one in which they must see far too many patients per day, accept
unpleasant burdens with insurers, be on call many hours and yet not be able to
offer what they know would be better
care. They see it as a no win situation and so avoid primary care even if that
might otherwise be their preference.
Less prestige, high debt loads and a knowledge that
PCPs work in a non-sustainable business model forcing them to see an excessive
number of patients per day in order to meet overhead and still garner an income
about one half that of the specialist is, combined, enough to discourage
medical school graduates from selecting primary care as a career.
The next post in this series will focus on the PCP’s
need for time – to listen, to think, to prevent, to treat, to coordinate.
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