The Doctor Can't See You Now

The looming health care crisis that could derail new reforms—public option or not.

| Mon Oct. 5, 2009 6:31 PM EDT

It's a year from now, and you wake up with a sore throat. You're not worried, because not too long ago the Obama administration successfully passed comprehensive health care reform, expanding coverage to you and many of the 46 million Americans previously without it. So you call your family doctor to schedule an appointment; the doctor, however, is booked, and can't see you for two months. You decide to wait it out. A couple weeks pass; your throat worsens. Fearing something more serious, you go where you know a doctor will treat you: the emergency room. There, after a couple of hours of waiting, a physician and his team run you through a battery of complicated, expensive tests. The mystery ailment? Strep throat—something your doctor could've spotted in 10 minutes and for maybe $50 or $60. For the four hours you spent in the ER, the cost is 10 times that.

Pretty bleak, right? Yet this scenario—of extended delays to see a doctor, of patients spilling over into emergency rooms, of costs soaring ever higher—isn't far from reality. Indeed, in Massachusetts, where near-universal health care came into force several years ago and now covers more than 97 percent of the population, the rapid influx of patients has strained the system and wait times to see a primary-care doctor can stretch more than three months. Some primary-care doctors have ceased taking new patients at all, forcing individuals into unnecessary appointments with more expensive specialists or trips to the ER. And while Massachusetts' health care experiment isn't a perfect indicator of what national reform might look like, this kind of access crisis, experts say, could derail the Obama administration's best-laid plans for reform.

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So far, the public debate and media coverage concerning comprehensive health care reform has largely focused on insurance. Whether it's a government-run public plan, nonprofit co-ops, or tweaking the system already in place, the country is divided on how to cover the uninsured. Yet vastly underplayed is how health care, irrespective of the insurance model in place, will be delivered to those with coverage. Not as controversial a topic as insurance, health care delivery is nonetheless vital to any new legislation; even the most revolutionary health insurance plan will be a bust by failing to lower costs and improve outcomes if the system in place—the doctors and nurses and hospitals and clinics and so on—to deliver that care buckles under the deluge of new patients. And our delivery system needs help. Look no further than the foundation of American health care—primary-care medicine, which consists of family medicine, pediatrics, internal medicine, and obstetrics and gynecology—and the serious crisis it faces for a glimpse of how even the most ambitious health care legislation could fail without major delivery changes.

If primary-care medicine in the US were a patient, its diagnosis would be grim. The first responders to illness and pain, who can spot and treat chronic conditions in their early stages, primary-care doctors are in greater demand each year. In 2006, just more than 250,000 primary-care doctors practiced in the US—by some estimates, that was about several thousand to more than 7,000 less than the demand. The Association of American Medical Colleges projects that by 2025 the demand for primary-care doctors will have soared to nearly 320,000 doctors nationwide, a 29 percent increase from 2006 and the most for all types of physicians.

But while demand skyrockets, supply of primary care doctors lags far behind. Statistics from the AAMC estimate a shortfall of 46,000 primary care doctors by 2025, a gap that will lead to pervasive access problems and force patients to seek out emergency rooms or costly specialists. "If all of a sudden President Obama increases access to the uninsured, there will be a huge capacity that the demand will not be met for," says Dr. Ted Epperly, president of the American Academy of Family Physicians (AAFP). "People will have access issues, and they will be sicker."

Which brings the question: Where have all the primary-care doctors gone? The problem starts on medical-school campuses, where the pipeline for primary-care medicine is drying up. As the demand for primary care continues to increase, the percentage of graduates today choosing the field—about 30 percent—is stagnant at the same level as in 1980. The remaining 70 percent choose more lucrative specialties like radiology or cardiology or any number of niche fields that weren't around 30 years ago. In 2006, a mere 42 percent of residency positions in family medicine were filled by medical-school graduates, a decrease from 73 percent a decade earlier.

Part of this supply problem is financial. Graduates see that primary-care doctors earn among the least of all doctors, a deterrent for new doctors who enter the workforce with an average of $155,000 in debt and climbing. A 2008 salary survey found that internists, pediatricians, and family physicians ranked in the bottom three at about $180,000 to $190,000 a year. (Diagnostic radiology topped the list, with an average salary of well over $400,000 a year.) Other salary surveys suggest that primary-care figure might be $30,000 or $40,000 lower.

Yet the problem isn't purely financial, but cultural, too. Primary-care experts inside and outside of academia interviewed by Mother Jones cited an academic environment in medical schools that touts more specialized fields and undervalues primary care. Dr. Russell Robertson, who's on the faculty at Northwestern University's medical school, said students often get the impression that the only doctors who go into primary care are the ones who aren't smart or ambitious enough to succeed in more specialized fields. "There's so much data and misinformation that's perpetuated in osteopathic and allopathic medical schools, that basically the only people who go into primary care are the ones who can't go into other specialties," Robertson says.

The primary-care crisis extends to practicing physicians, almost half of whom say they would seriously consider leaving primary care if they could, according to a 2008 poll by the Physicians' Foundation. Because the American health care system embraces a fee-for-service payment model—basically, the more imaging tests and complicated procedures you perform, the more you get paid—doctors who offer preventive care, who don't conduct MRIs or other expensive tests, have to shuffle patients in and out as fast as possible to collect more reimbursement fees per visit. The result is less time with patients, lesser quality care, and exhausted doctors. "You see as many patients in the day as you can. If quality happens as a byproduct of that, that's great—but [insurance companies are] not going to look at that," says Dr. Jay Fathi, a family physician at Seattle's Swedish Medical Center, one of the largest nonprofit health care providers in the Pacific Northwest. "You're on roller skates all day."

Studies and reports for decades have shown that greater access to primary-care doctors provides benefits reaped across the population. By spending more time with their patients and learning their personal backgrounds and medical histories, primary-care doctors deliver higher quality care, prevent chronic conditions, improve quality of life, and lower mortality rates. And, crucially, more preventive care substantially lowers health care costs. "If you build on a primary-care model, you get more satisfied patients, better outcomes in terms of equality of care, and it costs less," says Dr. Eric Larson, director of the Group Health Research Institute at Group Health Cooperative in Seattle. "All the major industrial countries generally have built their system [on] primary care and build off it. We're doing just the opposite."

The good news is the Obama administration and some members of Congress to an extent understand this. They believe in the benefits of more preventive care, and recognize what needs to be fixed in our unbalanced system. To address the burdensome debt levels of new doctors, $200 million in stimulus funding went to expand the National Health Service Corps, a government program that offers loan repayment for med-school graduates who often practice primary care in underserved areas; under the House tri-committee health care legislation, another $4 billion would be allocated to NHSC over a decade.

With regard to payment, the House and Senate health care bills would increase Medicare reimbursements to primary-care doctors, which, today at about $30 to $50 per patient for a typical office visit, are long overdue for an increase. Doing so would begin to allow doctors to slow down and spend more time with patients instead of darting from one to the next. The bills would also invest more to boost primary-care access in underserved areas, and increase training opportunities in fields like family medicine, general internal medicine, general pediatrics, and geriatrics.

Even better would be major investment in concepts like the patient-centered medical home, an integrated system that coordinates all elements of a patient's care in one setting and offers round-the-clock access for patients. This kind of system, which is in use at a few scattered locations in the US, would reward doctors not for how many patients they can see in a day, but for how well they treat their patients and what their outcomes are. At the Seattle-based Group Health Cooperative's patient-centered medical home, just one year showed promising results with 29 percent fewer emergency room visits, 11 percent fewer hospitalizations that primary care can prevent, and 6 percent fewer in-person visits.

What remains to be seen is whether primary-care-focused funding will survive the gauntlet of lobbyists and special interests involved in the health care fight and, if a bill even passes, the cost-cutting process before the legislation lands on Obama's desk. Failure to bolster primary care, experts say, could be ruinous for any attempt at reform and almost certainly shut out millions of Americans from crucial health care—even if they are insured. "Giving coverage," says Ted Epperly of the AAFP, "doesn't create a better system unless you have a delivery system that's also fixed."