The Affordable Care Act is expected to provide health insurance for 34 million Americans who need it and, if all goes as planned, fix inefficiencies in delivering medical care. But the new system isn’t yet prepared to deal with the growing shortage of primary-care doctors.
By 2025, the U.S. will require 52,000 more nonspecialist physicians than it has now. This is mainly because there will be more Americans, especially older ones. The increased number of insured people will only worsen the problem. Projections suggest that when that time comes, the U.S. will have at least 35,000 too few general practitioners. And those we have will be badly distributed, leaving many rural towns and poor urban neighborhoods underserved.
No simple solution is possible because this predicament is knitted into American health care -- an insurance-driven, government-subsidized system in which general practitioners’ time and attention isn’t priced as high as specialists’ surgeries and procedures. As long as medical school graduates can expect to earn only half as much practicing primary care as they would in, say, cardiology or anesthesiology, the specialties will keep luring 75 percent or more of them away.
This is why it probably wouldn’t help to increase the number of medical residencies financed by Medicare, as some have suggested. Such a change wouldn’t necessarily expand the supply of generalists appreciably, nor ensure that they practice where they are most needed. From 1979 to 1999, the number of U.S. physicians per capita rose 51 percent, but for every one of them who moved to a low-supply region, four went to places already teeming with doctors.
Nor does the National Health Service Corps provide the whole answer. The NHSC gives scholarships for students in primary care and as much as $60,000 in medical school loan repayment for new doctors who work two years in primary care in underserved communities. That’s a good reward, though obviously not enough to matter financially over a career or to increase the basic appeal of general medicine.
How might more new doctors be persuaded to pursue primary care? One strategy gaining some traction is to transform the work of general medical care. Many doctors see patients in isolated offices, putting in long hours, doing their own paperwork and never communicating with any of the patients’ other providers.
An alternative now being tried in several places across the country is the “medical home” strategy, in which primary-care doctors work in teams with nurses, nurse practitioners, physicians assistants and others to take care of every aspect of a patient’s health, from preventive-care education to treatment of illness and injury. In return, the team receives a global payment that amounts to more than they would be paid by adding up individual fees for services. Bonuses are provided, too, if the team improves patient care.
The Capital District Physicians’ Health Plan Inc., a nonprofit insurance provider in upstate New York, has dozens of physician practices now operating on this model. Payments to doctors in these offices are 40 percent greater than before -- and even higher for those with sicker patients. At the same time, cost growth in these practices has been lower than average for the region, and the patients are using hospitals, emergency rooms and advanced imaging less.
Medical homes make primary care more appealing by not only upping the pay but also allowing doctors (and all other team members) to work at the top of their ability, making their jobs more satisfying day to day.
Such a change could keep generalists from retiring early or entering specialties to escape the grind and, perhaps more important, attract more students to primary care -- if medical schools also get with the program.
Standard educational procedure has been for medical students in their third and fourth years to work in clerkships in specialty departments of hospitals, spending a month or two learning the rudiments of urology, ophthalmology, surgery and so on. By the time they graduate, they have had many mentors who are specialists, but none who practice general medicine outside the hospital.
What’s needed are clerkships in community primary care that give students a strong team experience, and that last as long as a year, so they can learn the rewards of getting to know their patients. Studies of this approach are under way, but according to George Thibault, president of the Josiah Macy Jr. Foundation, which supports research on improving medical education, the experience so far seems to make students more enthusiastic about general medicine.
Medical schools should also recruit prospective students from the neighborhoods and rural communities that lack an adequate number of primary-care doctors.
The Affordable Care Act includes some funding for establishing medical homes and for offering education in community-based clinics. Medical schools and insurance plans should help push these efforts. As the U.S. health-care system is transformed in the years ahead, it should become a place where primary-care doctors thrive.
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