Health care changes could impact primary care doctors

For almost three decades, Dr. Charles Pinkerton has practiced medicine in Portsmouth as a primary care physician. Since he arrived in 1980, he has seen the best and the worst of the health care system up close and his diagnosis is sobering.

There are plenty of issues at play in his wide-ranging survey of what affects him and his patients — they include inadequate Medicare reimbursements, bureaucratic fighting with health insurance companies and demoralizing, regular hikes in medical liability insurance premiums.

But one of his top concerns for the future is one that doesn't usually make headlines in the health care debate, but it may prove be the most important determining factor in the success of whatever reform bill is passed in Congress — a nationwide shortage of primary care physicians like himself.

"I still enjoy very much what I do," said Pinkerton, an internal medicine specialist. But the demands on primary care physicians, who are the main providers of less-costly but outcome-rich preventive medicine, have increased over the years. And health care economics have changed so dramatically that the crucial aspect of primary care medicine has been downgraded for a technologically focused, procedure-driven reimbursement system.

For Pinkerton and his former five partners it led to a painful choice earlier this year to sell their practice to Portsmouth Regional Hospital.

The primary care physician shortage has been decades in the making and is due in part to lower pay, higher debt coming out of medical school and more stress on the job.

A potential flood of tens of millions of formally uninsured patients into the system could overwhelm it because primary care physicians are the first line of defense.

The need for more doctors comes up at almost every congressional hearing and White House forum on health care. During his Portsmouth town hall appearance last month, President Barack Obama mentioned the shortage and said his administration is addressing the issue.

The Association of American Medical Colleges estimates the overall shortage of doctors may grow to 124,400 by 2025 — and that the average medical school graduate is entering the market more than $140,000 in debt.

According to a study in a recent issue of the Annals of Internal Medicine, adverse work conditions are also a factor in the decline in primary care physicians.

"Unfavorable work conditions are associated with stress, burnout and intent to leave for primary care physicians," said study author Dr. Anita Varkey, an assistant professor at the Loyola University Chicago Stritch School of Medicine.

The study results mirror what Pinkerton said is typical of a primary care practice — 53.1 percent of physicians reported time pressure during office visits, 48.1 percent said their work pace was chaotic, 78.4 percent noted low control over their work and 26.5 percent reported burnout.

As few as one in five new medical school graduates enter the primary care field.

"You don't have American medical graduates going into primary care fields in other than very tiny numbers and even some of the residency slots that used to be filled by foreign graduates are going unfilled," said Dr. Stephen Schoenbaum, executive vice president for programs, with the Commonwealth Fund Commission, a nonpartisan public policy think tank.

Like Pinkerton, more primary care physicians may end up as employees of hospitals or larger health organizations. "We are a loss leader for the hospital," Pinkerton said.

He's uncertain of the long-term consequences of this shift but he does know that primary care physicians will have to be paid more — he traces the beginning of the decline to 1983 when Medicare reimbursements were frozen — and that the time-wasting bureaucratic entanglements doctors have to deal with must be decreased.

Pinkerton believes the current political rhetoric over reform is misguided and ignores some of the most fundamental issues at play — the federal government has far influence on rising health care costs and overall quality (through Medicare) than is generally believed and that patients are sheltered from the true cost reality of their health care, which leads to a belief that coverage is cheap and plentiful when, in fact, it's not.

He doesn't think a so-called public option will make a positive impact and that patients should be more active and fiscally aware of their choices.

Schoenbaum of the Commonwealth Fund Commission said the primary care physician shortage "is going to get a lot harder before it gets better" but it does provide an opportunity for change — which can't come soon enough for Pinkerton.

"Over time the issues have become magnified and distressing as we have fewer primary care physicians to take care of people's medical needs," he said. "More and more, people are having to go more costly sub specialists and emergency rooms to get the care they need."

The American College of Physicians 129,000 member internists has a good report at:

http://www.acponline.org/pressroom/key_drivers_cost.htm?hp

After noting 10 key drivers of health care costs, Controlling Health Care Costs presents public policy options to control health care costs generated by each of the key drivers:

Advancing Technology, Demographics and Declining Health Status
Lack of Productivity Growth
Inappropriate Utilization
Payment System Distortions
Consumer Price Insensitivity
Medical Errors and Inefficiency
Medical Malpractice
Defensive Medicine
Higher Prices
Administrative Costs

There is going to have to be another level of practitioner to see patients on an regular basis. Full M.D. sitting in little offices is definitely not cost effective in an urban setting.

A primary tenet of Clintoncare was that there were too many doctors and the way to lower healthcare costs was to limit their number. I understand that even though Clintoncare did not pass, they were successful in limiting government loans for some specialties.

The same government that concocted the farm policy will be doing your health policy.

He’s uncertain of the long-term consequences of this shift but he does know that primary care physicians will have to be paid more — he traces the beginning of the decline to 1983 when Medicare reimbursements were frozen — and that the time-wasting bureaucratic entanglements doctors have to deal with must be decreased.

I’m sure the 35 or so new government agencies will help with this. /s

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ObamaCare will give you veterinary level medical care: third rate quack non MDs, after long waits, with no empowerment to order proper tests, with no ability to properly diagnose or treat anything.

But hey, it will be all for the low cost of a 60% federal tax rate.

What the main question here is putting nearly ALL providers onto Medicare and Medicaid reimbursement ONLY.

The plan is to force a screeching halt to medical tech. advancements that are driving HC inflation by just cutting reimbursements to well below cost.

This is where the “savings” in the 0 plan is, no kidding. They think it will be simple.

All reasons I left primary care internal medicine after 20 years in favor of a hospitalist practice. I could no longer justify the toll it was taking on myself and my family.
Even in a busy hospital practice, 3/4 of the applicants available for hire did not go to medical school in this country.

Obamacare will only make the situation worse. Good luck trying to find a primary care physician, much less an American educated one. And contrary to some people’s belief, an MD is preferable to a mid level practitioner. The education and experience are vastly different.

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