Health overhaul likely to strain doctor shortage

Mar 28, 2010 By LAURAN NEERGAARD , AP Medical Writer
In this March 23, 2010 file photo, President Barack Obama and Vice President Joe Biden smile in the East Room of the White House in Washington, before the president signed the health care bill. Doubted and deeply in need of a comeback, President Barack Obama had a political dream week: the biggest reform to health care in decades, an overhaul of college loans, and a U.S. deal with its old foe Russia to shrink the nuclear arsenals of both countries.(AP Photo/Charles Dharapak, File)

(AP) -- Better beat the crowd and find a doctor. Primary care physicians already are in short supply in parts of the country, and the landmark health overhaul that will bring them millions more newly insured patients in the next few years promises extra strain.

The new law goes beyond offering coverage to the uninsured, with steps to improve the quality of care for the average person and help keep us well instead of today's seek-care-after-you're-sick culture. To benefit, you'll need a regular health provider.

Yet recently published reports predict a shortfall of roughly 40,000 primary care over the next decade, a field losing out to the better pay, better hours and higher profile of many other specialties. Provisions in the new law aim to start reversing that tide, from bonus payments for certain physicians to expanded community health centers that will pick up some of the slack.

A growing movement to change how primary care is practiced may do more to help with the influx. Instead of the traditional 10-minutes-with-the-doc-style office, a "medical home" would enhance access with a doctor-led team of nurses, physician assistants and disease educators working together; these teams could see more people while giving extra attention to those who need it most.

"A lot of things can be done in the team fashion where you don't need the patient to see the physician every three months," says Dr. Sam Jones of Fairfax Family Practice Centers, a large Virginia group of 10 primary care offices outside the nation's capital that is morphing into this medical home model.

"We think it's the right thing to do. We were going to do this regardless of what happens with ," adds Jones. His office, in affiliation with Virginia Commonwealth University, also provides hands-on residency training to beginning doctors in this kind of care.

Only 30 percent of U.S. doctors practice primary care. The government says 65 million people live in areas designated as having a shortage of , places already in need of more than 16,600 additional providers to fill the gaps. Among other steps, the new law provides a 10 percent bonus from Medicare for primary care doctors serving in those areas.

Massachusetts offers a snapshot of how giving more people insurance naturally drives demand. The Massachusetts Medical Society last fall reported just over half of internists and 40 percent of family and general practitioners weren't accepting new patients, an increase in recent years as the state implemented nearly universal coverage.

Nationally, the big surge for primary care won't start until 2014, when the bulk of the 32 million uninsured starts coming online.

Sooner will come some catch-up demand, as group health plans and Medicare end co-payments for important preventive care measures such as colon cancer screenings or cholesterol checks. Even the insured increasingly put off such steps as the economy worsened, meaning doctors may see a blip in diagnoses as those people return, says Dr. Lori Heim, president of the American Academy of Family Physicians.

That's one of the first steps in the new law's emphasis on wellness care over sickness care, with policies that encourage trying programs like the "patient-centered medical home" that Jones' practice is putting in place in suburban Virginia.

It's not easy to switch from the reactive - "George, it's your first visit to check your diabetes in two years!" - to the proactive approach of getting George in on time.

First Jones' practice adopted an electronic medical record, to keep patients' information up to date and help them coordinate necessary specialist visits while decreasing redundancies.

Then came a patient registry so the team can start tracking who needs what testing or follow-up and make sure patients get it on time.

Rolling out next is a custom Web-based service named My Preventive Care that lets the practice's patients link to their electronic medical record, answer some lifestyle and risk questions, and receive an individually tailored list of wellness steps to consider.

Say Don's cholesterol test, scheduled after his yearly checkup, came back borderline high. That new lab result will show up, with discussion of diet, exercise and medication options to lower it in light of his other risk factors. He might try some on his own, or call up the doctor - who also gets an electronic copy - for a more in-depth discussion.

"It prevents things from falling through the cracks," says Dr. Alex Krist, a Fairfax Family Practice physician and VCU associate professor who designed and tested the computer program with a $1.2 million federal grant. In a small study of test-users, preventive services such as cancer screenings and cholesterol checks increased between 3 percent and 12 percent.

Pilot tests of medical homes, through the American Academy of Family Physicians and Medicare, are under way around the country. Initial results suggest they can improve quality, but it's not clear if they save money.

Primary care can't do it alone. Broader changes are needed to decrease the financial incentives that spur too much specialist-driven care, says Dr. David Goodman of the Dartmouth Institute for Health Policy and Clinical Practice.

"What we need is not just a medical home, but a medical neighborhood."

Explore further: Electronic health records tied to shorter time in ER

More information: American Academy of Family Physicians: http://www.aafp.org

Fairfax Family Practice Centers: http://www.fairfaxfamilypractice.com

Dartmouth Institute for Health Policy and Clinical Practice: http://tdi.dartmouth.edu/

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User comments : 18

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david_42
not rated yet Mar 28, 2010
Medical doctors need to adopt the model long used by dentists with technicians collecting data and performing many of the less complex procedures. Even when preliminary screening has been done, all too often the doctor ends up asking the same questions.
marjon
1 / 5 (1) Mar 28, 2010
Soon you will be fined if you don't see some doctor every year for a 'wellness' check.
You will be just another cog in the state wheel.
antialias
5 / 5 (1) Mar 29, 2010
Better beat the crowd and find a doctor. Primary care physicians already are in short supply in parts of the country, and the landmark health overhaul that will bring them millions more newly insured patients in the next few years promises extra strain.


But having many more patients in the countryside will make being a rural doctor profitable again. This will give others an incentive to set up shop away from the big cities. So one shouldn't construe this as being something bad.
CSharpner
1 / 5 (2) Mar 29, 2010
The massive numbers of doctors expected to quit because of the passage of this bill will further exacerbate the doctor to patient ratio.
JayK
3 / 5 (2) Mar 29, 2010
So because we didn't have enough doctors in the first place is an encouragement to not provide the access to those that need them? This is the dumbest argument against health care ever, which would explain why marjon commented already.
Skeptic_Heretic
4 / 5 (2) Mar 31, 2010
So because we didn't have enough doctors in the first place is an encouragement to not provide the access to those that need them? This is the dumbest argument against health care ever, which would explain why marjon commented already.

The real argument is if physicals are mandated as necessary it will decrease the already strained available doctor supply. Effectively those in need of treatment won't be able to get it because the system is filled with regulatory checks that cannot be pushed back due to legislation.

I don't see that requirement in this bill, but I haven't seen the amendments yet. In any event, having fewer busier doctors will only serve to continue to increase prices. We need to subsidize medical training.
JayK
3.8 / 5 (4) Mar 31, 2010
We need to subsidize medical training.

I think we need a review of the cost of medical training, first.

But for those that say "I have mine, screw you" by way of saying a doctor shortage is justification to obstruct a revamping of health care, well that's beyond standard selfishness and goes into Palin-selfishness, a ground best not traveled by those that have any self-respect.
Skeptic_Heretic
2 / 5 (2) Mar 31, 2010
But for those that say "I have mine, screw you" by way of saying a doctor shortage is justification to obstruct a revamping of health care, well that's beyond standard selfishness and goes into Palin-selfishness, a ground best not traveled by those that have any self-respect.

Well that's not a large group of people. There are a good many like myself who have Health Insurance and don't use it because I find physicals to be unnecessary in most eventualities. Now that I'm hitting my mid 30's that viewpoint is changing, because I'm feeling damn old and probably have developed health problems due to my penchant for a particular subset of recreational vices. Now I think it'd be very dangerous to those who require medical attention, unlike myself, for people who really don't need it, like myself, to be ahead of them in line for a physical. It strikes me as potentially detrimental if the goal really is to improve overall health.
JayK
3 / 5 (2) Mar 31, 2010
So people always know when they need medical attention? How about employers that require regular physicals? Americans are waiting longer before getting medical attention for issues, preventative medicine is far too low to keep the American populace healthy, and was that way before the recession. We've become habituated to the Doc-in-the-box and Emergency Room solutions.
Skeptic_Heretic
4.7 / 5 (3) Mar 31, 2010
So people always know when they need medical attention? How about employers that require regular physicals? Americans are waiting longer before getting medical attention for issues, preventative medicine is far too low to keep the American populace healthy, and was that way before the recession. We've become habituated to the Doc-in-the-box and Emergency Room solutions.

A lot of that behavior is because we don't receive anywhere near the amounts of leisure time that other countries have. Working and commuting up to 90% of your life away greatly reduces overall health.
JayK
3.7 / 5 (3) Mar 31, 2010
A lot of that behavior is because we don't receive anywhere near the amounts of leisure time that other countries have. Working and commuting up to 90% of your life away greatly reduces overall health.

Got citations to that? It isn't that I don't believe you, it is just that that would be incredibly complex to try to Google. I think you have a good point, but that the problem is far too complex to blame on single issues, rather it is a societal behavior problem that will take generational sized changes to correct.
marjon
1 / 5 (2) Apr 01, 2010
So people always know when they need medical attention? How about employers that require regular physicals? Americans are waiting longer before getting medical attention for issues, preventative medicine is far too low to keep the American populace healthy, and was that way before the recession. We've become habituated to the Doc-in-the-box and Emergency Room solutions.

A lot of that behavior is because we don't receive anywhere near the amounts of leisure time that other countries have. Working and commuting up to 90% of your life away greatly reduces overall health.

Get a different job.
Skeptic_Heretic
5 / 5 (1) Apr 01, 2010
Got citations to that? It isn't that I don't believe you, it is just that that would be incredibly complex to try to Google.

Here's just a few:
http://www.forbes...ute.html

http://www.safewo...ork.html

http://sciencelin...3656.php

Get a different job.

Not an option. Find a new forum for your lunacy.
Caliban
1.5 / 5 (2) Apr 04, 2010

Got citations to that? It isn't that I don't believe you, it is just that that would be incredibly complex to try to Google. I think you have a good point, but that the problem is far too complex to blame on single issues, rather it is a societal behavior problem that will take generational sized changes to correct.


Probably about 20 more years will take care of the "generational" component.

As far as increased demand for "wellcare"- Perhaps all of you are unaware that the average time a Dr spends with a patient is on the order of 8 MINUTES(no joke), the remainder is handled by other staff or referred out-clinic. This excepts private clinics and VIPs(of course).
What I hear is people claiming that Drs will lose revenue. Quite the contrary. They'll be no busier than ever, and get better reimbursement.
And besides- is a Doctor concerned with people's health, or with a 500SL and a country club membership?
Skeptic_Heretic
not rated yet Apr 04, 2010
Do you think a full physical in under 8 minutes is anywhere near the quality that a doctor would like to give to his patients?
Caliban
1.5 / 5 (2) Apr 04, 2010
Do you think a full physical in under 8 minutes is anywhere near the quality that a doctor would like to give to his patients?


Didn't say that.
That's what you get now, and most of the process is carried out by others. So we probably won't be seeing much change in the model of care, initially.

However, I foresee that many more people will be able to go into medicine as doctors than have recently, as the reimbursement structure just got significantly improved, and hence a doctor WILL BE ABLE to spend more time with a patient than has been the case in the recent past.
Skeptic_Heretic
not rated yet Apr 05, 2010
However, I foresee that many more people will be able to go into medicine as doctors than have recently, as the reimbursement structure just got significantly improved, and hence a doctor WILL BE ABLE to spend more time with a patient than has been the case in the recent past.

Doctors have limited time with patients due to their demand, not due to how much money they want to make. If you increase the amount of money they make per visit they'll simply see less patients thereby exacerbating the problem of having too few doctors to handle the patient load.
marjon
1 / 5 (2) Apr 05, 2010
Medical doctors set the rules and the state enforces those rules regarding education and what an MD can do, what a RN can do, what a PA can do, what a DO can do and what a chiropractor can do.
Breaking that guild is a good first step.