How to Increase the Number of Primary Care Physicians

The recently passed healthcare reform legislation in the United States will soon give 32 million uninsured Americans coverage. While this is literally a lifesaver for the families and individuals who do not currently have medical insurance, it presents an extremely large challenge for the healthcare delivery system.Primary care physicians are the most important cog in the U.S. healthcare machine and there are not nearly enough physicians who practice in this area. To make matters worse, the medical students who are entering practice are staying away from the primary care specialty in droves.This begs several questions. What factors are causing medical students to avoid becoming primary care physicians and what can the healthcare delivery system do about this? Also, with fewer physicians, who exactly will treat the 32 million newly-insured patients?

Young physicians spend many years of often grueling education and training. This includes years of undergraduate school, medical school, internships and residency training. This is both exhausting and expensive.When most residents are contemplating their first private practice job, they are deeply in debt and barely earning enough to pay the interest on this debt. These are extremely intelligent and motivated people who have watched their friends, who chose non-medical professions, begin to enjoy a compensation that is commensurate to their academic training and work ethic.As a result of this economic and psychological stress, most of the best and the brightest from medical schools choose more lucrative specialty fields. This leaves very few to be trained as primary physicians.

A recent article in “USA Today” entitled “Doctors tack on fees for patients” shows the economic reality of being a primary care physician in the United States. It noted that a growing number of doctors are asking patients to pay fees for services that are not covered by insurance. The extra payments include such things as; “no show” fees of $30 to $50 for missed appointment, fees for completing health forms for work and school and annual administration fees of $35 to $120 or more as a type of “retainer” for simply being a patient of the practice.The primary payers of medical charges – insurance companies – are not pleased with this arrangement. Wellpointe, the nation’s largest insurer and the focus of some scorn by the Obama administration for their recent attempt to increase insurance coverage fees, noted that these “a la carte” payments might violate provider agreements if doctors charge for items that insurers feel should be included in their payments.

The question of whether all citizens have a right to reasonably priced healthcare or whether this care should be rationed based on the ability to pay for it is the crux of the healthcare debate. About 50 percent of U.S. citizens believe healthcare is a fundamental right and should be universally available. The rest of the country’s citizens feel strongly that individuals should either pay for insurance that covers most of the costs of healthcare or they should pay the market rate from their own pockets. The passage of the healthcare reform legislation, while it did allow for more people getting affordable insurance, did not definitively clarify the universal healthcare argument.Putting aside the philosophical differences about the availability of healthcare, governmental healthcare planners, medical insurance companies and physician groups are grappling with what can be done to encourage more medical students and residents to become primary care physicians. This is not philosophical exercise. It will determine how effectively the newly insured, senior citizens and even the people who currently have health insurance receive medical care.

In a market-driven economy such as that of the United States, supply and demand usually dictate price. In the case of primary care physicians, if there are 32 million additional people who need the services of primary care physicians and there are not enough physicians to meet this demand, the price for this service should rise. Or, other compensatory elements must be brought to bear by the government or the patients who use the service. Therefore, if a young doctor decides to meet this “demand” for primary care physicians and become one, she/he will likely have to receive some financial incentive for doing this. This situation leads to several choices for insurance companies, federal government, the patients and the physicians. Some of these will not be pleasant for all of the stakeholders of healthcare in the U.S.

One option to encourage more primary care physicians would be to offer financial incentives, in the form of forgiveness of debt for medical education, to those students who choose to become one. Along with this debt-forgiveness, other considerations such as agreement on the part of the physician to serve rural and inner city populations could also be a part of this incentive.Another partial solution would be to increase the funding for programs such as the Medicare program and expand the coverage to include patients of these primary care physicians, using these funds to better compensate these doctors for their service. While this strategy will likely be unacceptable to the group who feels that healthcare should be treated as any other fee-for-service enterprise, it would give financial incentives for doctors to become primary care physicians.The forces of free enterprise seem to be driving another partial solution for stimulating more income (or at least less uncollected costs of doing business) for primary care physicians. This would be the phenomenon of charging, a la carte, for services that are not paid by insurance companies that was noted above.The early-adopters of this strategy are getting some push-back from the insurance companies and some patients, but it seems logical that when the additional 32 million patients get coverage and there are not enough physicians to deal with this onslaught, insurance companies and patients alike will recognize that either physicians must be fairly compensated for their time, or there will be fewer physicians leading to less care.Perhaps the most important strategy for making primary care medicine more attractive to medical students is to give them better training on the business aspects of the practice of medicine. In spite of many years of science and clinical training, young doctors get almost no training in such mundane but important areas as managing the financial aspects of a practice, personal financial planning, goal-setting, non-clinical personnel management, personal growth and other non-scientific areas of life. This is a mistake and leads to frustration and unhappiness among newly licensed physicians.Companies such as CareerPhysician (www.careerphysician.com) have begun to offer this non-medical training for residents and fellows. Students who have participated in these programs have a better understanding of what to expect from the business of medicine and life. As medicine becomes more complicated, the physician who is better prepared for dealing with the financial and psychological stress of a practice will be more likely to enjoy his/her profession and continue to contribute to the overall delivery of healthcare.

The image of a kindly, general practitioner whose medical wisdom was only surpassed by his unquestioned dedication to doing everything and anything to help his patients is gone. It has been replaced by a healthcare system that is managed by private insurance companies and healthcare facilities whose managements are rewarded for efficiency and money-saving programs. It is made up of Medicare and Medicaid programs whose policies manage to anger both the physicians and the patients. Plus, it involves large pharmaceutical and medical device companies that invest billions of dollars on products that they expect to earn substantial profits on.In the middle of all of this, inundated by the paperwork that is necessary to track all of this efficiency is the physician. The years of training and personal sacrifice are not that important to the people who call the shots on payment for care. Patient care is seen as important to the people who supervise payments but not so important that business considerations are neglected.Is there any wonder why more smart young students avoid primary care medicine and opt for more lucrative specialties or avoid the practice of medicine altogether? Perhaps that will change. The tsunami of newly insured people will test the ability of the healthcare system to respond and it might very well lead to more a better primary care physicians.