Who Will Care For The Newly Insured?

As more Americans gain access to primary care, fewer physicians are providing it. Dr. Wendy Johnson examines many barriers to growing the primary care workforce and urgently calls for change.

By Wendy Johnson, M.D.

A middle-aged woman sits pensively in the corner of the exam room. The physician has just explained, in Spanish, that she will have to increase her doses of insulin if she is to control her diabetes. He carefully reviews the changes in her complicated regimen until she nods in understanding, then he goes over the results of her recent lab tests, changes her medications for hypertension and cholesterol based on her exam and lab results, and listens patiently as she talks about her insomnia and her anxiety over her teenage son who is experimenting with drugs and her partner who recently lost his job.  He knows that if she is to successfully manage her own illness, she will also need help with these other stressors in her life.
 
For this hour of work, the family practice physician bills about $120. To compare, a colonoscopy, which takes a gastroenterologist about 30 minutes, costs about $1000. The average charge for a cardiologist to perform a heart angiogram is about the same. All these procedures require skill and years of training, but the primary care doctor has to combine vast generalist knowledge of medicine with deep empathy; strong, often cross-cultural, communication skills; and a willingness to deal with patients’ psychosocial as well as biomedical issues. If the primary care doctor does his job well, those other more costly specialist interventions might be prevented. Unfortunately, finding a primary care provider willing and able to provide this kind of care is increasingly difficult. 

2014 will see an enormous increase in the rolls of the insured – Medicaid has 400,000 new enrollees and four times that many have enrolled in private insurance – but access to quality health care might not follow automatically.  The hurdles currently being negotiated by those trying to sign up for health insurance are just the first barrier. Once they obtain new health insurance, thousands of people will be seeking primary care providers only to find that none are readily available.
 
In New Mexico, and elsewhere in the country, there exists a severe primary care shortage.  According to the University of New Mexico, the state is short by 2,000 doctors overall and about 600 primary care doctors. Compounding the problem is the misdistribution of doctors throughout the state as about half the physicians in New Mexico practice in and around Albuquerque.  The state is expected to add up to 172,000 to the Medicaid rolls over the next year and because New Mexico has an older population compared to the rest of the country, a higher proportion of those can be expected to have chronic and complicated medical problems.  Finally, nearly 40% of New Mexico’s primary care physicians are over 60 and nearing retirement, and not nearly enough younger doctors are available to take their place.
 
The trends are not encouraging. Every year more graduating doctors choose to enter medical specialties rather than pediatrics, internal medicine or family practice. Dysfunctional payment policies mean that primary care doctors can earn less than a fourth of the salary of specialists and often work longer hours.  Billing schemes which perpetuate this distortion in how and what we value in our health care system have led to the primary care shortage and are directly linked to poorer health outcomes and more unnecessary and expensive care.
 
A report released recently by The Commonwealth Fund reiterated what many studies have shown in the past few years:  The US has the most expensive and least effective health care in the world.  Not only do we spend the most overall, but even insured Americans spend more out of pocket than do our peers in other rich countries. The study also found that the US has the worst access to primary care and the highest emergency department use while we have comparatively good access to specialty care. And we have the greatest disparity between primary care and specialist pay.  We perform more coronary bypass grafts than any other country, and we are near the top in amputation rates due to diabetes.  One can imagine that this might be due to the way that primary care is marginalized in our health care system.
 
We know that good primary care saves lives. Medicare recipients who live in primary care shortage areas are nearly twice as likely to undergo a preventable hospitalization. Unfortunately, more and more of us are destined to live in these areas – up to 44 million of us after expansions in insurance coverage kick in under the Affordable Care Act, according to a recent study in Health Affairs. And the outlook is bleak for the future, with a projected deficit of 65,000 primary care physicians by 2025.
 
Unless there is a dramatic change in our health care system, this trend will not be reversed. Only about two percent of medical students expressed interest in becoming general internists in a recent survey, and about half of medical students expressing interest in primary care change their minds by the time they are done with their training.  As the Medical Director of a community clinic in Santa Fe, I can understand their reasoning. In addition to lower pay and lower prestige compared to other physicians, our health care system rewards those dedicated to providing primary care with long hours, challenging work environments and scant resources to provide the services our patients need to prevent those costly hospitalizations. Unless we are willing to address the inequities and distortions in our health system which handsomely compensate sub-specialists doctors and hospital, pharmaceutical and insurance company CEOs while quickly overwhelming and burning out dedicated primary care providers, we will not be able to achieve the kind of health care we all want and deserve.
 
Dr. Wendy Johnson is Medical Director of La Familia Medical Center in Santa Fe, New Mexico.  A version of this article first appeared in the Santa Fe New Mexican.  
Posted by Sonya Collins on Jan 9, 2014 10:33 AM US/Eastern
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