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Medical experts foresee critical shortage in primary care soon

By Rick Stouffer
Sunday, May 2, 2010

Andrew Fisher wants to be the kind of physician the United States sorely lacks, but he is keeping his options open, depending on how health care reform evolves.

The 32-year-old native Minnesotan has a year left in his residency program as a primary care doctor at the University of Pittsburgh Medical Center, concentrating on elderly patients.

"Why primary care• I wanted to do something that would help people who need care, and I feel like I'm doing that," Fisher said. "I'm treating the older and sicker."

Fisher's plan to serve as the initial stop for the ailing elderly in the health care system is a mindset that experts say is seriously lacking among the nation's young doctor population.

The Association of American Medical Colleges projects that by 2025, there will a nationwide shortage of 46,000 primary care doctors.

Pennsylvania had about 16,300 primary care physicians in 2008, according to data from the Kaiser Family Health Foundation, the most recent available. Based on current need, a University of Pennsylvania expert estimates the state's current shortage at about 1,000 primary care doctors, or about 7 percent of the total.

The shortage of primary care physicians is attributed to many reasons. Among them are low compensation compared with specialists, a lack of interest by medical school graduates, liability problems and a growing number of primary care doctors opting for early retirement. How primary care is viewed, discussed and taught in many medical schools, is cited.

"Primary care is one of the lowest paid physician professions today," said Ralph Schmeltz, for more than 40 years a practicing internal medicine doctor prior to retiring last July, and president-elect of the Pennsylvania Medical Society.

Health care reform's mandate that all Americans have health insurance soon will run into the reality of a lack of new primary care doctors such as Andrew Fisher at all levels.

An estimated 32 million people nationwide will be added to insurance rolls within the next five years, the result of health care reform signed into law in March. In Pennsylvania, the number of uninsured is estimated at about 1 million, according to the state Department of Health.

Primary care practice includes family, general internal medicine, general pediatrics and geriatric physicians.

"We see the shortage in Pennsylvania climbing to 20 percent from about 7 percent over the next decade, without the impact of health care reform, which we don't think will make a huge difference," said Richard Cooper, a retired oncologist and current professor of medicine at the University of Pennsylvania in Philadelphia.

"The major issue won't be how many more people will seek care, but how many more people will be alive and need care," said Cooper, who serves as co-chairman of the Council on Physician and Nurse Supply.

Some health care industry experts see the combination of added patients and a primary care physician shortage resulting in no solution to the existing health care situation.

Even with some form of insurance coverage, thousands of Pennsylvanians and millions of Americans may continue visiting hospitals when care -- regardless of severity of need -- is required, the experts believe.

"The combination of an insufficient number of primary care physicians, with the increase in the number of insured wanting care means nothing will change," said Jeffrey Hoffman, a senior partner in the health care practice at Kurt Salmon Associates, based in San Bruno, Calif.

"People will continue to access hospital emergency rooms for care, particularly if half the people added to insurance rolls are in a Medicaid-like plan," Hoffman said, referring to the federal-state insurance program that traditionally has paid providers less than commercial insurers for services.

It's not uncommon for newly designated physicians to begin practice with school debt totaling $160,000 or more. Fisher's debt load is $200,000. The average annual primary care physician's salary is about $157,000, but some medical specialists command two or three times that salary, experts said.

Fisher, who hopes to remain in the Pittsburgh area once his residency is completed, estimates he initially will earn between $110,000 and $150,000 annually.

But he's watching how health care reform evolves in the next 12 to 18 months, because he's unsure how reform will be paid for, how costs will be managed and if doctors will continue to be responsible for controlling costs.

"I might go back to critical care, which I liked, depending on how reform evolves," Fisher said.

Many industry watchers say the answer to the shortage includes paying more to primary care physicians, opening medical schools to more students, increasing the number of openings in residency programs at teaching hospitals, and decreasing patient levels and reducing mandated paperwork for existing primary care doctors.

Some experts aren't convinced the above ways of coping will work or even be attempted. "I'm sure that the supply of doctors is artificially limited by organized medicine," said Martin S. Gaynor, a professor of economics and health policy at Carnegie Mellon University.

"Less than half the applicants for medical schools are admitted, plus the industry limits the number of foreign-trained physicians who can practice in the U.S.," Gaynor maintains.

Both Gaynor and Cooper argue that many of the duties family practice physicians perform are best supplied by other professionals.

"Eighty percent of what a family practice doctor does can be done by nurse practitioners," Cooper said. "How many well-baby checkups does a family practice physician have to do; how many times must they deal with a case of the sniffles or a chronic back condition?"

Pennsylvania has the fourth-highest number of nurse practitioners in the country — about 6,800 — according to Susan Schrand, executive director of the Pennsylvania Coalition of Nurse Practitioners.

Nurse practitioners are registered nurses who typically have undergraduate and master's degrees in nursing.

Many family practice physicians spend a great deal of time with elderly patients talking about loneliness, Cooper said. "You don't need someone who spent $250,000 on an education to do that. That's like using a limousine to take people to the grocery store."



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