Chevy Chase, Md. — In any given day, Dr. Tiffini Lucas may examine a wailing, feverish two-year old, advise a senior on exercises for arthritic pain and remove an atypical mole from a middle-aged mother’s back.
Lucas is a primary care physician.
Contemporary Family Medicine, located in Chevy Chase, Md., is a small primary care practice. (Elena Schneider/Medill News Service)
She is one of approximately 300,000 primary care doctors who are the first line of defense for American health.
However, those numbers are in steady decline. In 2009, 65 million Americans were classified as living in areas with a shortage of primary care doctors, according to a report released by the federal Health Resources and Services Administration.
More than five years ago, the American College of Physicians warned, “primary care, the backbone of the nation’s health care system, is at grave risk of collapse.”
Not only does the primary care landscape have doctors and experts worried now, but President Barack Obama’s health care reform law — which will add 30 million new patients to the system by 2014 — has many even more concerned about the future.
“You talk about a shortage now?” Lucas said. “There will be a significant shortage [after the reform]. It could be really ugly.”
Vanishing house calls
For much of the 20th century, the family doctor was an American fixture, as portrayed in iconic Norman Rockwell paintings.
While the house call has virtually vanished today, Dr. Tom Bodenheimer, a 40-year veteran of family medicine doctor from California, said that visits to a family doctor can usually take care of 95 percent of a patient’s health problems.
The classic Norman Rockwell illustration "Before the Shot," which first appeared in the Saturday Evening Post in 1958.
“It is taking care of the whole patient, not just one organ system,” Bodenheimer said. “It’s a long-term relationship.”
Historically, the health care system does not prioritize this long-term relationship, Bodenheimer said. In Medicare reimbursements, specialists are often paid twice as much as primary care doctors for the same procedure, Lucas said. With private insurance companies, the price comparisons are not so clear since doctors are often forbidden from releasing reimbursement information.
“For example, I will take off [an atypical] mole, get it to pathology, and have a certain charge and the insurance company will reimburse me,” Lucas said. “The dermatologist will do the exact same thing and the insurance company will pay them more for the exact same service. The care is the same, but they have inherently paid practitioners less.”
This prioritization of care — on the acute and severe, not on the preventable and common — has forced general practices to take a back seat, especially in pay and reputation, according to experts.
For some Americans, this means trips to the emergency room instead of annual visits to their family doctor.
“Primary care should take care of most needs. We should not be sending patients to this expensive care with high risk of harm,” Dr. Barbara Starfield, a primary care policy expert and Johns Hopkins University professor, said. “Since [emergency room doctors] don’t know the patient, they can’t put it in the context of their life.”
Losing lifestyle and salary
For doctors, primary care can offer few attractions. Typically, family practitioners are paid less, work more hours and earn less prestige.
“I never really thought of the money part [in medical school], I just thought about what I wanted to do,” Lucas said. “But when you come out, and when you start working, it’s a much different story. I’ve got the same amount of student loans as a neurosurgeon.”
The pay gap between specialists and primary care doctors is difficult to overcome.
“Unfortunately, they put in a system that has perpetuated itself,” Goertz said. “20 years ago, the income difference [between specialists and primary care doctors] was about $50,000 per year, but now, the difference is between $150,000 and $200,000 per year.”
The payment system favors specialists over primary care doctors largely because of the nature of their work.
“A specialist or surgeon can do more things, especially with technology, so their ability to generate income is much easier than for primary care doctors,” Alwyn Cassil, director of public affairs at the Center for Studying Health System Change, said. “For primary care, their ability to maintain their income is to see more patients, which possibly hurts quality of care.”
With two children at home, Lucas said there must be more incentives to keep her and her colleagues in business.
“I have to balance having time with my family and being able to pay my staff,” Lucas said.
‘Beginning of the pipeline’
To begin to erase the shortage, many experts said more medical students need to go into the field.
Dr. Roland Goertz, president of the American Academy of Family Physicians, medical schools were the unsaid “beginning of the pipeline” for channeling students into specialties instead of primary care. The gap can begin as early as the admissions process.
“Historically, in medical schools, the clinical [primary] care doctors are pulled into working in the hospitals to make money [for the university].” Goertz said, who practiced family medicine in his rural home in central Texas. “So the majority of doctors who fill the admissions committees are the scientists and specialists, not the general practitioners. If the majority are specialists, are they going to pick people that will go into primary care? I don’t think so.”
In a 2007 survey, only 7 percent of fourth-year students at 11 medicals schools said they planned to go into primary care, according to the Health Affairs Journal.
“Medical school professors, themselves, are [pre]dominantly trained specialists, so they don’t know about primary care and do not advise students to look into it,” Johns Hopkins University Professor Leiyu Shi said. “It perpetuates itself.”
For Dr. Mark Knudson, Vice Chair of Education at Wake Forest School of Medicine in Winston-Salem, N.C., it comes down to branding. It is not just prejudices in medical school, but the prejudices in society.
“If patients valued primary care above the skill of their neurosurgeon or how nice their dermatologists’ practice was, if society valued it more, it would be more sought after,” Knudson said.
Primary care and health care reform
The Patient Protection and Affordable Care Act, which passed last March in a Democratic-controlled Congress, made landmark changes to the system, touching several issues faced by primary care doctors.
In particular, the reform offers financial incentives and educational advantages, like debt forgiveness and loan accessibility, for primary care doctors. Under the new law, practitioners working in designated “shortage areas,” will receive a 10 percent Medicare payment bonus for five years.
Despite these advances, Lucas said she is still worried about the strains on the system that will accompany the 30 million new patients.
“When you look at the act, in terms of what it’s going to try and accomplish, it all sounds great from a patient perspective,” Lucas said. “But it’s really the administrative side that worries me.”
In 2009, a Health Affairs Journal study found that in a practice, a general practitioner spends about $70,000 per year on paperwork — another deterrent for medical students interested in general practice.
Under the act, small practices will be required to digitize their files, possibly reducing the amount of money spent, but it makes only a few strides in reorganizing the payment system.
“For the time being, administrative battles will stay the same,” Shi said, later suggesting doctors should hire an office manager to handle billing and filing. “[This reform] is not a single-payer system. Instead, doctors must handle a number of patients with different insurance companies and different payment schedules.”
For some, the reform is a starting point.
“The idea that we’re going to get it right the first time around is nonsense,” Lucas said. “But to say that it’s got to be perfect before we even start to implement anything, it will never happen. There are too many layers to health care.”
Even so, Goertz said this is what the AAFP has been fighting for for 20 years –the opportunity to try.
“From a general practitioner’s viewpoint, the question on our mind is, if we don’t take the offer to move the needle now, when will we come?,” Goertz said. “It’s not perfect, but it’s the step in the right direction.
In particular, the reform’s new focus on preventative care is expected to fund more research and development in the primary care field. Goertz said he is joined by the AAFP in his general optimism about the reform’s ability to help family doctors.
However, some doctors remain skeptical that the system will survive with so many new patients.
“How are you going to put 30 million-plus patients into our fairly dysfunctional [health] system?” Cassil said. “The primary care infrastructure has gone to hell in a hand basket in the last decade.”
Back in the office
Dr. Tiffini Lucas examines an average of 15 patients a day, trying to balance time management and quality of care. (Elena Schneider/Medill News Service)
“I’m hopeful because I still have patients to take care of,” Lucas said. “It’s what has kept me here.”
For both doctors and experts, practices like Lucas’ are central to improving health care.
“This is where we must start,” Starfield said. “We’re not going to fix the health care problem in this country until we fix primary care.”
