The Doctor Is OutEditor's note: This op-ed originally ran on Forbes.com in January 2009. It reviews the growing shortage of primary care physicians, and suggests several market-based solutions. One of those solutions is to expand alliances between physicians and retail clinics (also called limited services clinics) like those offered at Walgreens, CVS, and Wal-Mart. My new report, Easy Access, Quality Care, looks at how one state, New York, could lower barriers to retail clinics and help expand access to basic health care services—but it holds lessons for any state looking to expand affordable health care access.
Market-driven solutions for the shortage of primary-care physicians
February 17, 2011
States will likely face even greater access problems beginning in 2014, when full implementation of the Affordable Care Act begins (if it has not been overturned by Congress or the courts before then).
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Americans know that the folksy family physician who once made house calls, the one from the days of Norman Rockwell and idealized medical dramas like Marcus Welby, is largely extinct. But we still expect to see a doctor when we need one. If a flurry of recent reports is correct, however, the primary-care profession itself is now in jeopardy.
Unless trends change soon, a lack of primary-care providers would endanger the nation's well-being and drive up health care costs.
In a recent survey by the Physician's Foundation, nearly 50% of physicians stated that "over the next three years they plan to reduce the number of patients they see or stop practicing entirely."
The situation looks even worse when one considers the preferences of aspiring doctors: A September 2008 article in the Journal of the American Medical Association reported that only 2% of graduating medical school students planned to go into primary-care internal medicine. The American Medical Association is predicting a shortage of up to 44,000 primary-care physicians by 2025.
Why are primary-care doctors fleeing the field? Start with the paperwork.
Physicians report spending an increasing amount of time dealing with red tape from insurers that reduces the time they can spend with patients and increases back-room costs.
And as administrative burdens rise, reimbursements from both private and public insurers—Medicare and Medicaid—have stayed constant or gone down.
As a result, primary-care physicians earn significantly less than other doctors, like orthopedic surgeons. They've reluctantly begun turning their offices into patient mills, seeing ever-larger numbers of patients to counterbalance costs and keep their offices open. As more doctors leave the field, pressure on their remaining colleagues only increases.
Ironically, even as the nation's primary-care infrastructure crumbles, policymakers are debating universal health-insurance schemes that would inject millions more patients into an already strained system.
Take Massachusetts. In 2006, the state mandated that individuals buy health insurance—and over 400,000 did. But there aren't enough doctors to see them. In September, the Boston Globe reported that "the wait to see primary care doctors in Massachusetts has grown to as long as 100 days, while the number of practices accepting new patients has dipped in the past four years."
Is there a quick fix? Probably not. But some basic market reforms would help.
For one, increase reimbursements. Primary-care physicians should anchor the nation's commitment to disease prevention and management. But reduced payments make this task harder. Since private insurers typically follow Medicare's lead, Congress must increase physician reimbursements—paying doctors more for keeping people healthy and limiting the potentially expensive complications that follow with poorly managed conditions like diabetes, heart disease and obesity.
Second, expand primary care options for patients. Patients with sore throats and ear infections can be treated quickly, effectively and inexpensively by nurse practitioners in retail clinics, which have begun operating in increasing numbers around the country.
Some states and physicians' groups have tried to block these clinics' expansion out of mistaken fears that they break up patient care. Basic care, however, is better than no care at all; some clinics even offer electronic health records (EHRs) and partner with hospitals and physicians to refer patients. This trend should accelerate with the widespread adoption of EHRs, reducing fragmentation of care and inappropriate use of emergency rooms.
Rather than blocking retail clinics, doctors should find ways to encourage and build alliances with them. If routine ailments can be addressed at these outposts, doctors will have more time to promote prevention and treat patients with more complex health problems.
A third solution is to reform the tax code. Based on a Word War II-era IRS ruling, employer-provided health insurance is tax-deductible, while individually purchased health insurance generally isn't. Reconciling the tax treatment between employer- and individually purchased health insurance would encourage more people to opt for high-deductible health plans coupled with health savings accounts (HSAs), where they could pay for more routine expenses out-of-pocket.
This system would give consumers an incentive to seek out health care bargains (like $4 generic drugs at Wal-Mart and push insurers to focus more on disease prevention. Less time and personnel devoted to wrangling payments from insurers will free up doctors and staff to focus on better care and follow up with their patients.
Lastly, limit malpractice litigation. In a recent survey, the Massachusetts Medical Society (MMS) asked doctors how often they practiced "defensive medicine"—prescribing tests, procedures or even hospitalizations not because they thought the patient needed them but to ward off lawsuits. Over 80% admitted that they had resorted to some form of this practice. The MMS estimates that defensive medicine costs the state a staggering $1.4 billion. Reducing litigation—through special medical courts or arbitration—would lower malpractice insurance premiums, increase doctors' take-home pay and improve their ability to offer quality health care to their patients.
It's not too late to create a vibrant marketplace for primary care, a division of health care everyone agrees we need. We can do it by paying more for primary-care excellence, expanding choice and competition at the level of basic health care and removing incentives in the system that lead to overspending and defensive medicine. The sooner we act, the sooner we can put primary-care doctors—and their patients—on the road to recovery.
Paul Howard is the director and senior fellow at the Manhattan Institute's Center for Medical Progress.