primary care is a value…but to who ?

In an ideal (unrealistic) world a primary care provider should be able to handle a wide variety of issues with enough expertise to make a case to insurers, and the general population that they have inherit value that deserves a set compensation.

This is not an ideal world and primary care has not made it’s case.

Medical subspecialists will do what they can to provide primary care. The Marcus Welby era, although nostalgic, has faded away.

To pull what I’m referring to out from that site, since I wonder if the link will work:

Massachusetts had 82 active primary care physicians per 100,000 population in 2000, higher than the rate of 69 per 100,000 for the entire country.

There were 1,093 physician assistants practicing in Massachusetts in 2000. This is equal to 17.2 per 100,000, compare with a national rate of 14.4.

Unless the state has had a huge out flux of professionals in the past 7 years it would not seem that there is a shortage of primary care workers.

What seems more likely is that they are satisfied with the incomes they are currently making, and are not willing to take on more patients.

Massachusetts data are not representative of the national picture.

As mentioned above Massachusettes has a tiny population …..yet has 4 large medical schools.

I did my training there and many of my attendings had small outpatient practices, did a lot of clinical research, and taught.

Mass. is a Mecca for subspecialty training and care. it was not unusual for patients to travel from other states, countries and continents to receive care here. Needless to say, primary care has virtually no attraction for the subspecialty gurus or their trainees. The amount of NIH money, coupled with pharma money keeps the Bay State far more interested in pursuing sub specialty practitioners.

I think there is no argument that primary care physicians provide a great value. Likewise, no argument in that that subspecialists are for the most part not going to practice primary care.

Why would they ?

What incentive does any physician have to practice primary care ?

“Until the payment system recognizes the high overhead of primary care docs, we won’t have much progress with changing access to care. ”

agreed, but it is already too late..primary care as a field….has largely vanished…

according to the AMA IN 2005..the sub specialists outnumber primary care physicians 2;1

the data links are

http://www.bls.gov/oco/ocos074.htm

I am looking at the data table number 1
(actually for 2003)

The large majority of primary care docs are either FP’s and IM’s. Factually there a large declines in the sheer number of students choosing FP programs

http://www.aafp.org/online/en/home/residents/match/graph5.html

and there is a massive drop in the number of IM’s doing outpateint primary care. Of the 20,000 or so hospitalists…at least 10,000 were doing office primary care as recently as 2002.

http://www.hospitalmedicine.org/Content/NavigationMenu/Media/GrowthofHospitalMedicineNationwide/Growth_of_Hospital_M.htm

I have no data at my finger tips , but after speaking with several recruiters for hospitalist programs…the biggest supply of recruits are office based internists.

Compunding the loss of 10,000 of primary care internists , many large IM training programs show 0 %- 10 % actually choosing primary care.

Maybe Vansihed is the wrong word, but the above data indicate a strong trend away from primary care occuaptions.

It seems as if now is the time to open a cash-only primary care practice.

There’s no question that primary care access for this country overall is in trouble..Just look at the number of primary care residency slots nationally…only about 260 in Internal medicine…That’s 5 new primary care internists per state per year..then figure half of these are women who will take time to have families and will therefore be less than fulltime equivalents. Now, of those 260 only about two thirds are filled by US trained MD’s. Family medicine is even worse!! AS a matter of fact, our nation is currently dependent on foreign trained MD’s in order to run the residency programs..so recruitment isn’t just based upon exceptional quality but neccessity…and how morally fair is that to other, especially underdeveloped nations!
Insurances understand the value of well trained primary care physicians who can server as gate keepers..doing more in a more cost effective setting (a recent article in tthe Green Journal supports this) Access to care will become increasingly hard for the geriatric (growing) population as primary care md’s limit the number of m’care they take on…that’s simply economics and we can blame congress for this. Medicare is short on funding, for a number of reasons, but in large part because congress is too gutless to means test it. It starts out with means testing (the more you make the more you pay in..up to a cap) but once one retires the CEO of a fortune 500 company whose income is still over 6 figures still pays the same premium as some poor slob whose best in life was to work in a backwoods sawmill cutting pulpwood and is trying to get by on a $600/mo social security check……….Just think how much it would help primary care if every M’care patient had a co-pay (over the usual M’care allowed charge) that was graded and tied to his or hers last income tax return..not much somewhere’s between 3- 15 dollars……suddenly primary care has a financial cushion that hasn’t taxed m’care a cent more and only cost the average patient 30- 150 dollars a year out of pocket more…it’s going to take something like this to avert the coming access crisis!!!