Comments on: The primary care shortage

By: ardeshir talieh

ardeshir talieh — Sun, 29 Jun 2008 03:56:27 +0000

The entire system is wrong it must all be reinvenetd ….Think about all aspects of medicine form training , schools, private practice, HMOs , Medicare , Hospitals they are all in deep trouble …….

By: dave

dave — Fri, 25 Apr 2008 01:45:26 +0000

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!!!

By: ninguem

ninguem — Thu, 02 Aug 2007 17:41:34 +0000

Massachusetts has a high physician/population ratio, but they are concentrated in administrative, academic, or research positions. They’re not actually doing front-line clinical medicine.

When it comes to primary care in working-class blue-collar Massachusetts, they’re hurting for docs.

By: CHenry

CHenry — Wed, 01 Aug 2007 03:47:05 +0000

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

By: paul

paul — Tue, 31 Jul 2007 00:04:20 +0000

oh…by the way….

I am not encouraged by the trends away from primary care. A system which would encourage primary care doctors to flourish is desperately needed.

Sadly,what happens in the midwest is not
a reflection of the East or West Coast practice climate.

By: paul

paul — Mon, 30 Jul 2007 23:55:06 +0000

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.

By: Dr. Bob (FP)

Dr. Bob (FP) — Mon, 30 Jul 2007 23:24:34 +0000

How does that equal “vanished”? That still leaves thousands of primary care docs & there are wide regional variations. The most common type of doc in my city is a Family Physician (about 100 in a city of 225,000), no other specialty even comes close. We also happen to be in a state that ranks high on quality, but low on Medicare costs. Fits in well with the Barbara Starfield articles. In fact most of the midwest states (Dakotas, Iowa, Kansas, Minnesota, Nebraska) all rank among the highest when you look at the quality indicators, yet spend thousands less per medicare benificiary. These trends nicely parrallel the relative number of primary care docs & specialists. And no, it isn’t because of the lower cost of living. Many of the southern states with similar cost of living, are exactly opposite on all of those indicators & costs (Louisiana is the worst on all counts).

By: paul

paul — Mon, 30 Jul 2007 03:27:32 +0000

“Until the payment system recognizes the high overhead of primary care docs, we wonâ€™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

By: Dr. Bob (FP)

Dr. Bob (FP) — Mon, 30 Jul 2007 02:29:03 +0000

How about looking at the evidence? Barbara Starfield & colleagues at Johns Hopkins have been studying the data for years (google for her articles) and showing over and over again that the more primary physicians you have, the lower the morbidity, mortality, and costs. Conversely, the more specialists you have the higher the morbidity, mortality, and costs. That’s one of the main reasons our system costs more than everybody elses & produces worse results.

This link:
http://www.aafp.org/online/en/home/policy/familymedvalue/mostcited.html

will hook you up with a 100 or so articles in medical, public health, & economic journals detailing the evidence. They detail over & over again the effects of a primary care based system and increased supply of primary care docs – lower morbidity, lower mortality, lower costs, better access, fewer racial & economic disparities.

I do agree with the problem of the Massachusetts system though. If all you do is open Medicaid up to more people, the problem won’t be addressed. You can’t take care of a majority medicaid population at medicaid rates and stay solvent without some outside funding. When your overhead is $40 per visit and Medicaid only pays you $35 per visit, money has to come from somewhere else. As the costs of practice get closer to $50 per visit, Medicare doesn’t pencil out either. Simply giving more people access to government health plans doesn’t do anything to fix the problem. That is why fewer & fewer docs are going into 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.

By: paul

paul — Mon, 30 Jul 2007 02:03:21 +0000

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 ?