but patients cannot find a doctor


Category : Medical Rants


Where Have All the Doctors Gone?

The primary care crisis raises questions not just about future access but about current morale.

“There was a tremendous amount of disenchantment, frustration, all bordering around one thing,” Tim Norbeck, the executive director of the Physicians’ Foundation, said of the survey. "Doctors feel they can’t spend enough time with their patients because of the paperwork and red tape hassles.”

Mr. Norbeck added: “Physicians went into medicine to spend more time with their patients, and that time has just been eroding. There’s serious reason to believe that there won’t be enough doctors to cover people sooner than we thought.”

Regular readers of this blog will recall how often I emphasize time.  As a physician our only currency is time.  Whenever we are not seeing patients, we are not making money.

We have the confluence of many undesirable problems.  Unfortunately, we can trace many problems back to the creation of a government bureaucracy – Medicare.

Please follow my argument before you start your commentary.  Medicare provides a wonderful benefit to patients.  Health care is expensive.  The price of health care has increased much faster than income. (Please note that I chose the word price rather than cost.) 

Because prices are increasing, Medicare has tried classic bureaucratic techniques to minimize expenses.  Our billing system requires extensive documentation.  If we do not document well, then we are not paid appropriately.

In an effort to pay physicians more appropriately, Medicare adopted RBRVS.  But then they made a huge mistake.  They let the AMA develop the RUC – The primary care reimbursement mess.  The members of that secret society include very few primary care physicians and many proceduralists.  Dr. John Goodson does a wonderful job explaining the implications of the RUC on primary care payment.

At a similar time, primary care married managed care.  During the late 1980s, primary care was all the rage.  Managed care provided better payment for primary care.  The subspecialists revolted and primary care suffered.  Managed care made primary care and subspecialty care opponents for physician payments.  Primary care has not yet recovered from losing this battle.

And managed care added another wrinkle which plagues all physicians today – prior authorization.  We have to spend our valuable time begging over the telephone so that our patient can get an imaging study or a consultation, or even a hospitalization.

The most recent actor in this play came with the adoption of hospital medicine as a career option.  Hospital medicine probably takes over 90% of internal medicine graduates who do not subspecialize, leaving very few for outpatient medicine.

So we have multiple problems for anyone wanting to do outpatient medicine.  We have other options which allow us to change to inpatient physicians.  For those who love outpatient primary care, we have the growing trend towards retainer medicine.  Retainer medicine, which has many positive features, decreases the number of patients that a physician sees.

Dr. Chen is correct.

I won’t envy Mr. Obama as he steps into the White House in January. Any attempt to make health care more accessible will be doomed to failure without an adequate number of primary care physicians and a strong primary care system. The situation in Massachusetts should be a wake-up call. Since a landmark law was enacted in 2006 requiring health insurance for nearly all residents, the state has struggled to provide primary care to the estimated 440,000 newly insured.

Mr. Obama and his team may find ways to give more Americans access to the waiting room, but what if there’s no doctor on the other side of the door? The crisis in primary care must be addressed before any real change can occur; otherwise, the flood of new patients may instead turn out to be a final strike for our ailing health care system.

And at that point for all of us, doctors and patients, the game would be over.

I hope they are reading and understanding.


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Comments (4)

This report indicated thousands of doctors will switch to direct practice concierge medicine and hundred so thousands of primary care doctors will simply just quit practice. For sure Obama like Romney in Mass. can provide access to a waiting list, but not access to care. Only willing doctors can do that, and primary care doctors are no longer willing or able financially to run any faster or in many cases any more on the hamster wheel. The switch to concierge medicine could save primary care and provide enough such doctors to do the job

Thomas W. LaGrelius, MD, FAAFP
President, SIMPD http://www.simpd.org (formerly concierge doctors society)
Owner, SPFC http://www.skyparkpfc.com

MDVIP has already displaced approximately 750,000 patients. WIth 2000 physicians practicing this model 4,800,000 patients or 1.5 % of the U.S. patient population has already been displaced. The system is so broken my wealthier patients asked me to start this practice (advertising budget … zero dollars … word of mouth only). Now I can see 100 patients and actually afford to pay my student loans (used to have 4000 and work 80 to 100 hours a week in a practice that was losing money!!!)

My mother had terminal cancer about 15 years ago and eventually passed away. We had the best insurance that money could buy yet my mother spent 2 days getting over chemo and the rest of the time trying to get the insurance companies to pay for her treatment. Obama had a similar story with his mother. The scary thing is that people are now paying even high premiums and getting less in return. It needs to stop.

So, You Want To Be A Doctor…..

In recent times, others have appeared to express concern about the apparent shortage of primary care doctors in particular in the United States. Both presently as well as in the years to come, others speculate that the shortage of doctors will continue to progress to even greater absence of PCPs that what exists now. Less than 20 percent of medical school graduates go for primary care as a specialty as a residency program today. Typically, the main reason believed by many is lack of pay compared with other medical specialties. Some anticipate a shortage of 60 thousand or so primary care doctors in the future within the United States. The PCP doctors who practice right now would not recommend their specialty, or their profession, it has been reported.
It is estimated that the U.S. needs presently tens of thousands more primary care physicians to fully satisfy the necessities of those members of the public health. Ironically, PCPs have been determined to be the backbone of the U.S. Health care system, which I believe them to be. For example, PCPs manage the many chronically ill patients, who benefit the most from the much needed coordination and continuity of care that PCPs historically have strived to provide for them. Nearly half of the U.S. population has at least one chronic illness- with many of those having more than one of these types of these illnesses. A good portion of these very ill patients have numerous illnesses that are chronic, and this is responsible for well over 50 percent of the entire Medicare budget, who are largely cared and treated by PCPs.
The shortage of primary care physicians is possibly due to other variables as well- such as administrative hassles that are quite vexing for the physician vocation overall- along with ever increasing patient loads complicated by the progressively increasing cost to provide care for their patients due to decreasing reimbursements from various organizations the doctors receive for the services they provide. For reasons such as this, it is believed that some PCPs are retiring early, or simply seeking an alternative career path. As mentioned earlier, the PCP specialty is not desirable for a late stage medical student, so this is quite concerning to the public health in the United States. The number of medical school graduates entering family practice residencies has decreased by about half over the past decade or so. PCPs also have extensive student loans from their training to complicate their rather excessive workloads as caregivers with decreased pay, comparatively speaking.
Despite the shortage of these doctors, primary care physicians do in fact care for the populations they serve and are dedicated to their welfare, as difficult as it may be for them at times. Studies have shown that mortality rates would decrease due to increased patient outcomes if there were more PCPs to serve those in need of treatment. This specialty would also optimize preventative care more for their patients. Studies have also shown that, if enough PCPs are practicing in a given geographical area, hospital admissions are decreased, as well as visits to emergency rooms. This is due to the ideal continuity in health care these PCPs provide if numbered correctly to serve a given population of citizens. In addition, PCP care has proven to improve the quality of care given to patients, as well as the outcomes for these patients as a result are more favorable. Most importantly, the overall quality of life for their patients is much improved if there are enough PCPs to handle the overwhelming load of responsibility they presently have due to this shortage of their specialty that is suppose to increase mildly if at all in the years to come. The American College of Physicians believes that a patient- centered national health care workforce policy is needed to address these issues that would ideally be of most benefit for the public health. Policymakers should take this into serious consideration.
“In nothing do men more nearly approach the Gods then in giving health to men.” — Cicero
Dan Abshear (ex-military medic and physician assistant for nearly 20 years)
Author’s note: What has been written has been based upon information and belief of a layperson, yet also the assessments of a patient.

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