2:42 AM, Mar. 28, 2012
They are the quarterbacks of the health care system — generalists who monitor the entire body, give preventive care, spot problems early and send patients to specialists if needed.
Despite their key role, primary care physicians are in increasingly short supply, and a new study says the shortage is expected to become critical soon in Louisville — as it has been in many rural areas of Kentucky for years.
The impending Louisville shortage is due to a perfect storm of factors — an aging population that will need more care, a large number of doctors approaching retirement, and medical students shunning primary care practices for specialties with higher pay and better hours.
By 2020, Jefferson County will need 455 new primary care doctors — almost as many as the number that work in local medical practices now. The new doctors will be needed to replace current doctors who are expected to retire and to meet federal guidelines for serving the projected 2020 population, according to the study the Louisville Primary Care Association commissioned.
And that doesn’t take into account the extra demand for more doctors when health reform could cause millions more Americans to have health insurance in 2014 if upheld by the Supreme Court.
“We see a real workforce crisis in the future — in the immediate future,” said Bill Wagner, executive director of Family Health Centers, a group of community clinics serving low-income residents. “It is a perfect storm.”
Family Health Centers is a member of the primary care association. Others are the Park DuValle Community Health Centers, the Louisville Metro Department of Public Health & Wellness, and the University of Louisville’s dental school and primary care centers.
The study, conducted by REACH Inc. and based on a survey of local physicians, found that about one-third of all the primary care doctors — general internists, family practitioners and pediatricians — are 56 or older and plan to retire within 10 years.
The combination of impending retirements, expected population growth and the trend toward doctors working strictly inside hospitals or urgent-care centers rather than holding office hours means that:
• Jefferson County will need to attract 220 new family practitioners by 2020, or more than the current supply of 167 who don’t work solely at institutions such as the VA Medical Center or hospices.
• An additional 192 general internists and 43 pediatricians will be needed.
• While Louisville has 697 primary care doctors overall, only 517 of them are in typical office settings where they can have an ongoing relationship with patients — and 178 of those are expected to retire by 2020.
To replace those retirees and add other new doctors to meet federal guidelines calling for 100 primary care physicians per 100,000 people, the study projected that 455 new primary care doctors will be needed by 2020.
And not enough younger doctors are in line to fill that gap.
Shift to higher pay
Saddled with $100,000 or more in medical school loans, graduates in recent years haven’t chosen lower-paying primary care as often as older generations did, statistics show.
In the past 15 years, the number of U.S. medical school seniors who entered residencies in family medicine has fallen from 17 percent in 1997 to 8 percent last year, according to the Association of American Medical Colleges. However, the number has rebounded slightly since 2009.
The picture is similar at the U of L School of Medicine. The number of entering medical students the school believed would go into primary care upon graduation, based on statements at the time of admission, has declined 50 percent in the past 11 or 12 years, said Dr. Steve Wheeler, associate dean for admissions.
“The debt load in medical school has increased, the ability to repay debt is influenced by salary once you get out, and primary care is at the low end of that spectrum,” said Wheeler, who is also associate professor of family and geriatric medicine.
On average, primary care doctors are paid as little as half as much as specialists, such as radiologists and invasive cardiologists, according to a national compensation survey.
Yet they typically see many more patients a day and must complete exhaustive paperwork to oversee patients’ overall care.
The time demands and administrative burden are perhaps as important as the pay gap in students’ decisions to shun primary care in recent years, experts said.
“I think it has become a much more difficult environment to enjoy working with your patients in,” Wheeler said.
“It’s more difficult, more stressful, and less rewarding” than it used to be, Dr. Greg Ciliberti, a Louisville internist for 26 years. “And then you’ve got the other stress of, you’re trying to run a business and you never get a raise.”
Not just rural
In Kentucky, physician supply has typically been seen as a rural problem, given that some counties are served by a handful of doctors — while Louisville is home to large hospital companies and a university medical school.
But both in Louisville and nationwide, “I don’t think there’s any question that it’s not just a rural issue,” said Dr. Dan Varga, chair of the Kentucky Medical Association’s physician workforce committee.
“No matter where you’re talking about, we clearly have an aging primary care workforce,” because primary care has been “so unpopular” a career choice in recent years, said Varga, chief medical officer of Kentucky’s St. Joseph hospitals and a former Louisville internist.
“There just aren’t as many students who see that as their call,” Wheeler said.
Given that trend, Wagner said he doubts that medical schools will train enough primary care doctors to fill the gap.
Wagner said his clinics already have a difficult time recruiting primary care doctors in the face of competition from higher-paying hospital operations that increasingly are hiring doctors as full-time employees.
That can leave doctors at Family Health Centers and similar clinics stretched even further to handle their patient load.
“There’s not enough of us,” said Dr. Sarah Fortuna, a staff doctor at FHC’s Iroquois clinic on Taylor Boulevard, during a brief break between seeing patients, updating charts and conferring with a medical technician. “We’re getting more and more patients, but we’re not getting any more staff.”
Fortuna said she probably doesn’t get enough time with her patients.
“I try,” she said. “But is the clock ticking in the back of my head? Yes. I know I have to get to day care at the end of the day, and my techs have other things they have to get to as well.
“I try to stop long enough to give them the time, but there’s days when I go home and go, ‘I know I’ve made (patients) come back in three weeks because I want to talk to them more.’ ”
Fortuna, 39, a single mother and former Air Force doctor, said she doesn’t regret her decision to go into primary care. She likes treating a wide variety of conditions and is “a people person, so I wanted to have long-term relationships with my patients.”
Making the switch
Fortuna said it would be nice to make more money, but that’s not enough to make her switch to a specialty.
But many primary care doctors have done just that.
Fortuna said she trained in a group of eight primary care residents at Eglin Air Force Base in Florida, ending in 2003 — and four of them have since entered specialties.
“They were faced with longer and longer hours in private practice, and most of them didn’t want to do that,” she said. “They wanted to have a life. So they opted out.”
Dr. Dan Garcia, a Louisville allergist, was a pediatrician for 17 years before becoming an allergist in the early 1990s — a move he said he made for his health and to see his family.
With long hours at the office combined with hospital rounds, “I wasn’t getting to see my children” because of caring for other people’s children, said Garcia, 64.
“We had our fifth child, and I came down one morning … Patrick was about 4 months old, and he looked at me like I was a complete stranger, because I hadn’t seen him for over a week,” Garcia said.
A heart bypass operation convinced Garcia he needed a slower pace, and he underwent two years of training to become an allergist. Instead of working 12 hours or more a day, he now works 8 to 10.
“It’s been well worth it,” he said. “The tail doesn’t wag the dog any more.”
Cost of solutions
Though there is a consensus that more primary care doctors are needed, the solutions aren’t easy — and often call for money that isn’t there.
Medical associations have advocated repaying emerging doctors’ medical-school debt as an incentive for them to enter primary care. The National Health Service Corps has such a repayment program, but only for doctors who agree to practice in underserved areas.
And national proposals to increase medical schools’ federal funding for training primary care physicians have lost out to deficit-cutting measures in recent years, said Christiane Mitchell, director of federal affairs for the Association of American Medical Colleges. She said the organization’s top priority is to avoid cuts to existing funding, though it believes federal training money should actually be increased.
With pay levels persuading many doctors to leave primary care or not enter it, some private health insurers and the federal Medicare program are moving to boost reimbursements for primary care physicians compared with specialists.
Last year, the Obama administration established a Medicare pilot program, called for under the 2010 health reform law, to pay primary care doctors to supervise teams of “physician extenders,” such as nurse practitioners, to treat target populations. The so-called “patient-centered medical home” program would directly reward primary care doctors for their time-consuming role in coordinating patients’ care.
Health insurer Aetna announced a pilot program in January to give extra monthly pay to physicians whose practices qualify as patient-centered medical homes, while last July Louisville-based Humana announced a program to award nearly $10 million to primary care practices that show quality improvements.
WellPoint, the parent company of Anthem health plans, also announced a national program in January to pay more to some primary care doctors who keep patients healthy.
But Anthem’s Kentucky organization took a broader and earlier approach in 2008 by boosting all primary care office-visit reimbursements to a level higher than specialists get, said Mike Lorch, an Anthem vice president.
“What we’re counting on, and what we firmly believe, is that … as you improve reimbursement so they can take better care of the patient, you’re going to see a payback in cost of care,” Lorch said.
Without regular access to a primary care doctor, he said, “a lot of times you’re going to end up in the (emergency room), and that’s the most expensive setting.”