Primary care physician shortage looms in Louisville

Written by
Patrick Howington
The Courier-Journal
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.”

SOURCE:

http://www.courier-journal.com/article/20120327/NEWS01/303280053/Louisville-primary-care-physicians-shortage?odyssey=tab|topnews|text|News

Supreme Court’s Medicaid Decision Could Reach Far Beyond Health Care

by for NPR

After Tuesday’s judicial fireworks, the Supreme Court wraps up arguments on the new health care law Wednesday by focusing on two questions. The first involves what would happen if the “individual mandate” — the core of the law that requires most people to have health insurance — is struck down. Would the rest of the law fall, too, or could some provisions stay?

But it’s the second argument the court will hear about the Affordable Care Act that could potentially have the most far-reaching consequences. At issue is whether the health law’s expansion of the Medicaid program for the poor unfairly forces the states to participate.

If the justices find the federal government is coercing the states, that decision could reach far beyond health care.

Medicaid is already one of the nation’s largest providers of health care services, says Diane Rowland, executive director of the Kaiser Commission on Medicaid and the Uninsured.

“It provides health insurance coverage to 1 in 3 American children, so it’s a fundamental part of the way in which we deliver health care services today,” she says.

But as large as the program is, Medicaid today in most states is still not available to people simply because they are poor. They have to be poor and something else — such as a child, a pregnant woman or older than 65. Under the health law, however, that would no longer be the case.

“Medicaid changes from a program that covers certain categories of low-income individuals to a program available for health coverage for all individuals,” Rowland says.

All individuals, that is, with incomes under 133 percent of the federal poverty line. This year that’s $14,856. According to the Congressional Budget Office, that will add about 17 million new people — mostly adults without children — to Medicaid’s 60 million or so enrollees by the year 2016.

Currently, states share the cost of Medicaid with the federal government. Wealthier states pay half; poorer states pay a smaller share. But the federal government recognized that states are strapped for cash these days. So most of the new cost — all of it at first; 90 percent eventually — is being paid by the federal government.

But that’s not stopping states from claiming that this expansion amounts to unconstitutional arm-twisting. That’s because if they don’t follow through with the new changes, they have to pull out of Medicaid altogether — or so they claim.

Former Bush administration Solicitor General Paul Clement is representing the 26 states that are suing over the Medicaid provisions of the health law.

He says what the law means is that if states don’t agree to the expansions, “we’re going to take away all of your money, including all of the money that you’ve kind of gotten used to, all of the money that you’ve used for different groups of people. And that does seem a little more coercive.”

Medicaid is, in fact, a voluntary program. States don’t have to participate. But they all do. And Clement says so much money is at stake — more than $400 billion in 2010 — that dropping out is simply unrealistic.

“How any state at this point could say, ‘We’re just going to turn down Medicaid funding from the federal government’ — I don’t think any set of citizens would allow that to happen,” Clement says. “Because it’s all this money that’s being taken from the state taxpayers that would then be going to every state in the union but that state; it just wouldn’t work.”

But is this latest expansion of Medicaid really coercive? Sara Rosenbaum, a law professor and Medicaid expert at George Washington University, says it’s hardly different from many of the expansions that have come before.

“States already cover a lot of adults,” Rosenbaum says. “They cover parents; they cover adults with disabilities; they cover adults who are pregnant. And so all this expansion does is really to fill in the remaining gaps. And it’s something that many states have wanted to do over the years.”

While states are worried about how much they might ultimately have to pay for all those new adults, even if it’s only 10 percent of the cost, Rosenbaum says, over the long term, they might actually save money.

“There are studies that suggest by just 2019 alone, states will have saved about $100 billion in state funding for uncompensated care, especially for adults,” she says.

But the real reason people are watching the Medicaid arguments so closely has nothing to do with Medicaid. It’s the potential impact on the relationship between the federal government and the states. This is one of the few times the court has taken up what’s known as the “spending clause” of the Constitution.

“It’s long been established by the Supreme Court that Congress can attach conditions to federal funds that it gives the states,” says Elizabeth Wydra of the Constitutional Accountability Center, a liberal think tank. “States can follow the requirements … or they can opt out of receiving the funds altogether.”

But while earlier cases have suggested that there could be limits to those conditions, the court has never said what those limits are. And it’s not just Medicaid at stake.

“That places in jeopardy, in addition to the entire Medicaid program, a host of other very beneficial federal grant programs in the education context, child welfare and other programs,” Wydra says. In fact, it could affect virtually any program in which the federal government gives money to the states with conditions attached.

So far, no lower court has agreed that the Medicaid expansion coerces the states. But no one expected the Supreme Court to hear this part of the challenge against the health law, either.

SOURCE:

http://www.npr.org/blogs/health/2012/03/28/149485784/supreme-courts-medicaid-decision-could-reach-far-beyond-health-care