Doug Moran on Shortage of Primary Care Physicians

OurBlook interview with Doug Moran, former deputy secretary for health and human resources for the State of Virginia

Do you believe there is a shortage of primary care physicians across the U.S., and if so will the problem become worse with the impact of healthcare reform passage?

DM: Absolutely we have a primary care physician shortage. The population of primary care physicians (PCPs) (and pediatricians) is aging. Even with medical schools aggressively recruiting and expanding enrollment, there aren’t enough PCPs entering the field to backfill for those retiring.

Healthcare reform (as proposed by the Obama Administration) will likely make this situation worse. First, expanding the number of insured will, theoretically, further tax the base of PCPs. I say theoretically because many of the uninsured receive care from free clinics and emergency rooms. Some of these will continue this behavior with or without insurance. Others will shift to PCPs. This will exacerbate the shortage. Also, the State Children’s Health Insurance Programs (SCHIP/CHIPRA) have shown some concerning trends related to usage by newly insured. They tend to have a greater frequency of doctors visits. Yet they have fewer well child and preventative visits. This creates more strain on the system without improving real patient health.

The second risk from healthcare reform is the payment disincentives. Medicaid reimbursements are often insufficient to cover the PCPs costs. Many PCP and pediatricians are choosing to either limit the number of SCHIP/Medicaid patients or stop accepting them entirely.

Some say there is a shortage of PCPs in rural areas but not urban areas or around academic medical centers. Do you agree or disagree?

DM: In Virginia, the shortages in our rural areas are most acute, but there are also shortages in suburban and urban areas. My understanding is that most states are experiencing similar challenges.

Some who feel there is a shortage suggest methods such as video consultations and mobile vans, or expanded roles for nurses and physician assistants. Are these enough to make a dent in the problem or are other methods needed as well?

DM: I believe there is merit in all of these ideas. In order for them to have a material impact on the problem, the medical industry will require significant process changes. Fundamental improvements in efficiency and productivity always require an equally fundamental change in business processes. Electronic medical records, better on-line diagnostic tools, and automation of prescriptions are a few that come to mind. The industry will also need to find economies of scale by centralizing services like imaging.

One significant barrier to this is consumer behavior. Americans demand high quality, convenience and lower costs. These three are incompatible. Another barrier is medical liability. Tort reform must put reasonable caps on punitive damages. It must also create disincentives for frivolous lawsuits.

Without tort reform, no real change is possible. Physicians practice defensive medicine to avoid lawsuits. Some of the business process changes listed above (e.g., electronic medical records and on-line diagnostic/treatment tools) will help. Until physicians have some level of protection, they will continue to overuse expensive procedures and redundant or unnecessary tests.

Have you seen first-hand any examples of doctor shortages where you live?

DM: I served on Virginia’s Children’s Health Insurance Program Advisory Committee (the body that oversaw Virginia’s SCHIP Program) for the past six years. Access to care was one of our biggest concerns. While I have not personally experienced the effects of the shortage, I saw data that demonstrated the extent of the problem.

You have a new book coming out next year about leadership. If there is a doctor shortage problem, will natural market forces solve it, or does some sort of leadership effort have to take place to impel a solution? How do you see such leadership occurring?

DM: I believe that the only solution to the entire healthcare situation requires strong leadership. I am a strong believer in the power of markets to fix problems. The problem is that we have fundamentally broken the market through regulation and the existing insurance model. There is no longer a connection between the consumer (the patient) and the supplier (the physician). Until that relationship is restored, the market cannot work. Neither party is truly accountable to the other. Without this accountability, the market cannot work.

That is why leadership is demanded. I am reminded of the Einstein quotation, “We can't solve problems by using the same kind of thinking we used when we created them." Leadership is required to think differently about this problem and to come up with an answer that revolutionizes the way healthcare is provided in this country. The primary leadership attributes required to fix healthcare are: Character, Vision, Boldness, Integrity, Composure and Accountability.

Character is dependent on knowing who we are and what we believe. Policy makers in Washington need to make more principled decisions. The same is true for doctors. One of my biggest concerns about the healthcare debate is the dearth of input from physicians. We need to see more character and conviction from those involved.

Leaders will need to have a compelling vision. The current model is not the answer. Government isn’t the answer, either. Simply walk into any motor vehicle department or social services agency to see how poorly government delivers existing services. The problem is that no one has articulated a vision for what healthcare can be. The debate seems to focus on fixing what is wrong.

That is where boldness comes in. Describing a vision of the future is risky. It requires boldness. Leadership demands boldness.

Leaders understand the importance of integrity. Integrity means telling the whole truth. In healthcare, the whole truth is not very pretty. We cannot have high quality, convenience and low costs. Tradeoffs are required. By trying to obtain all three, we have gotten none. Integrity also means being willing to look at an issue from all sides. Polarization of Washington has prevented this type of thorough analysis.

From a consumer standpoint, healthcare demands greater accountability. As a small business owner, I have acquired insurance that restores the market relationship between my physician and me. My plan uses high deductibles and a Health Savings Account. I am now an active participant in my healthcare. I see how the money is spent and will explore options to ensure that I am getting a good return of my medical investments. Both the physician and I have skin in the game.

The long-term solution requires that we put greater accountability back into the system. We, the consumers, need to better understand how our decisions impact costs and quality. The only way to gain this understanding and to feel its effects is to restore the connection between patient and doctor. That means the physician provides a service, and the patient pays for it. Insurance should be a vehicle for paying for catastrophic/unexpected healthcare needs. It shouldn’t be for routine treatment.

Is there anything else you'd like to say about the doctor shortage issue?

DM: Our efforts to reform healthcare remind me of a doctor who tries to treat the symptoms of a condition rather than the underlying cause. Fixing the symptoms may be easy, but doing so may mask or worsen the underlying problem. Politicians’ need to be doing something to “fix the problem” may make things worse.

My father used to tell me, “For every complex problem, there is a simple answer… and it is usually wrong.” There are many simple answers to healthcare, and they are wrong! The ultimate solution will be disruptive, painful and complex. Until everyone ... politicians, physicians, insurers, and most of all patients ... understands this, we will continue to create sub-optimal solutions.

(Doug's new book will be called "If You Will Lead," based on the Rudyard Kipling poem "If" ... www.ifyouwilllead.com. He has been deputy secretary for health and human resources for the State of Virginia and was CIO of Capital One Bank's Financial Services Division.)

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Comments (1)

Principal of O'Connor Communications
written by Lynda O'Connor, March 09, 2010

Doug Moran has stated things that I have never before heard. He is insighful and informative.

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