Dr. Alford N. Vassall on Shortage of Primary Care Physicians

OurBlook interview with Dr. Alford N. Vassall

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?

AV: Yes, I do believe there is a shortage of primary care physicians within the country. There are a number of reasons why this is so.

• The first reason is that enough of salary is not paid to the individuals. This makes other specialties more attractive. Because this is a fee for service system, all salaries whether the physician is in solo practice, group practice or in a hospital practice are based on fees. The fees are too low compared to the overhead. In some areas, physicians who train in that community as a primary care physician cannot remain in the area to practice as they cannot make a living wage. This exists in multiple places, particularly in California.

• Secondly because of this, the spots available are most frequently taken by foreign trained physicians. The math works like this. Most of these individuals were trained in countries where their training was subsidized, or else relatively cheaper than the cost in the U.S. With a lower or no debt to start, these individuals can afford to take a primary care position. Their revenues after training have to support a lesser expense than the American trained physician.

• Health care reform in many ways is based on the Medicare model which is not intact. It suffers from utilizing resources and not paying the value of the relative cost. Not only is this unsustainable but it is on the verge of bankrupting the system because resources cannot be recycled in this way.

• No consideration in the healthcare reform actually looks at the cost of any activity and funds its support.

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?

AV: There is a shortage of PCPs in rural areas for several reasons. The physicians who are now graduating from medical school are more that 50 percent females in many instances. The other physician graduates want to have good quality of life. This means not being in solo practice and having partners to take up the load. This makes it more expensive than it used to be. Because of these factors, it is easier to find such support in urban areas. Additionally in rural areas, there are frequently not enough specialists to support the PCPs at the same level possible in the urban areas. This leaves some PCPs in the position where they have to provide a higher level of service than they desire to provide, increasing their risk as far as malpractice coverage goes. Again there is a certain level of fee for service support that is nonexistent, making this unlikely to change in the foreseeable future.

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?

AV: The problem of shortage is not properly addressed by having video consultations, mobile vans or by expanding the roles for nurses and physician assistants. The relative costs are increased not because of the lack of providers. It has to do with the number of visits generated per unit population. This actually has to do with the prevalence of disease. The prevalence of disease has more to do with individual behavior. Thus the number of visits needed and the severity of the condition to be addressed are related to the activity of the individual. Video consultation is still likely to be as costly because the time required for the provider to take care of each visit will still be the same. The shortage is rather about the increasing number of visits per unit population that is required.

Will healthcare reform also create or exacerbate shortage in specialties, and if so which ones and what can be done about it?

AV: The idea that reform will exacerbate shortage in specialties fails to recognize why the difference exists. It has to do with how the fee for service is applied to the services. EM services are poorly funded not because surgical services are funded excessively. They are poorly funded because of inadequate allowance for services. It is inadequate because of the increasing number of visits per unit population as the population makes more and more unhealthy choices. This cannot be done by decreasing payments.

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

AV: I practiced formerly in New Mexico and also in California. Even though California is a larger state, the problems encountered in the rural areas there are no different than in the rural areas of New Mexico. Smaller communities have fewer physicians such as ob-gyns, a large number of whom are female. This presents a unique problem as they tend to have mates of at least equal education and frequently there are no equivalent jobs for the spouses. This makes the shortage even more significant.

It is sometimes said that doctors and medical offices either just break even or actually lose money in treating Medicare patients, and this problem is much worse with Medicaid. Do you agree or disagree, and how will healthcare reform affect this situation?

AV: Most offices lose money taking care of Medicare patients. The reimbursement does not usually cover the office expenses of supplies, staff costs and malpractice insurance, utilities in addition to the cost of the physician’s time. This is the way it was when I was in practice. In contrast, Medicaid was frequently higher on many items. This varies from state to state and also from specialty to specialty. In obstetrics, some states are more willing to pay a more realistic proportion of the prenatal care as the cost of babies in the intensive care nursery is substantially higher. Healthcare reform will probably not improve this situation as this will not address the underlying cause, the increased consumption.

Are malpractice lawsuits a factor in this situation? If so, what needs to be done?

AV: Malpractice lawsuits are an increased factor as well. The issue is that there are individuals with poor outcomes who require care. Most frequently, as in the case of poor outcomes occurring after delivery, the antepartum and delivery care have virtually nothing to do with the outcome. However, poor outcomes require care and there is no system which is assigned to provide care for those who need assistance. The only way to do it in this system is with malpractice insurance. These premiums support the plaintiff attorneys, the defense attorneys as well as the patient needing care for a poor outcome. Consequently the trip in court is about convincing the jury that the person requiring care deserves it and when the award is made, it is used to support that individual as well as the attorney and the costs he generated in the cases that had no merit, according to the system. Is it any wonder that these contribute to the cost of care? In addition to the premium cost which has to be passed on to the patient, there is the cost of getting the appropriate tests to support one’s approach. Frequently this is quite costly as well. This is an inefficient use of resources.

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

AV: The doctor shortage issue has to do with the large number of visits required to provide health care support for an individual. This is increased as a result of poor individual choice and consequences that are attributed to the choice. It turns out that this shortage will always exist as long as the number of visits per individual keeps increasing. There will be no reduction in need, until this actually changes.

(Dr. Vassall is a contributing author to a recent book, "Audacious Aging" ... www.audaciousaging.com )

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