Frederic S. Goldstein on Shortage of Primary Care Physicians

OurBlook interview with Frederic S. Goldstein, president of U.S. Preventive Medicine, Inc.

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?

FG: The Balanced Budget Act in 1997 limited the number of doctors who could get residencies paid for by the government. That limitation, along with the aging population, is creating a shortage of both primary physicians and specialists. If healthcare reform ends up increasing the insured population, the shortages will get worse. In fact, Massachusetts has experienced some of the effects of placing a large number of newly insured individuals into a system without increasing the number of PCPs. Some people are having difficulties finding a physician while others have waited extended periods of time for appointments.

Medical schools have begun to address the problem by increasing opportunities for first-time students, but the residency cap remains. This is an issue that is not going to go away by itself.

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?

FG: While the rural areas clearly have a shortage of primary care physicians, in the urban areas this issue can also be acute, particularly for those in disadvantaged populations, the uninsured or those on Medicaid. It is difficult for Medicaid to increase the number of physicians willing to accept patients due to its low reimbursement.

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?

FG: The shortage of doctors and the need to reduce health care expenses have created both a challenge and an opportunity.

Today’s technology can help doctors reinvent the house call, instantly connecting with patients in far-flung locations. This means a specialist in a major urban hospital can consult one-on-one with a rural patient or colleague. In this way, leveraging specialized skills and experience with technology can help meet growing demand and improve efficiencies. The use of innovative outreach using mobile clinics or nurse practitioners can also help alleviate the problem.

One of the most important solutions, however, is an industry-wide shift from reactive, treatment-centric healthcare to a proactive, prevention-focused model. The medical home model begins to address this issue. However, we need to look beyond the clinic to models that empower patients, whether at home or at work, to be the center of the healthcare system as knowledgeable, active participants in their own health. The best way to unburden doctors is to keep more people healthy and reduce the growing prevalence of preventable chronic disease, which account for the majority of healthcare utilization and costs.

Simple blood tests combined with family history and lifestyle questionnaires can identify an individual’s top health risks. Based on these evaluations, a qualified healthcare provider can outline a strategy for reducing those risks and then provide support by phone, online and in-person to help the individual make lifestyle changes to reduce those risks.

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

FG: If experience holds true, an influx of previously uninsured patients will increase the burden on an already understaffed situation. PCPs will be required to see more patients and will likely identify more individuals requiring specialty care, but who refrained from seeking care when they had no coverage. Over time, as we have seen over the past decades, the population will get “sicker” and require more utilization at all levels if the system is not transformed. That is why we need to fundamentally shift the system and focus on keeping healthy people healthy, while better managing those with chronic diseases.

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

FG: We have seen the difficulties of trying to find providers to serve members in some of our Medicaid programs. Whether it be an obstetrician or a dentist, there are just not a lot of providers willing to accept Medicaid reimbursement. Add to this the fact that healthcare reform aims to increase the numbers eligible for Medicaid and the problem will be exacerbated as it has been by the growing rate of new Medicaid beneficiaries the states are enrolling due to the economic downturn.

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?

FG: Rates paid to providers by Medicare and Medicaid are lower than those paid by commercial plans. Providers have discussed for years how they subsidize the lower rates paid by these government programs through the higher reimbursement they get from the private sector. With the health reform proposal seeking to save hundreds of billions in the Medicare program, as currently structured, much of this can only come from lower reimbursement to providers.

Medicare and Medicaid are huge programs that are growing at an unsustainable rate; we must look to something new to fix them. Instead of trying to control the growth by focusing on the output side of the equation through reimbursement reductions and other mechanisms, we should begin to focus on the input side through the use of comprehensive prevention. Creating a healthier Medicare and Medicaid population will reduce the incidence of chronic disease which accounts for 83 percent of Medicaid expenses and even more in Medicare.

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

FG: Malpractice lawsuits have had an impact on some specialties and their availability. Examples include obstetrics and neurosurgery, where some communities have had difficulty keeping providers or providing these services at all. In Mississippi, there were some severe specialist shortages that appear to have been alleviated following tort reform in that state.

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

FG: The United States healthcare system is reaching a breaking point. If current trends continue, by 2011, our country will spend more than $2.8 trillion on healthcare ... nearly 20 percent of our GDP. However, only about four percent of the money spent on healthcare is invested in protecting health and preventing illness and injury. We can no longer afford a system where 70 percent of deaths and nearly 80 percent of healthcare costs stem from the same preventable chronic conditions. Employing our collective brainpower and creativity to solve one of our nation’s toughest problems is a natural progression of an American entrepreneurial tradition. Regardless of any legislative outcome, the American ingenuity that brought us airplanes and artificial hearts is steadily uncovering solutions to reverse today’s disturbing healthcare trends. Our nation’s physical and fiscal health depends on it.

(Mr. Goldstein previously expressed his views for us on incentivized health insurance and it's a pleasure to have him back. He received an M.S. in healthcare administration from Trinity University in San Antonio and a B.A. in zoology from the University of California at Berkeley. U.S. Preventive Medicine is in Jacksonville, Fla.)

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