Margaret Lewin on Shortage of Primary Physicians

OurBlook interview with Dr. Margaret Lewin, medical director of Cinergy Health

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?

ML: There absolutely is a shortage of primary physicians across the U.S. (See examples in the next response.)

It has been demonstrated that any affordable healthcare system ... anywhere in the world ... requires that 50 – 60 percent of physicians provide primary care. Without these numbers, the cost of delivering healthcare rises by more than one-third. The U.S. met that goal in the middle of the last century. By 2003, that number had steadily dropped to 37 percent. Now, fewer than 25 percent of the counties in New York State have the requisite number, and seven counties have a patient to primary care physician ratio akin to that found in some developing nations.

The problem is rapidly worsening. In a study of fourth-year medical students at 11 U.S. medical schools, only 2 percent reported that they were likely to enter careers in primary care internal medicine. Many family practice residency programs have closed because of the paucity of demand, fewer than 50 percent of remaining positions are filled by American medical graduates, and many positions are unfilled.

In addition, primary care physicians are retiring earlier, re-training for specialties or other professions, or covering their rising costs and decreasing reimbursements by decreasing the time spent in delivering primary care services in order to expand their scope of practice to such lucrative sidelines as giving Bo-tox.

The problem will become dramatically worse with the passage of healthcare reform, which will expand the number of insured patients and direct those patients to primary care doctors to evaluate and manage their care, increasing waiting times for appointments and overloading existing capacity. Fee schedules are expected to be lower than existing Medicare fees.

Moreover, a significant portion of the “savings” from Medicare will be attained by dropping fees further (as it is, it is planned that fees will be dropped by 21 percent in March of this year), thereby driving yet more primary doctors out of participation in Medicare or out of practice altogether. More doctors will close their doors to new Medicare patients and reduce the numbers of current patients covered by Medicare.

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?

ML: There is no question that rural areas are now suffering more from shortages of PCPs, but urban areas and those around academic medical centers also have extreme shortages, because the high cost of practicing medicine and universal low reimbursement rates even in those areas make the practice of primary care extremely difficult financially.

The disparity between rural and other areas is in part a matter of poor reimbursements, logistical difficulties (the time lost in getting from one place to another), the social costs of raising children of highly educated and trained professionals in (perceived) lesser education facilities, and dislocation from families, friends and professional contacts made while training in academic medical centers.

Some who feel there is a shortage suggests 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?

ML: This may work well in specialties such as radiology and surgery, but it’s not feasible for delegating primary care ... where the time-consuming, detailed history, hands-on physical examination and discussions with the patient are central to the medical care. The history and discussions will take as much time for the alternative sources of care, overloading them as well. Moreover, a physical examination requires “hands-on”, and cannot feasibly be done long-distance.

Mobile vans may replace the doctor’s physical office, but staffing will place the same demands as the existing system.

While some of this can be delegated to “mid-level practitioners” such as nurse practitioners and physician assistants, there is an extreme shortage of these professionals as well.

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

ML: As access to primary care decreases, waiting times for appointments will rise still further, and patients will use specialists to handle simple problems, dramatically lowering the productivity of those specialists. For example, patients will visit an ear-nose-throat surgeon for a sore throat, an orthopedist for a simple back sprain, a gastroenterologist for “heartburn”, a neurologist for a headache ... all complaints which are handled more quickly and inexpensively in the office of a primary care physician.

The additional patient load on the specialists will increase waiting times for appointments there as well, driving more patients to already-crowded emergency rooms ... where the most expensive care is delivered. Moreover, if specialist fees are dropped ... as is being discussed ... specialists will likely refuse to take these “simple” cases, concentrating instead on the better-reimbursed surgical and procedure-based cases or, more likely, stop practice altogether.

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

ML: New York City: There is a shortage of mammographers. My own patients can wait several months for a routine mammogram. The cost of performing mammograms has been rising exponentially (new high-tech equipment, and the cost of malpractice premiums); and the dramatic fall in reimbursement rates does not cover the actual cost of performing mammograms. As a result, several radiology groups do mammograms simply as a “loss leader” to maintain HMO contracts; other groups have stopped doing mammograms altogether; and one major group with more than 10,000 mammogram case files shut its doors completely.

In this last case, the group found it difficult to give away those files; a large hospital was eventually convinced to take them over. Existing groups find it very difficult to find new mammographers to replace those who have shifted to other radiology subspecialties.

As of Jan. 1, 2010, Medicare eliminated consultations from its coding ... thereby downgrading to a much lower level office visit a sophisticated consultation by a specialist and written report to the referring doctor. As a result, I must "beg favors" to get subspecialists (ex, cardiologists, nephrologists - kidney specialists - and oncologists -cancer specialists) to see my Medicare patients in consultation.

Upstate New York: There are 11 counties without an obstetrician. Broad geographic areas have no neurosurgeon, orthopedist or other specialists needed emergently for critically injured citizens.

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?

ML: I absolutely agree. There is not one service I perform for a Medicare or Medicaid patient which covers my cost of delivering that care. The difference is “cost-shifted” to my other patients. For example, in New York City, a complete history and physical on a new patient (CPT Code 99205) is reimbursed as follows:

Fee-for-Service: ranges from about $500 - $1200**.

The best-paying HMO: $315.

Medicare: $205.

Medicaid: $108.35

A follow-up visit covering several problems (such as high blood pressure, high cholesterol and diabetes) – CPT CODE 99214)::

Fee-For-Service: ranges from about $150 - $250**

The best-paying HMO: $152.

Medicare: $107.

Medicaid: $56.18

Increasing numbers of physicians do not participate in these programs, leaving the patient to pay fee-for-service which often is not reimbursed by the HMOs and is not covered at all by Medicare and Medicaid. Healthcare reform will exacerbate this by lowering fees dramatically.

** Fee-for-service can only be estimated, because it is a federal crime for physicians to confer with each other about their fees.

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

ML: Absolutely! It’s a major overhead cost which must be paid before a physician can even open the door to see the first patient, and premiums are steadily rising.

In addition to the dollar cost, considerable time must be spend in documenting the patient’s chart to prove that each and every decision was based on a thorough consideration of all the alternatives; the same amount of time and energy goes into documenting detailed conversations with the patient about the relative risks and benefits of prescribed medications, procedures, etc.

These considerations and conversations take place routinely ... that’s important ... but documenting them can take more time than actually performing them. This is particularly burdensome for primary care physicians, whose scope of practice is so broad that it’s not feasible to use pre-printed forms to document such issues. Moreover, since the most common cause of malpractice lawsuits is ‘failure to diagnose cancer’, the documentation burden is highest on the primary care doctor.

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

ML: The average medical student graduates between $150,000 and $200,000 in debt. One projection estimates that by 2031, repaying those loans will take between 40 and 50 percent of a primary physician’s after-tax income throughout most of his career.

Medical education must be better subsidized. One possible solution is “tuition-forgiveness”; a National Health Service Corps does repay loans in exchange for three years of practicing in underserved areas, but it has never been adequately funded, and only about one in seven applicants can be covered.

Physicians are not by nature “political animals” ... they spend their time and emotional energies caring for patients. They are not as effective in lobbying as other parts of the healthcare system (for example, the insurance companies, pharmaceutical industry, trial lawyers and device-makers). Moreover, there are stringent anti-trust laws which make illegal any organized protests by physicians. There are no such restrictions imposed on the insurance companies, and these restrictions are rarely ... if ever ... imposed on the other players. Doctors must be given the legal right to organize negotiations with insurance companies and the government, and tort reform must be enacted.

(We've had Dr. Lewin on our site with several other interviews ... a pleasure to have her back. She's at www.cinergyhealth.com .)