The primary care bottleneck to health care reform

Benjamin Brewer, a family physician who writes for the Wall Street Journal, points out that the supply of primary care physicians is not up to the task of handling a surge of new patients unleashed by proposals for universal health care. (See Primary Health Care Needs Fixing Before Universal Care Can Work.) In fact, primary care can’t even handle the load it’s under today, and things will get worse anyway as the population ages and the number of primary care docs fails to keep up.

Being a primary care doctor isn’t that enticing. Reimbursement is pretty low, hours can be long, autonomy is limited, and primary care physicians aren’t always well respected by specialists. Some primary care docs are responding by becoming hospitalists, opening concierge practices, or (especially the women) working part time. All of those things squeeze the supply of primary care even further. I’ll resist the urge to repeat my pro-immigration tirade, but let’s face it, primary care physician has become a classic immigrant position: a low-paid, unattractive job that Americans won’t fill.

One of the big pushes in health care right now is to rate the quality of physicians and to get them to be transparent about cost and quality. In theory that could help patients choose the best physician to take care of them. In practice, the only information that’s really relevant to a patient looking for a primary care physician is whether the doc is accepting new patients! It’s hard enough, at least in Boston, to find one who is.

I don’t have any great solutions to this problem. The medical home concept seems worthy enough, and it looks like it will be adopted at least on some scale. I don’t know whether it will make a huge difference. The use of “physician extenders,” i.e., Nurse Practitioners and Physician Assistants holds some promise although personally I’d rather see my doctor. Improving physician office workflow with techniques such as open access scheduling and clinical messaging can help, too, in some cases dramatically. Electronic health records probably won’t help capacity much if at all. There’s a real danger that even a well-implemented EHR will slow things down in a practice by putting more work on the physician.

My primary care doc is nearing retirement. I guess I better start looking around for his replacement.

March 27, 2008

7 thoughts on “The primary care bottleneck to health care reform”

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  4. Its hard to find a good PCP let alone a PCP in my opinion.

    As long as anesthesiology, radiology, derm, etc. offer far better pay for same if not better hours I do not think the cream and bulk of medical students graduating will want to go to family practice or internal medicine. Most of the internal medicine residents I’ve ever met end up wanting to do fellowships anyways.

    Now, there’s nothing wrong w/ going into specialty fields that pay well; its a free country and the cost of medical education is going up like crazy.

    however, to solve this problem I believe at some level, the cost of medical school education in the U.S. will have to be addressed. Paying off loans for the students that work with me is a real huge concern.

    Getting paid $200K + to go into anesthesia (for ex) versus $120-140K in primary care is not a hard decision to make for many students.

    -S.Y.

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