Boston
The U.S. House of Representatives' passage on Saturday of a health-reform bill that could extend health-insurance coverage to 96 percent of Americans has added new urgency to efforts to train more primary-care physicians, speakers told thousands of medical-school administrators and educators here on Monday.
"If you expand coverage without expanding primary care, you will overwhelm emergency rooms that are already overcrowded," said Tom Daschle, a former U.S. senator from South Dakota who is now a senior fellow at the Center for American Progress, a Washington think tank. Mr. Daschle had been President Obama's pick for secretary of health and human services before he withdrew amid a controversy over taxes he had failed to pay.
Health reform is the hot topic at this week's annual meeting of the Association of American Medical Colleges, which drew an estimated 3,700 attendees.
If health-care legislation makes it through the Senate and a compromise version is signed into law, millions more people could be eligible for insurance coverage. However, if the experience in Massachusetts, where a smaller-scale health-care overhaul was approved in 2006, is any indication, there won't be enough doctors to go around, warned Herbert Pardes, president and chief executive of New York-Presbyterian Hospital, a teaching hospital for the medical schools of Columbia and Cornell Universities.
"If we're going to tool up and treat more people, we need more doctors," he said. That would require lifting a cap on the number of residency positions that Medicare will pay for—a costly move lawmakers have been unwilling to make.
Several teaching hospitals in Massachusetts are struggling financially, partly because they are receiving less money from the federal government on the assumption that they would be treating fewer uninsured patients.
A Supply Problem
Meanwhile, a nationwide shortage of primary-care doctors is expected to worsen as baby boomers retire.
Debt is one obstacle. The average medical-school graduate today starts out owing about $156,000 in loans, according to the medical colleges' association. "It is utterly absurd that our graduates have that kind of debt," said Arthur S. Levine, dean of the University of Pittsburgh School of Medicine. "Every day, students tell me they'd like to be primary-care doctors, but they can't afford to."
Primary-care doctors not only earn significantly less than those in other specialties, but they are reimbursed by Medicare at much lower rates.
Attendees urged the medical colleges' association to continue lobbying for loan-forgiveness plans and more-generous reimbursement policies for family doctors.
Mr. Daschle also said the United States relies too heavily on international medical graduates to fill primary-care slots.
"I don't feel good about going to other countries and taking their best and brightest and offering them the opportunity to serve here," he said.
Despite the challenges of caring for millions more people, most medical educators here were excited about the prospect of vastly expanded health-insurance coverage and the opportunity to transform the American health-care system.
Part of the problem with the system, Mr. Daschle argued, is that too much money is spent on costly interventions like heart transplants and too little is spent on preventive care.
"Every other society starts at the base of the pyramid and works their way up to the top until the money runs out," he said. "In the United States, we start at the top of the pyramid and work our way down, and the money does run out."
Many academic medical centers, which are known for providing costly, specialized care, are trying to bolster the bottom of the pyramid by educating children in their communities about healthy living and steering adults to neighborhood clinics and health fairs, participants noted.
Another way academic medical centers can help improve the delivery of health care is by participating in a system of "health-care innovation zones," Darrell G. Kirch, president of the association, told attendees on Sunday.
The association has been working with Congress on recently introduced legislation (HR 3664), which it hopes to see wrapped into an overall health-care bill, that would encourage academic health centers to experiment with other hospitals and health-care providers to help specific patient populations.
"Just as we have a moral imperative to give people basic health insurance, we have an innovation imperative—as educators, researchers, clinicians—to finally make our health-care system work well for everyone," he said.
Comments
1. akprof - November 10, 2009 at 11:38 am
Loan forgiveness options are one approach that I would favor - but only for those docs who go into a few areas of practice: primary care, internal medicine, geriatrics - those are the specialities that are over-represented among physicians with regard to large proportions of Medicare patients. And only those who accept Medicare patients, of course.
2. drmink - November 10, 2009 at 01:20 pm
Why not simply increase the number of vacancies at residency programs. Just because everyone wants to be an orthopedic surgeon or dermatologist doesn't mean they should get that "match". That was one aspect of the Clinton health plan that should have been part of this health reform plan.
The alternative is to give PAs and NPs more autonomy and allow them to directly compete for patients. They are cheaper, can perform 90% of the practice scope just as competently, and you can train them in 1/4th the time.
3. paradoxer - November 10, 2009 at 03:32 pm
It is simply not true that primary care is not an affordable option now that Income Based Repayment (IBR) is available to everyone who has more debt than income. Couple IBR with Public Service Loan Forgiveness and many physicians would qualify for principle and interest forgiveness equal to the original amount borrowed.
It's time to emphasize the other factors that cause medical students to choose other specialties.
4. aamcstaff - November 11, 2009 at 10:30 am
If PAs and NPs can do the same work (with less training) as physicians, it would follow that we don't need to train future primary care physicians for as long as we do now.
Shaving time off of pre-medical, undergraduate medical, and graduate medical years would considerably reduce students' debt load and would encourage future physicians to pursue those specialties with arguably less required expertise.
5. mxb22 - November 11, 2009 at 12:28 pm
You people are not thinking carefully. PAs and NPs don't know what they don't know. Only a physician can say, after examining a patient, that a PA or an NP could have handled that particular "simple" case. If we give FPs and GPs less training, or if we give PAs and NPs more clinical autonomy and responsibility, the number of mistaken diagnoses and mistreatments is bound to rise. How would you feel if you were told you were going to be examined by a nurse instead of a "real" doctor, even if you got a bargain price from the nurse? Are you willing to trust them to refer you to a "real" doctor when they've found something they know enough about to know that they don't know enough? But don't worry. There are bound to be more NPs and PAs in any case because the government doesn't really want to pay for the best possible health care, anymore than it wants to pay for the best possible soldiers (look at "combat pay"). And if it did pay for the best possible health care, and the best possible soldiers, then our taxes would be higher than even what the Europeans pay. Bottom line: We can't have it all. We can't get something for nothing. "Equal" health care, like "equal" education, is ultimately a snare and a delusion. But no politician who wants to win election will tell you that because he must offer "the audacity of hope." It would be better, as Obama's hero Lincoln said, if we "disenthrall ourselves." In other words, we should grow up.
6. drmink - November 11, 2009 at 07:10 pm
Some of the best care I've received in my life, as far as thoroughness, came from PAs. My daughter has often seen the NP instead of the pediatrician, even in cases where we had the choice. It all depends on what the role is. Most of medicine isn't diagnosis, it is management. Physicans and "extender" personnel use EXACTLY that same algorithms to determine what is going on with the patient. Frankly, experience is often more valuable than training for chronic conditions. Plus, only about 40% of physicians even take the time to read their medical journals, so even the more experienced ones often fail to keep up their knowledge.
As for a cheap military, I suggest you check this out: http://usmilitary.about.com/od/fy2008paycharts/a/combat.htm
The $500 additional dollars, tax-free, each month probably helps pay for a decent military. Plus, I'd like a savings account with a 10% interest rate.