A crisis in primary care accelerates

Primary care doctors are frustrated and disheartened and many of them plan to limit or close their medical practices over the next three years, according to a new survey from the Physicians Foundation.

The study's findings aren't all together new; it's been clear that a crisis in primary care medicine has been building for some time. But they're an important reminder the current debate over national health reform has to deal with widening cracks in the health care delivery system.

Simply put, if there aren't enough primary doctors -- family physicians, internists and pediatricians -- to take care of patients' basic medical care, it won't matter if everyone has health insurance. Access to care will be seriously compromised.

How bad are things according to the new survey of almost 12,000 doctors?

* 49 percent of the doctors surveyed said they plan to see fewer patients or stop practicing. This includes 11 percent who said they plan to retire; 13 percent who said they wanted to leave patient care and find a job in a non-clinical setting; 20 percent who said they planned to cut back on patients seen and 10 percent who said they want to work part-time.

* 78 percent of doctors said medicine is "no longer rewarding" or "less rewarding." Only 6 percent described the morale of their colleagues as positive.

* 76 percent of physicians said they are "overextended and overworked" or working at "full capacity."

* 94 percent of doctors said they have to devote more time to paperwork and 63 percent said adminstrative obligations cause them to spend less time with patients.

It's clear that a payment system that rewards specialty care and high tech medical interventions and that under-values the essential components of primary care -- taking time to get to know patients, understand their problems, and coordinate services -- is a major contributing factor.

"(Primary care physicians') incomes are lower than surgeons and other specialists, and a lot of what (they) do is not compensated," Dr. Ann S. O'Malley, a senior researcher at the Center for Studying Health System Change, told Managed Care magazine last year.

"The time they spend coordinating care on the phone, talking to social workers, and talking to specialists about care provided to the same patients just does not get compensated," she continued.

N. Thomas Connally, a retired internist, offers another important perspective on the issue:

"In any rational health care system, primary care doctors are central to keeping quality of care high and costs low. Unfortunately, the system in the U.S. is far from rational and the number of primary care doctors is plummeting...Over the past ten years, as many as one in five primary care providers have left the profession. There's a broad expert consensus that we face a critical shortage of general practitioners and that the problem is only getting worse."

What can to be done about this alarming medical manpower problem?

Several expert health care observers suggest that an overhaul of the way doctors are reimbursed is long overdue. Primary care practitioners should be better rewarded for the crucially important role they play in helping prevent illness and maintain patients' health, these experts argue.

Don't underestimate how controversial such a move would be, however. Unless there's a significant effort to expand payments to physicians overall, an unlikely prospect in the current environment, any attempt to alter reimbursement formulas will be met with fierce resistance by entrenched interests -- the medical specialties that profit from the peculiarities of the systems currently in place for paying doctors.

What's indisputable is that financial incentives shape the delivery of health care, as they do every other sector of the economy. If providing basic medical care is an important component of health reform, policymakers in Washington will have to address the inequalities in physicians' payments fueling the accelerating crisis in primary care.

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