Out of practice

While patients are frequently the headliners in woeful stories about a broken health-care system, there is another unhappy group, one being squeezed by overwork, underpay and suffocating bureaucracy: primary-care physicians.

These doctors—the first to see patients and the centerpiece of the American health-care system—are so disenchanted that less than 3 percent of graduates from medical school choose primary care.

A recent report from the California HealthCare Foundation warned that without new incentives, a drop in primary-care physicians will cause critical shortages detrimental to health-care statewide—especially in rural areas already sparse in primary caregivers.

In the comprehensive June report, “Fewer and More Specialized: A New Assessment of Physician Supply in California,” the foundation noted that the supply of primary doctors was 20 percent lower than previous estimates by the American Medical Association. California tallied only 59 primary-care physicians per 100,000 citizens, with 60-80 considered a sufficient supply. A mere 16 of California’s 58 counties fell within the acceptable range.

The shortage was most acute in rural areas. In eight counties, the primary-care physician supply was less than the stated minimum—most of them in the Central Valley and Inland Empire. An aging physician workforce coupled with difficulties recruiting new doctors is responsible for the shortage.

“If these trends continue,” summarized the report, “the shortage of primary care physicians in California is likely to worsen, which could pose a significant threat to health care access in the state.”

Where there are adequate numbers of primary-care physicians, health care is better and costs less because diseases are treated when they’re relatively inexpensive, said Dr. Jose Arevalo, senior medical director for Sutter Independent Physicians, which represents small practices typically with one to three doctors.

Thankfully for Sacramentans, the area is saturated with medical groups that emphasize basic care and also prove popular with many primary-care physicians, said Bill Sandberg, executive director of the Sierra Sacramento Valley Medical Society. With Kaiser Permanente, the Mercy Healthcare Group, Sutter Health and the UC Davis Health System all serving Northern California, most of the region has a wealth of primary-care docs. Sacramento County has more than 60 primary-care doctors per 100,000 patients.

Not so lucky are outlying areas.

Nearby Yuba County—which includes Marysville and Beale Air Force Base—tallied a pathetic 17 primary-care physicians per 100,000 citizens—far below the minimum needed.

Statewide, one-third of primary-care physicians are 55 or older, according to the CHCF report; in Sierra, Trinity, Modoc, Lassen, Amador, Inyo and Mendocino counties more than half are that old.

California also has the fewest number of physicians nationwide under the age of 40, according to David Ford, associate director of medical and regulatory policy for the California Medical Association. “We’re losing docs off one end and not replacing them on the other,” he noted.

There are an “ever-smaller number of physicians doing an ever-increasing amount of work—especially in Medi-Cal,” bemoaned Ford. Half of California doctors don’t treat Medi-Cal patients, which make up one-fifth of the state’s patients under 65. Ford cited studies that show 7.5 percent of the state’s doctors shoulder 80 percent of the workload.

Primary-care docs are often burdened by the excessive paperwork needed to deal with a variety of private insurers, as well as government programs such as Medicare and Medi-Cal, which often reimburse at embarrassingly low rates. Medi-Cal pays only $24 per established patient visit, according to a report by the California Academy of Family Physicians.

“Doctors in general are really dissatisfied with the current reimbursement level and the existing prior authorization process,” said Arevalo. CMA’s Ford noted that Medi-Cal requires prior approval for 8,000 of its 20,000 treatment codes before a doctor can provide treatment.

“They’re getting killed financially,” agreed Dr. George Meyer, governor of the Northern California chapter of the American College of Physicians. “In order for them to get paid the amount they think they should get paid … [doctors] turn out three or four patients an hour—whether they’re 18 or 80 years old.”

Some doctors push this number up to five or six an hour, said Dr. William Mora, who practices integrative medicine in Sacramento. Formerly with Sutter’s medical group, Mora said he couldn’t properly diagnose and treat patients under traditional time constraints. Now working independently, he typically spends 30 minutes to an hour with patients per visit.

One of the biggest pressures on doctors is debt. An average family-medicine doctor leaves medical school with $150,000 or more in student loans.

“If you’ve specialized in primary care,” said Mora, “and you immediately have to start paying the loan back and want to buy a house … it’s hard to make enough money, at least initially, to pay off those debts.”

The average family-medicine physician made $164,000 in 2006, according to the California Academy of Family Physicians. By contrast, specialists made significantly more, and with fewer demands than these front-line physicians. On average, dermatologists made nearly $349,000, and a diagnostic radiologist made a whopping $446,500 in 2006.

“These [specialists] have a great lifestyle,” said Meyer, who practices internal medicine, because the existing health-care system rewards procedures and output, not “noodling out a problem” the way primary-care physicians do.

Ford said that doctors close to retirement may simply close their practice rather than selling to a younger physician. To help with the paperwork load, younger doctors will often join one of the large medical systems.

One popular destination for many primary-care physicians is Northern California’s Kaiser Permanente network. Its integrated model that links doctors, hospitals, laboratories and billing within a robust electronic medical record network has been hailed as a model of efficiency and quality by noted New Yorker medical writer Dr. Atul Gawande, also a surgeon and health-policy adviser.

“Over 99 percent of our primary-care physician positions are filled,” noted Dr. Chris Palkowski, physician in chief at Kaiser’s Roseville Medical Center. Formerly a private physician in distant Humboldt County, Palkowski has experienced both sides of the bureaucratic fence.

“When I was in private practice, we had more individuals in the business office than we had doctors seeing patients,” said Palkowski. At Kaiser, he said, doctors are relieved of most administrative duties, including billing.

Because the existing shortages are most acute among low-income and underserved populations, access to a doctor has become especially difficult within ethnic communities—especially for patients on Medi-Cal. Medi-Cal patients are served by a mere 46 primary-care doctors for every 100,000 patients, far below Medicaid’s recommendation of 60-80 doctors, according to a 2002 CHCF report.

As a Latino, Arevalo said this issue is of particular interest to him. “Whatever happens with health-care reform, we still will have a number of uninsured patients out there,” he said. One way to address this shortage is to support women and minorities in primary-care roles.

“When women and minorities enter medical school, they’re far more likely to serve in underserved areas,” agreed Ford.

How are doctors responding to this crunch? Many of them are hiring “physician extenders,” such as physician’s assistants or nurse practitioners to see patients.

To further repair the shortage of primary-care doctors, the CHCF report suggests offering greater financial incentives for primary-care doctors—especially in underserved areas. These include help with repaying loans and higher reimbursement rates for Medi-Cal, Medicare and private insurance plans. It also means pushing doctors to training programs like the University of California’s Program in Medical Education; and further technical assistance, like streamlining information technology or EMRs to improve efficiency and reduce paperwork.

Nationally, U.S. Rep. Doris Matsui has co-sponsored a bill to address the shortage of public health workers nationwide. The Public Health Workforce Investment Act of 2009 would provide incentives for public health students and graduates who serve in local public health departments and community health centers. These include scholarships, loan repayments, grants, mid-career training and other incentives. The act is now included as part of House Resolution 3200, Congress’ major health-care reform bill, also known as America’s Affordable Health Choices Act of 2009.

Pending legislation in California would reauthorize funding of the Steven M. Thompson Physician Corps Loan Repayment Program, which assists physicians working in rural and underserved areas.