Report diagnoses doctor shortage

Affordable Care Act to strain declining base of primary care physicians

Dr. Garry Pearson of St. Mary’s Jefferson City Medical Clinic listens as patient Iola Potts of Tipton, Mo., breathes deeply during an exam. Potts was a patient at the Tipton clinic, but drives to Jefferson City to see her favorite doctor.

Dr. Garry Pearson of St. Mary’s Jefferson City Medical Clinic listens as patient Iola Potts of Tipton, Mo., breathes deeply during an exam. Potts was a patient at the Tipton clinic, but drives to Jefferson City to see her favorite doctor. Photo by Julie Smith.

When medical students visit Dr. Garry Pearson’s practice at the Jefferson City Medical Clinic, the family practitioner always asks what they’re going to be when they grow up.

“Not what you do. I can tell you that,” the students always tell him.

But a team of researchers recently published an article that identifies the United States will need nearly 52,000 additional primary care physicians, like Pearson, by 2025.

Most of the need will come from population growth, but some will come from an aging population and from more people being insured by the Affordable Care Act, according to the article, “Projecting U.S. Primary Care Physician Workforce Needs: 2010-2025.”

Pearson has practiced family medicine for nearly 30 years, and he says his practice is completely different now than when he started. He believes it will continue to evolve.

With more and more specialties for doctors to specialize in, he said he doesn’t get to use some of his skills.

The physician became interested in family medicine, primary care, when he rotated to various internships after medical school.

“I learned something in every specialty, and I really enjoyed all of it,” he said. “I was raised in a rural area, and the doctors did it all back then, surgery, everything.

“I liked that.”

Affordable Care Act and primary care

In 2010, President Obama signed the Affordable Care Act, a law that includes comprehensive health insurance reforms that will roll out over the next few years. Since the act became a law, it has implemented a new Patient’s Bill of Rights. It has also allowed people with Medicare to get key preventive services for free and has given them a discount on brand-name drugs. In 2012, it outlined Accountable Care Organizations and programs to allow doctors and health care providers to work together and provide better care to patients.

This year, the act gives states a choice to form their own health exchanges or to implement the federal government’s model of the Health Insurance Marketplace, which begins Jan. 2014. Information about the Health Insurance Marketplace plans will become available Oct. 1, and people will receive subsidies to be able to shop for health insurance by choosing from low-cost insurance programs. The law also gives states the option of expanding Medicaid to up to 138 percent of the federal poverty level, with full federal funding for the first three years and at least 90 percent funding the following years.

The law will make millions of Americans eligible for affordable health coverage, increasing the need for additional primary care physicians.

Missouri’s government has not yet decided what the state will do.

While a bill to expand Medicaid to 138 percent of the federal poverty level was rejected in a House committee, one bill has been approved in another. The second bill would expand Medicaid to up to 100 percent of the federal poverty level and create a state health exchange with subsidies. The bill still needs approved by a second House committee, the House chamber, the Senate and Gov. Nixon.

Joe Pierle, CEO of the Missouri Primary Care Association, believes the two biggest threats to the Affordable Care Act are politics and the shortage of primary care providers.

“If we give everyone health insurance or some form of health coverage, but they don’t have a provider, then we’re really not accomplishing much,” he said.

The same study that pinpointed the increased demand for primary care because of the Affordable Care Act cited that when “Massachusetts mandated health insurance in 2006, primary care wait times increased, even though the state has the second highest ratio of primary care physicians to population of any state and a robust network of community health centers.”

The Association of American Medical Colleges (AAMC) predicts universal health care coverage under the Affordable Care Act will increase the use of all physicians by 4 percent.

“We have a shortage,” Pierle said. “It’s going to continue to get even more desperate.”

Why is there a shortage?

Pierle said a lack of medical students going into primary care may be to blame for the shortage of providers.

“We’re not kicking out the numbers that we need out of school,” he said. “There are any number of reasons why students aren’t choosing to go into primary care.”

Dr. Steven Zweig, professor and chairman of University of Missouri School of Medicine’s Department of Family and Community Medicine, said he certainly sees areas experiencing a shortage of primary care, but the Columbia school hasn’t seen a decline in students going into the profession, which includes family medicine, internal medicine and pediatrics.

“We probably have more primary care physicians now than we’ve ever had,” Zweig said of the country’s health care system. “We also have a population that is growing.

“The worrisome part is that we have fewer doctors going into primary care than previously, so there’s an impending mismatch.”

He identifies income and medical school debt as factors that may persuade someone to specialize and forgo the primary care route.

According to AAMC, the average debt for graduates from state medical schools, like the University of Missouri’s, is nearly $156,000. The average debt for graduates of private medical schools is more than $183,000. These figures don’t include undergrad or living expense debt.

“Now, all doctors make a lot of money, don’t get me wrong,” Zweig said. “But, if you are worried about that debt, you can see some fields make a lot more money than other fields.”

According to the most recent Medical Group Management Association Physician Compensation and Production Survey, the average salary of a primary care physician the first year out of residency is $212,840 and the average salary for a specialized physician is $384,467.

“There’s an argument that suggests students might preferentially select those that tend to make more money,” Zweig said.

What is Missouri doing?

Zweig said nearly 8 percent of graduates from medical schools go into family medicine for residency training and that number is 16 percent for University of Missouri School of Medicine graduates.

“We’ve been successful at generating interest in students and picking students who might be interested,” Zweig said. “It’s about picking students who are interested and then helping encourage their interests at a much higher rate than average around the country.”

The Columbia school’s family medicine residency program is a three-year program, with 12 residents added each year.

“We’ve graduated about 400 residents in our residency program since we’ve had it,” Zweig said. “Almost 70 percent of those graduates of our family medicine program are practicing in Missouri.

“So, if you are interested in expanding primary care in your state, one way to do that is to help make family medicine programs in your state.”

Missouri’s Department of Health and Senior Services’ program, Primary Care Resource Initiative for Missouri (PRIMO), encourages people to go into primary care.

The program has four components — student loans, recruitment and placement, health professional loan repayment and health care delivery systems — and it “awards forgivable loans to students pursuing health care training leading to Missouri licensure or registration” in certain health care fields. After obtaining licensure, participants are required to work in rural or underserved areas of the state.

Future of primary care

Jan Shipley, executive director of Mid-Missouri Area Health Education Center, said getting people to practice primary care with underserved populations is one of her organization’s goals. The organization’s mission “is committed to enhancing access to quality health care, particularly primary and preventive care, by growing and supporting Missouri’s health care workforce.”

“Primary care is our emphasis,” Shipley said. “We have a pipeline program where we work with kids from the time they’re young, introducing them to health care careers through all the years in between to when they’re practicing providers.”

She said demand for primary care is going through the roof and she doesn’t see it changing.

“We’re trying to be part of the solution, but we’ve seen it coming for a long time,” Shipley said. “There’s more demand and less supply.”

Pearson said he sees nurse practitioners and physician assistants playing a greater role in the future of primary care.

“That’s the future, whether we like it or not,” he said. “Everybody wants to be sub-specialized and make the big bucks. I don’t see how we can change that.”

Accompanying photo: Dr. Garry Pearson

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