Health and Science

Health-Care Reform's Major Hurdle: Doctor Shortages


The health-care reform legislation is expected to create more jobs in the health-care sector but there's one major side effect it may not cure: There may not be enough doctors to see all of the people who are now covered.


“Add another 32 million people to health-insurance rolls and … you’ll have more people getting regular checkups and routine healthcare,” said Barry Bluestone, a labor economist and professor at Northeastern University, who estimates that there will be a 10 to 20 percent increase in health-care visits to doctor’s offices and clinics as a result of the legislation.

Health care was already expected to see explosive job growth — even given the recession — due to all the aging Baby Boomers. This legislation just kicked it up a few notches.

The biggest demand will be for primary-care physicians, as well as for the nurses and staff who work in clinics and doctors’ offices, as more people come in for regular checkups and screenings — from cholesterol checks to breast exams.

Plus, there will be a bump in demand for people who work in diagnostics — from the technicians who operate the MRI and CAT-scan machines to those who process blood tests — as well as pharmacists to process the prescriptions of people who previously couldn’t afford medications.

And, along with all of that comes the need for more administrative workers, from receptionists to accountants in the back office.

That sounds like great news — job growth in an economic recovery that is dependent on job creation. But there’s one small problem — most students coming out of medical school are more inclined to go toward higher-paying specialties like cardiology and radiology, which pay two to three times what most primary-care doctors make. And, when you consider that students come out of medical school with $150,000 in debt or more, it’s a no-brainer that more of them choose the higher-paying areas of medicine.

“I don’t think it’s going to encourage enough primary-care physicians,” Dr. Robert Centor, the academic general internist at the University of Alabama School of Medicine and author of the DB’s Medical Rants blog, said of the health-care legislation.

Centor says he thinks there are three main reasons: The pay issue, plus the fact that primary-care doctors have to deal with a lot more haggling with insurance companies and the subsequent paperwork, and one prickly issue — respect. A lot of medical professionals see it as more prestigious to be a specialist rather than a primary-care doctor.

“Primary care has been denigrated over the years and too many people look down on primary care and so therefore … there’s this hidden curriculum to not go into it because it’s not as good a field,” Centor explained.

“I would argue that primary care is every bit as hard — if not harder — than radiology,” Centor said. “We need radiologists but they shouldn’t make three times as much,” he said.

Right now, 30 percent of the medical work force is made up of primary-care physicians, compared with 70 percent who become specialists, according to the American Academy of Family Physicians.

Quality Care Declining?

Will health-care reform impact the quality of care? Click on the video at left.

Lawmakers were conscious of the need to offer incentives to lure more students into primary-care practices when they wrote the legislation.

“There are provisions in the bill to help increase the work force,” said Tim McBride, a health economist and assistant dean at Washington University who helped advise lawmakers while they were crafting the legislation.

The provisions include scholarships for students studying to be primary-care physicians, pediatricians, nurses and social workers, among others, as well as incentives to get them to work in underserved areas.

Specifically, the legislation increases student-loan forgiveness programs — particularly for those that choose to work in a shortage area like primary care — and offers up to 10 percent in bonuses for those who choose to go into primary care.

Plus, it calls for the creation of a special committee to study this changing landscape for primary care.

Anticipation of the health legislation has already started to push up the number of students interested in family practice: The number of medical students who chose family medicine for their residencies jumped 9.3 percent this year and the number of students choosing to go into family practice rose 3.1 percent, according to the AAFP.

“I think primary-care medicine became much more visible in the debate about health-care reform,” said Dr. Lori Heim, president of the AAFP.

However, she said more must be done to meet demand.

“If we’re going to close the primary-care physician gap, we need to graduate twice as many family physicians as we are now graduating,” she said.

“The legislation does several things to move the needle that way,” Heim explained, but said it’s not enough.

“It’s a start. It’s a platform that we need to build on," she said. The incentives “are, in and of themselves, not sufficient.”

As for those who are worried that their doctor’s office may get overcrowded, Heim said that probably won’t happen because doctors close their practice to new patients when they reach their capacity. What’s more likely, she said, is that patients who now qualify for insurance in underserved areas, often remote rural areas, may have trouble finding a doctor accepting new patients.

On the upside, if health-care reform can generate more new primary-care practices, it will actually help stimulate local economies, Heim suggested.

The addition of family-medicine practice to a community has an impact of $900,000 on that community, according to a survey by the Robert Graham Center.

The key is going to be the students.

“Just as health-care reform needs to be comprehensive, addressing the work-force issue needs to be comprehensive,” Heim said. “You have to look at medical students, training of residents and retaining physicians in practice. The strategy has to encompass all three of those components.”

“The legislation addresses each one of those components, but it doesn’t go far enough,” she said.

Centor generally supports the legislation but agrees more must be done.

“There are ways to get people excited about family medicine — this bill isn’t doing it,” he said.

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