BOSTON — Among the many hurdles facing President Barack Obama's plan to revamp the nation's health care system is a shortage of primary care physicians — those legions of overworked doctors who provide the front line of medical care for both the sick and those hoping to stay healthy.
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As Massachusetts' experience shows, extending health care to 50 million uninsured Americans will only further stress the system and could force many of those newly insured back into costly emergency rooms for routine care if they can't find a primary care doctor, health care observers said.
Massachusetts, home of the nation's most ambitious health care law, has seen the need for primary care doctors shoot up with the addition of 428,000 people to the ranks of the insured under a 2006 law that mandates health care for nearly all residents.
To keep up with the demand for primary care doctors, the country will need to add another 40,000 to the existing 100,000 doctors over the next decade or face a soaring backlog, according to Dr. Ted Epperly, president of the Kansas-based American Academy of Family Physicians.
"It's like giving everyone free bus passes, but there are only two buses," he said.
The need for more primary care doctors comes as the country's shortage of all doctors is expected to worsen, according to a study by the Association of American Medical Colleges, which found the rate of first-year enrollees in U.S. medical schools has declined steadily since 1980.
If current patterns persist, the study shows the country will have about 159,000 fewer doctors than it needs by 2025.
A raft of ideas has been proposed to ease that pressure — from boosting loan repayment programs for medical students studying primary care to narrowing the salary gap between primary care doctors and specialists like brain surgeons and cardiologists.
All the efforts have a single objective — increasing the number of primary care doctors to give them spend more time with the patients who need them the most.
As part of his health care overhaul, Obama has stressed the need to "elevate the profile of family care physicians and nurses as opposed to just the specialists who are typically going to make more money."
Obama has said that more insured Americans will require both an increase in primary care doctors and a team approach to care.
"If you look at what's happening in some states, like Massachusetts, where they tried to create a universal system — and they haven't quite gotten there yet — they have had a problem with an overload of patients," he said in July.
He even chose as his pick for U.S. surgeon general Dr. Regina Benjamin, who has made her name delivering primary care to poor and immigrant communities in Alabama. Benjamin also worked in the National Health Service Corps, a program that helps young doctors pay off medical school loans by serving in poorer communities.
In a 2008 survey of physicians, the Massachusetts Medical Society found the average wait time to see an adult primary care doctor was 50 days, with some doctors reporting wait times for new patients of up to 100 days. That's compared to 2005, before the law was signed, when the average wait was 47 days and the longest was 87 days.
The society also found a drop in the number of primary care doctors accepting new patients. In 2008, 42 percent had closed their practice to new patients compared with 33 percent in 2004, before the law was signed.
Family doctors need a raise
Part of the problem is that those trained to intervene after a heart attack typically earn more than those who help prevent the heart attack from happening in the first place, said John Auerbach, the Massachusetts Medical Society's immediate past president.
"We have devalued the work of what a primary care physician does," he said.
Epperly, of the American Academy of Family Physicians, said primary care doctors need a 30 percent pay increase. The average family doctor makes about $160,000 year, he said. A 30 percent increase would bring them over $200,000, compared with the average $300,000 for a specialist, he said.
When Dr. Robert Flaherty launched a private practice in 2001, he soon found himself cramming in as many patients as possible to make ends meet, leaving little time to discuss with them the steps they could take to prevent future health troubles.
"I constantly felt that conflict of going faster than I should," said Flaherty, 40, who gave up his practice after four years for a hospital post. "Everyone knows if you want to make a decent living, become a specialist; if you want to be banging your head, go into primary care."
Massachusetts is trying to expand access to primary care by encouraging doctors to adopt a team approach by relying more heavily on nurse practitioners and health educators for basic care and counseling, said Massachusetts Health and Human Services Secretary Dr. JudyAnn Bigby.
Nurse practitioners already figure prominently in the operation of private clinics set up in pharmacies, offering basic services like flu shots and treatments for minor ailments. CVS Caremark Corp. and Walgreen Co., which operate hundreds of the clinics around the country, say they are faster than a visit to a primary care doctor and less expensive than a trip to the emergency room.
The state also offers loan repayments up to $75,000 for new doctors who agree to work in community health centers for three years. So far, 70 new doctors have signed up.
Another way to expand primary care is to have some specialists provide the equivalent of primary care, according to Dr. Georges Benjamin, executive director of the American Public Health Association.
He said obstetrician-gynecologists essentially serve as primary care physicians for many women — a model that could be used for patients who rely on other specialists.
Ryan Van Ramshorst is the kind of young primary care doctor advocates say the country needs to fill the gap. A fourth-year medical student at Baylor College of Medicine in Texas, Ramshorst is doing his residency in general pediatrics.
"When I wrote on my medical school application that I wanted to help people, I really meant it," he said.
The federal National Health Service Corps, the same program that helped Regina Benjamin, is helping him, covering two years of his tuition and expenses in exchange for him spending at least two years in a clinic in an underserved area.
Ramshorst said he's thankful for the opportunity but said plans to expand the corps — the Obama administration has announced $200 million in federal stimulus funds to boost the corps by 3,300 doctors and clinicians — is no replacement for adding more primary care doctors and increasing pay.
"We need something with a bigger scope," he said.
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