Primary Care Shortage Reaches Critical Levels

Oregon physicians identify no one easy solution

This is the first story in a five-part series on the shortage of primary care in Oregon. 
November 4, 2009 -- The dwindling shortage of primary care physicians threatens to haunt the Oregon Health Plan when 115,000 newcomers enter the fold early next year.

“It’s definitely going to stretch a system that’s already stretched too thin,” said Anna York, who teaches at Franklin High School in Portland. York, who has a three-month-old daughter, is most concerned about her students and their families’ struggles to find a primary care physician.
"The students can get minimal healthcare through the district, but then they get referred out. You have to be incredibly flexible about the Oregon Health Plan because the waits are insane.”
That’s in Multnomah County, an urban area with 335 physicians per 100,000 compared with the 134 physicians per 100,000 in Oregon’s rural areas, according to the latest census data. All signs point to a worsening of the situation, with the Department of Health and Human Services predicting a shortage of at least 35,000 primary care doctors by 2025.
Specialty physicians can expect to make much more than their primary care counterparts, a difference that amounts to hundreds of thousands dollars annually. For example, the median compensation for radiologists has risen above $400,000 during the past decade, while most internists, pediatricians and family practitioners earn less than $175,000,  according to the Medical Group Management Association Physician Compensation and Productivity Survey,
A survey conducted by Modern Healthcare in 2008 looked at income levels for 21 of the most common types of physicians, and found that pediatricians, family practitioners, hositalists and internists were the lowest paid. Of the U.S. News and World Report’s top 16 medical schools (none of which are in Oregon), only two had more than 50 percent of their residency students going into primary care --the University of Washington and the University of Massachusetts-Worcester.
Although the primary care shortage is widely recognized and lamented, a key policymaker in Oregon who could make a difference remains mum. As head of the Medicare Payment Advisory Commission, Glenn M. Hackbarth is a longtime federal official and health executive in charge of setting compensation levels for specialists and primary care physicians.
According to The New York Times: “As chairman of one of the more obscure federal agencies, Glenn M. Hackbarth is little known outside the world of healthcare and his hometown, Bend, Oregon. If President Obama has his way, Mr. Hackbarth could become one of the most important people in government, with the power to say how Medicare spends more than $450 billion a year.”
The Lund Report contacted Hackbarth who wouldn’t talk about pending legislation to change physician compensation. He would only say, “I don’t do any on-the-record interviews.” When The Lund Report asked if he knew anyone else (not on MEDPAC) who’d discuss the issue, he said, “I don’t make any referrals,” but mentioned we could contact him once Congress passes healthcare reform, and conceded, “That indeed won’t be for a long time.”
Baker City physician Chuck Hofmann wasn’t surprised to hear about Hackbarth’s reticence.
“The federal government’s been behind the ball,” said Hofmann, who’s been appointed to the Oregon Health Policy Board, which intends to form a work force subcommittee at its Nov. 10 meeting.
The top Medicare commission shouldn’t shoulder the blame on its own, he insisted. “MEDPAC has made good recommendations, but historically their recommendations have been shot down by Congress. That might be the type of system Jefferson had in mind, but it doesn’t do much for sick people.”
Even considering the high stakes, Hofmann is wary of Obama’s proposal to rely on decision making by MEDPAC. “I don’t know that giving MEDPAC free reign is necessarily a good idea because it relies on having a thoughtful and benevolent group of people,” he said
Hofmann’s “very concerned” about quick solutions under consideration by the “America’s Healthy Future Act” proposed by Sen. Max Baucus (D-Mont.). “The finance bill calls for a 10 percent increase in Medicaid bills to pay primary care, but all that’s going to do is prevent a few physicians from retiring,” he said. “We’ve been robbing Peter to pay Paul for so long that everyone knows it’s broken.”
To address the primary care shortage, health officials must start chipping away at the root causes. On the top of Hofmann’s list are the horrendous amounts of paperwork that primary care physicians must endure.
Primary care physicians also insist that Medicare coding procedures are confusing and take endless amounts of time. The only way physicians can improve their income is by ordering expensive tests or making a new diagnosis. And while most physicians can designate a certified medical secretary to complete their paperwork, Medicare requires that primary care physicians do all of the paperwork themselves.
That’s also where the discussions begin with the American Board of Internal Medicine. “It’s not just the salary, it’s the lack of controllability of the lifestyle that’s a concern,” said Dr. Barry Egener, medical director of the Portland-based Foundation for Medical Excellence who sits on the ABIM’s board.
Describing the “pointless hours of paperwork” internists  must fill out for Medicare each day, Egener laments that the system lacks a fair payment method. “I work with a lot of other docs who are in distress,” he said, comparing internists’ low pay and bureaucratic dealings to an internship with AmeriCorps. He said it’s like doing piece work with the only way to increase income by seeing more patients.
Who should primary care physicians lobby to address these administrative burdens? Probably not Glenn Hackbarth of MEDPAC.