Wednesday, February 2, 2011

Primary Care Shortages, Malpractice, and Obamacare

I'm going to put my three part discussion of action potentials on hold while we talk about primary care physicians, Obamacare, and health insurance.

Primary care physicians in this country make some of the lowest salaries in the business, and are expected to see ever more patients in an aging population. The average medical school debt is  $157,944 according to the AMA. The average primary care visit is approximately 10 minutes.

Primary care physicians (PCPs)have a lot stacked against them. They spend about the same amount of time in a residency as other specialties (I found this fantastic site that breaks down the time required per residency and where people choose to go) They also pay a fair bit in malpractice insurance compared to their salaries (it is stupidly difficult to find any numbers that are helpful here. This is the best and most recent I could find)  I've seen that PCPs can pay anywhere from $6,000 a year to nearly $60,000 a year. Balance that with the huge amounts of debt and the low pay, and you can see very quickly that the financial appeal is very low. Yes malpractice is higher for other specialties (With Ob/Gyn at the very top, proportionally, with anywhere from $55,000 to $200,000 depending on the state) but these specialties also make MUCH more. One of the highest paid specialties is coincidentally the one I'm interested in: neurosurgery, with estimates around the $530,000 mark and malpractice averaging $100,000 and capping at around $300,000 in some states. (Though believe me, this is NOT the reason I want to do it.)

Medical school debt? Not taxable, because it will all be paid back with interest. Residency salary? Taxable under the current IRS laws. Lawsuits are moving forward with that, but I'm not sure if that will change any time soon. Also, there was a brief kerfuffle over whether or not medical residents are in or out of school, and thus responsible for repayment of loans. I know that they can apply for deferments, but due to the economy those are drying up.

Plus the Baby Boomers are beginning to retire, and will continue to do so for probably another decade. This means that not only will the vast majority of people that are of retirable age do so, so will the primary care doctors that are of the same generation. The United States has an aging population and we need people in primary care and geriatrics to help us manage it.

There are some wild estimates to our primary care shortage, anywhere from 16,000 to 46,000 doctors that will be needed as this phenomena occurs. But there is no money in primary care, and the hours are punishing. In addition, rural areas that are already poorly served by the medical communities will also face critical doctor shortages. It seems as if we will be facing critical doctor shortages period, since this is hardly something that is limited to Northern California.

And as a result of the poor economy and enormous deficits, some medical schools have begun to slash enrollment. This is counterintuitive if they are going to be able to produce enough physicians to manage the aging and retiring population and replace all of the retiring physicians.

Ahh, medical malpractice, the bane of many physician's lives. Malpractice costs have skyrocketed in our litigation-happy culture, with the highest proportional costs in Ob/Gyn and the lowest in primary care. Basically lawyers have found a great way to get rich quick, and do so by tapping the veins of doctors that make more money. Frankly I'm glad that doctors make more money: they have more debt, more responsibility, and take more time out of their lives to become licensed to practice. It is truly a shame that primary care doctors have to practice defensive medicine in order to not have to deal with excess litigation. It costs this country billions of dollars but it seems a natural way to avoid lawsuits.

The problem of course comes with situations where people that don't understand medicine are the ones making laws that govern doctors. A doctor can do everything right and still end up with a dead patient, and somehow that is cause for a lawsuit. The science behind medicine often comes down to statistics: the chances that a given treatment or medication will help in the patient's case. This is often the situation for oncology, for example, where depending on the location, type, and stage of cancer, the decision to treat comes down to statistic probability of the treatment prolonging life and quality of life. It is impossible to predict how a patient's idiosyncratic genetic makeup will react to every medication and every treatment, and so medical probabilities are often the best way to make such decisions. When this goes wrong (and it happens very rarely) everyone in the medical community suffers because a politician or an insurance company sees the damage and decides to make it a sticking point. And so a doctor writes an order for a CT scan for that 1 in a billion chance that this person this time has an aneurism when they come in complaining of a headache, because they don't want to get sued.

I'm not suggesting that bad doctors or doctors who make stupid mistakes shouldn't pay for them. They should absolutely help pay for any damage they've done. But they shouldn't have to pay for other people's mistakes, which is where the system is at the moment. We have a vaccine injury court where people who had that 1 in a million chance of having a reaction to a vaccine (which is an incredibly safe procedure) can get some damages even though the physician did nothing wrong.

Right now, private medical insurance and public programs like Medicare and Medicaid pay for medical care for the average person. Emergency rooms MUST provide care regardless of insurance status, and private hospitals may transfer a patient to an ER if they lack insurance, but only after stabilizing. Also, COBRA stipulates that a hospital that gets public money must see patients without insurance. I can't imagine any self-respecting doctor refusing to care for a patient if they don't have the insurance or the means to pay, however. From what I understand, primary care doctors not only get less in terms of reimbursement from insurance, Medicare and Medicaid than other specialties, but they also take a financial hit in this fashion as well.

Under Obamacare, (I know it is meant to be derisive, but I like that he was so instrumental in getting it passed) the plight of the average PCP seems uncertain. Medicare and Medicaid payments remain uncertain, but more people will have insurance (mandated or face penalties, with government subsidies) which means that doctors will actually be able to get their fair share. On the other hand, the overseers of the program will make recommendations of budget cuts if the program goes over budget, and PCPs will probably feel the brunt of that first.  Here is a wonderful breakdown of how exactly the plan will affect primary care doctors and insurance.

Also, many physicians that responded to that survey said that they simply did not have the time to see more patients, since an influx of 39 million insured patients will definitely increase case loads.

Medical schools have to increase their enrollment to prepare to care for an aging population, otherwise shortages can get even more desperate. There is a 3 week waiting list to get to a primary care physician, and it may take longer before the newest crop of doctors graduates  from medical school.

After all of this reading and research, one thing is certain: physicians are GROANING under a bloated bureaucracy and resent having to spend their time with paperwork and billing in order to provide quality care. Too much time is spent with non-clinical or health related tasks, and too much is spent hassling with insurance companies to get reimbursed.

I resented the Republican's efforts to repeal Obamacare: it just seemed like yet another of their tactics to use misdirection and falsehoods to undermine Obama's goals for this country. But I must say that after reading all of this, I am deeply torn as to whether or not it should be repealed. There is a lot in these surveys that shows that doctors (overwhelmingly represented here by PCPs) are not happy with all of this. If one thing is certain, it's that most of the respondents that wrote comments think that malpractice is the primary problem with medicine, and I'd have to agree. Some of these comments are made out of sheer ignorance (where has public free health care failed? I can't think of anywhere) but it seems like a single payer system plus tort reform is really what we need here. I also wholeheartedly agree that doing this without getting an actual board of doctors to weigh in is incredibly stupid and shortsighted.Who better to tell the politicians what is really needed to improve the system?

And so we come full circle. Given the options available and the kinds of financial and bureaucratic issues that primary care doctors have to deal with, who wants to go into primary care? This is a snowballing effect, until the insurance companies are thrown out (will never happen in this country. Their lobbies are too powerful) and doctors can practice without constant fear of litigation.

Thanks for reading all of this. I know it was pretty heavy, but these are the issues that we face. These are the kinds of choices that medical students have to make going into internships and residencies. This is the kind of situation that will affect decisions to practice medicine in the first place.

I know a lot of doctors don't do it for the money, but frankly once you've been a med student and a resident and a freshman doctor, a little compensation for your time, effort, and money would really be nice. In the specialty I want to go into, it will take me 10 years, including med school, internship and residency, to become an independent doctor. It is heady to consider.

1 comment:

  1. Good article. I'm entering into medical school in the fall and these thoughts are definitely on my mind. The political atmosphere and all the rhetoric make it hard to do what any policy analyst knows about efficient healthcare: it needs a single payer system. Thanks for the insights, and the links were great!