Disappearing Docs

A looming shortage of primary care providers is changing the face of health care

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About the time the first wave of Baby Boomers was opening its solicitations to join AARP, Madison was interrupted with the alarming news that nursing schools could no longer recruit enough faculty to train more nurses. As it turns out, medical schools were quietly plugging the dike of their own impending crisis. Then, in a 2008 report titled “Who Will Care For Our Patients?,” the Wisconsin Council on Medical Education and Workforce warned us that a physician shortage was deepening, eroding the health of Wisconsinites in all areas of the state—even in a city famously surrounded by reality.

The report analyzed data and trends and spelled out some cold, hard facts about the escalating—as in, exponentially—shortage of primary care physicians. Last year, for example, the state had nearly four hundred fewer than we need to adequately care for our population, according to the Wisconsin Hospital Association, which wrote the report on behalf of WCMEW. In a Wisconsin Medical Society survey of 8,000 practicing physicians, the report also concluded, more than a quarter were “dissatisfied with their practice environment, their hours, or their incomes … with 35 percent of physicians indicating the wait times for visits have increased over the past three years.”

Primary care is an umbrella term for the family doctors, internists, pediatricians and others who vaccinate our kids, order our mammograms and colonoscopies, and manage our pillboxes when we’re old and gray. But if we don’t fix this problem before health care reform at long last allows the state’s currently un- and under-insured citizens to join us in the canoe, say experts, we will all be up a creek without a stethoscope.

None of this is news to the Madison medical community. The Council’s sobering report had a predecessor four years earlier that clearly demonstrated how the demand for primary care physicians already exceeded the supply. More importantly, though, the thinning ranks of physicians in the departments of family and internal medicine at the University of Wisconsin Medical School, where fewer students are choosing primary care, has been an unfortunate but widely known fact in the medical community going back a decade or more.

“If you look at the physician workforce, more than a third are in primary care,” says Valerie Gilchrist, professor and chair of the UW Department of Family Medicine. “If you look at the graduates of medical schools, less than a fifth are choosing primary care.”

Valerie Gilchrist (above) and Sandra Kenmetz (below) are UW Department of Family Medicine faculty members leading the primary care redesign efforts to address the dwindling supply of physicians in practice.Growing, Growing, Gone

One big reason primary care is less popular is this: relative to their peers in specialty medicine, general practitioners earn salaries that simply pale in comparison. In Wisconsin and everywhere. A national study released this summer by physician recruiters Merritt Hawkins & Associates put the average family physician salary at $173,000, “the lowest of any specialty,” while orthopedic surgeons pulled in an average of $481,000.

“We’ve come to accept the notion that a specialist who looks at your sore throat should be paid more than the primary care doctor,” says Martin Preizler, former president and CEO of Physicians Plus Insurance Corporation. “In some diagnostic circumstances that may be justified, although not across the board.”

“We’ve all gone up [in salary] but the gap has widened,” adds UW Health physician Sandra Kamnetz, who’s been practicing family medicine in Madison for the last twenty-five years and is currently overseeing a major primary care overhaul at the university’s Department of Family Medicine.

Kamnetz traveled to Texas in September for a biannual meeting with her colleagues from other large, multi-specialty clinics across the country (think Mayo, Geisinger, Kaiser and Group Health out of Seattle). They talked health reform, electronic medical records and, of course, the triple threat to practicing family medicine: salary discrepancies, practice issues and lifestyles that discourage bright, young minds from following her into the field.

“We’ve burned out poorly compensated docs,” she said during a session break. “When I came out [of med school] you Paul Reber leads Dean's efforts to retool its clinics to take on the statewide shortfall, estimated at anywhere from 14 to 57 percent by 2030 depending on changes to the health care delivery system.delivered babies, you helped with surgery, you hospitalized your patients, you saw patients in the office, you were involved in the community. You didn’t have a whole lot of life.”

Add UW–Madison’s average of $120,000 in student loan debt for students graduating from its medical school to that picture, and it’s not a pretty one.

But why, if we’re in such dire need of primary care providers, would salary discrepancies be so wide—and widening? Wouldn’t the laws of economics play into the equation—that if demand exceeds supply, suppliers become more valuable? Welcome to Health Care 101.

“Health care defies normal demand and supply economics,” says Preizler. “It’s known that as more specialists practice in a community, rather than competition lowering prices, the specialists tend to do more tests and procedures to sustain their incomes, thereby pushing up total costs.”

“Perverse incentives” is the common term health care experts use to describe the conundrum of controlling costs in a fee-for-service and volume-based insurance model. The more care you provide, the deeper your pockets, whether you’re the doc, the insurance company, the clinic or the hospital. The irony is that the care isn’t necessarily better; it’s just more.

The E.R. EpidemicChirs Modena, St. Mary's director of emergency services, says national figures show 60 percent of ER visits are for non-emergencies, but thanks to a regional network of urgent care clincs, her emergency room has seen less than half of that.

Who will care for the patients? As the Boomers continue to age into a greater need for primary care, and if our citizens who currently need health insurance gain access under reform, the answer to that question will likely be named Chris Modena. And people like her. An emergency room nurse who has watched the primary care shortage evolve, Modena has seen first-hand its effects here in Madison.

“The shortage seems to be getting worse,” says Modena, director of emergency services at St. Mary’s Hospital. “Certainly there aren’t as many physician names on our rosters to refer patients to for care of chronic illness.”

Statewide, the problem is particularly ominous in rural communities and inner-city Milwaukee—populations who can’t afford or even get to the high-quality care that a well-insured Madisonian, by comparison, might take for granted. Often ER visits are at night, when the primary and urgent care clinics are closed. And without a clinic nearby to treat a persistent cough or manage chronic back pain, folks end up prolonging poor health or using the emergency room for basic health care, all of Jessica Bartell heads GHC's efforts to keep primary care its primary focus.Gretchen Diem is part of a team of "physician extenders" at Meriter Medical Clinics.which ratchets up costs for everybody.

Modena says her hospital has seen “a new group of uninsured” patients in the ER in the last year—the recently unemployed. And while a recent expansion “could easily double our current capacity,” she says the higher costs of ER care will continue to be a challenge, as will follow-up primary care after an ER visit—a critical step in nursing patients back to good health.

Fortunately, Modena and her colleagues have been busy looking for efficiencies in staffing and resources that they expect will enhance both access to and quality of care.

“We have undergone a culture change in that we believe that patients need to get to the doctor as quickly as possible,” says Modena. “And it’s actually a cost-savings move as well as a patient satisfier because you reduce the amount of time that someone’s actually in the emergency room by eliminating the up-front waiting time.

“Now? You see a nurse, you see a doctor … So then when the patient comes in the focus is not, ‘How are you going to pay for your visit?’ The focus is, ‘How fast can I get you to the doctor?’”

And how fast can they get you stitched up and back to your regular physician—that is, if you have one.

Home Sweet Home

Internal medicine physician Jessica Bartell only sees patients in the hospital on occasional “social calls.” Her employer, Group Health Cooperative of South Central Wisconsin, focuses on primary care in five outpatient clinics in and around Madison. To keep track of her patients while they’re in the care of a hospitalist—a relatively new kind of M.D. who manages hospital stays—she relies on electronic medical records and a “care team” approach to medicine. Both innovations have begun to revolutionize the primary care environment long plagued with mountains of paperwork and an antiquated—and perversely incented—care model of one-patient, one-doctor-at-a-time.

At GHC every doctor is part of a team of two to four physicians, a nurse practitioner or a physician’s assistant, and a registered nurse. Every patient has access to the team with an online account called MyChart that tracks health and health insurance information, including co-pays, appointments, patient visits, phone and e-mail correspondence, and test results. The account is also a clearinghouse for health and wellness information. Want to get a handle on your high cholesterol? MyChart will connect you to knowledgeable resources.
This team approach to primary care medicine with M.D.s as captains, nurtured with the efficiencies and cost-savings of the latest technology, is part of a new movement referred to as a “patient-centered medical home.”

It’s actually an old movement with a contemporary name and an urgent mission. Medical homes in Madison go back a century—to clinics with familiar names such as Dean, Jackson and Quisling, to a time when the pharmacist at Rennebohm’s recognized every scribbled signature on an Rx scrip. It was an era when Doc Dean delivered every baby in the family—and the neighbor kids, too—and the surgeon who snipped your tonsils at Madison General would be the same one who patched your uncle’s hernia at Meriter all those years later.
In the 1970s the UW Medical School established both the Department of Family Medicine and the primary care track in Internal Medicine, formalizing the medical home concept that’s now being retooled to save twenty-first-century health care from the financial and technological excesses of its latter twentieth-century self. In the ’80s and ’90s, with new drugs and treatments and a specialist to administer each one, health care costs were skyrocketing out of control. And by then, fewer and fewer general practitioners were around to coordinate your care—to help you manage your
diabetes or remind you that you’re due for a tetanus shot.

“We have had too much dependence upon the physician as the center of the care team,” says Preizler. “In many other industrialized western countries, physician extenders take care of the bulk of primary care and their overall costs are lower and outcomes better.”

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