Disappearing Docs

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

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It’s All in the Delivery

Endocrinologist Paul Reber has seen studies that show how access to primary care increases life expectancy.

“This is a specialist telling you this so it kind of hurts,” says Reber, who spends twenty percent of his career as a clinician and eighty percent as the VP of Clinical Excellence at Dean Health System.

He can also cite research that goes a long way in explaining why we have a shortage of primary care doctors.

“There’s work out of Duke [University] that says it would take about eighteen hours per day for a primary care physician to provide all of the preventative and chronic care that we now have evidence to justify,” says Reber. “That doesn’t have anything to do with acute care and that doesn’t have anything to do with family time.”

So, due to the shortage of primary care doctors that already exists in this country, Wisconsinites are almost certain to have been short-changed on the preventative and chronic care they could have received if more doctors had been available to provide it.
Since early 2008, Reber has been heading Dean’s efforts to transform its primary care program into a certified medical home. Last February, they launched pilot projects at five family and internal medicine clinics, a third of its primary care physician workforce, and another at a Dean & St. Mary’s regional clinic. Since every workplace has its own unique culture, the exercise began with a full work-up of staffing and resources.

“We did an analysis from A to Z,” says Reber, and then set the medical home philosophy in motion. “It’s predicated upon a relationship between a patient and primary care physician [who] leads a team of health care professionals, all of whom are operating to the peak of their expertise, neither above nor below,” he explains.

This kind of empathetic, re-tooled thinking is part of a mantra you’ve heard in some form or another if you’ve been anywhere but under rock during these last few months of debate over health reform. What Reber is getting at is this idea that a “yes we can” America should strive for a silver bullet that addresses and aligns cost, access and quality of care. For primary care, medical homes are the current bullet and, to complete the metaphor, the electronic health record is a gun in its arsenal.

Bucking the Trend

GHC was the first local provider to adopt MyChart, seven years ago. Like Reber, GHC’s Bartell wears two hats, an internal medicine physician and chief of quality and care innovation. She divides her time between her regular panel of patients, which she sees a day a week scattered over three days, and overseeing electronic health and other systems that keep GHC focused on its “Patient Centered, Community Involved” mission. It’s a mission that fills primary care vacancies quickly, she says, because the non-profit, member-owned co-op also owns the health plan, and its docs are salaried, not reimbursed for productivity.

“It doesn’t matter whether [patients] come into our clinic,” Bartell says. “We have the same incentives to take care of a question over the phone or through MyChart.”

Madison native Bartell attended Yale, then UW for med school, residency and a master’s in public health. She chose GHC as much for its focus on the patient as its focus on the doc. As the mother of three young daughters, work-life balance is no cliché, it’s a way of life for Bartell and the next generation of doctors who will practice primary care. Unfortunately, more will choose to specialize because they don’t want their “medical homes” to be their primary residences eighteen hours a day.

The New Win-Win?

But believe it or not, there’s some encouraging news. There are some smart people with a lot of ingenuity out there tinkering with the broken light at the end of our health care tunnel. The medical council that released the physician shortage report launched a job search website to enhance recruitment efforts in all specialties. In 2007 UW School of Medicine and Public Health opened the Wisconsin Academy for Rural Medicine to increase the pipeline of physicians who will practice in the state’s most underserved areas. New federal stimulus money targets loan repayments and forgiveness programs for primary care medical education.

And this fall UW Health launched primary care redesign projects in nine clinics that, like its competitors Dean and GHC, will optimize electronic housekeeping and preventative, evidence-based medicine. The future will look brighter when it’s healthier for the patient, easier for the team of providers, and more palatable to the insurance company that would process fewer and less expensive claim reimbursements.

“I think what we fully expect to see is that we’ve got timely access to health care—that patients’ needs are driving our interactions and relationships, and we’re maximizing the use of all of our resources,” says Mark Kirschbaum, senior VP of Quality and Innovation for UW Hospital and Clinics. “And ultimately that we’ve got a really engaging system that’s attractive to prospective providers. And we are able to keep those folks here and also be a place where people want to practice because it’s an idealized environment.

“It’s where they can really deliver on what they had wanted to do in the first place.”

Primary care, for example, is what Gretchen Diem wanted to do with her Ph.D. in health psychology. Which is why, when Meriter Hospital opened its newest clinic in the heart of downtown Madison in August, she left her work with bariatric surgery specialists at UW Health and joined a team of practitioners and physician extenders with a renewed focus on prevention. Diem’s office is one of six outpatient clinics, including two “fast-care” locations for minor conditions, opened in the last five years as part of Meriter’s own efforts to tackle the health care triad of cost, access and quality.

It turns out that up to sixty percent of all visits to physicians are for underlying mental health issues, says Diem. Stress, anxiety, depression—all of which seem to be going around in an economic recession.

By integrating mental and physical health, “You can improve access by decreasing overutilization and also by really helping patients learn how to take a more active role in their health in order to ward off and prevent some of the conditions,” says Diem. “We know that top chronic illnesses, most of them can be prevented by lifestyle choices.”

Patrick McKenna is busy pushing prevention as a physician who chose primary care for the variety and continuity that a general practice can offer. He is a second-year resident on rotation at UW Health’s Verona Clinic. A native of Antigo with bachelor’s and medical degrees from UW–Madison, he loves the relationships he gets to establish with patients from both rural and urban environments but plans on practicing in northern Wisconsin, allowing him to take advantage of rural health incentive programs that help with the student loan debt.

The married father of two is fulfilling his dream of “participating in the significant moments in people’s lives” and doesn’t spend much time worrying about the high cost of education or his future salary.

“Are there any poor docs?” McKenna asks. “Really, the answer is no.”

Sarah Lowery didn’t take advantage of any of the loan forgiveness or tuition reimbursement incentives, but she doesn’t have any regrets about debt, or her choice to join the small, independently owned Wildwood Family Clinic on Cottage Grove Road three years ago. Founded in 1978, the primary care practice is upgrading its second clinic in Cottage Grove with a brand-new building and both facilities will transfer to an electronic medical records system. The mother of three children under six has found her lifestyle balance working three-and-a-half days a week, plus she’s on call some nights and weekends and, of course, whenever a patient goes into labor. Like any doting mom, Lowery chaperones field trips and volunteers in her kindergartener’s classroom.

“I’m home by dinnertime,” she says.

Brennan Nardi is editor of Madison Magazine.

Read more Madison Magazine stories on health care access:

October 2009: Body of Work

February 2009: Doctor.com

February 2009: Independently Healthy

February 2008: Docs With Heart

September 2006: Top Doctors 2006/The Other Primary Care Provider

January 2005: A Dying Dilemma
 

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