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1 A dose of reality From The New York Times: on Sun Sep 13, 2009 4:01 am


WASHINGTON — Obama administration officials, alarmed at doctor shortages, are looking for ways to increase the supply of physicians to meet the needs of an aging population and millions of uninsured people who would gain coverage under legislation championed by the president.
The officials said they were particularly concerned about shortages of primary care providers who are the main source of health care for most Americans.
One proposal — to increase Medicare payments to general practitioners, at the expense of high-paid specialists — has touched off a lobbying fight.
Family doctors and internists are pressing Congress for an increase in their Medicare payments. But medical specialists are lobbying against any change that would cut their reimbursements. Congress, the specialists say, should find additional money to pay for primary care and should not redistribute dollars among doctors — a difficult argument at a time of huge budget deficits.
Some of the proposed solutions, while advancing one of President Obama’s goals, could frustrate others. Increasing the supply of doctors, for example, would increase access to care but could make it more difficult to rein in costs.
The need for more doctors comes up at almost every Congressional hearing and White House forum on health care. “We’re not producing enough primary care physicians,” Mr. Obama said at one forum. “The costs of medical education are so high that people feel that they’ve got to specialize.” New doctors typically owe more than $140,000 in loans when they graduate.
Lawmakers from both parties say the shortage of health care professionals is already having serious consequences. “We don’t have enough doctors in primary care or in any specialty,” said Representative Shelley Berkley, Democrat of Nevada.
Senator Orrin G. Hatch, Republican of Utah, said, “The work force shortage is reaching crisis proportions.”
Even people with insurance have problems finding doctors.
Miriam Harmatz, a lawyer in Miami, said: “My longtime primary care doctor left the practice of medicine five years ago because she could not make ends meet. The same thing happened a year later. Since then, many of the doctors I tried to see would not take my insurance because the payments were so low.”
To cope with the growing shortage, federal officials are considering several proposals. One would increase enrollment in medical schools and residency training programs. Another would encourage greater use of nurse practitioners and physician assistants. A third would expand the National Health Service Corps, which deploys doctors and nurses in rural areas and poor neighborhoods.
Senator Max Baucus, a Montana Democrat and chairman of the Finance Committee, said Medicare payments were skewed against primary care doctors — the very ones needed to coordinate the care of older people with chronic conditions like congestive heart failure, diabetes and Alzheimer’s disease.
“Primary care physicians are grossly underpaid compared with many specialists,” said Mr. Baucus, who vowed to increase primary care payments as part of legislation to overhaul the health care system.
The Medicare Payment Advisory Commission, an independent federal panel, has recommended an increase of up to 10 percent in the payment for many primary care services, including office visits. To offset the cost, it said, Congress should reduce payments for other services, an idea that riles many specialists.
Dr. Peter J. Mandell, a spokesman for the American Association of Orthopaedic Surgeons, said: “We have no problem with financial incentives for primary care. We do have a problem with doing it in a budget-neutral way.
“If there’s less money for hip and knee replacements, fewer of them will be done for people who need them.”
The Association of American Medical Colleges is advocating a 30 percent increase in medical school enrollment, which would produce 5,000 additional doctors each year.
“If we expand coverage, we need to make sure we have physicians to take care of a population that is growing and becoming older,” said Dr. Atul Grover, the chief lobbyist for the association. “Let’s say we insure everyone. What next? We won’t be able to take care of all those people overnight.”
The experience of Massachusetts is instructive. Under a far-reaching 2006 law, the state succeeded in reducing the number of uninsured. But many who gained coverage have been struggling to find primary care doctors, and the average waiting time for routine office visits has increased.
“Some of the newly insured patients still rely on hospital emergency rooms for nonemergency care,” said Erica L. Drazen, a health policy analyst at Computer Sciences Corporation.
The ratio of primary care doctors to population is higher in Massachusetts than in other states.
Increasing the supply of doctors could have major implications for health costs.
“It’s completely reasonable to say that adding more physicians to the work force is likely to increase health spending,” Dr. Grover said.
But he said: “We have to increase spending to save money. If you give people better access to preventive and routine care for chronic illnesses, some acute treatments will be less necessary.”
In many parts of the country, specialists are also in short supply.
Linde A. Schuster, 55, of Raton, N.M., said she, her daughter and her mther had all had medical problems that required them to visit doctors in Albuquerque.
“It’s a long, exhausting drive, three hours down and three hours back,” Ms. Schuster said.
The situation is even worse in some rural areas. Dr. Richard F. Paris, a family doctor in Hailey, Idaho, said neighboring Custer County had no doctors, even though it is larger than the state of Rhode Island. So he flies in three times a month, over the Sawtooth Mountains, to see patients.
The Obama administration is pouring hundreds of millions of dollars into community health centers.
But Mary K. Wakefield, the new administrator of the Health Resources and Services Administration, said many clinics were having difficulty finding doctors and nurses to fill vacancies.
Doctors trained in internal medicine have historically been seen as a major source of frontline primary care. But many of them are now going into subspecialties of internal medicine, like cardiology and oncology. (At present, SS disbursements are to be cut by 1/2 trillion over the next 10 years regardless)

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