Scripps Howard News ServiceHealth-reform legislation approved by the House last weekend would add tens of millions of Americans to the ranks of the insured.
And it would begin to address some of the deficiencies in the way family doctors are paid and trained so that there may be at least a few more primary-care physicians available to care for all those newly insured patients.
That's critical, because various estimates suggest the nation is already short some 40,000 to 80,000 family doctors, even as many primary-care physicians are retiring or cutting back their practices.
A special report by Scripps Howard News Service earlier this year found that as many as 60 million Americans lack a regular primary-care provider due to the physician shortage, and that fewer than a third of the nation's more than 600,000 doctors actually provide primary care.
Those estimates are based on the American Medical Association's master file of active physicians, which tends to be slow to register physician retirements. Researchers at Dartmouth College recently published another analysis of the physician work force based on U.S. Census employment surveys, and found they show about 10 percent fewer active doctors than AMA reports show.
That means that by the end of the next decade, there may be 100,000 fewer doctors of all types than has been officially projected.
Lawmakers are well aware of the need.
"I think our advocacy for primary care has yielded exciting results in this legislation, " said Rep. Allyson Schwartz, a Pennsylvania Democrat who saw many elements of the Preserving Patient Access to Primary-Care Act she introduced earlier this year included in the final House health package.
In particular, under the House measure, Medicare would pay extra to doctors who serve as "medical homes" for patients with chronic conditions -- basically, a bonus for time spent coordinating health-care services, maintaining flexible hours and taking steps to avoid costly hospital stays. There would also be demonstration projects to support the medical-home concept in select Medicare and Medicaid plans around the country.
The bill also bumps up Medicare payments to primary-care docs by 5 percent nationwide, and by 10 percent in areas designated as health-professional-shortage areas by the federal government.
Primary-care physicians typically make $150,000 or less a year, about half the average earnings of medical specialists, which is a powerful disincentive to choose family medicine. Only about 2 percent of medical-school graduates -- who go into residency with an average debt of $140,000 -- have been going into family medicine in recent years.
"I think the House has made a good start by beginning to increase payment for primary care, although not enough to close the gap with specialists and make being a general practitioner more attractive to students leaving medical school," said Dr. Lori Heim, president of the American Academy of Family Physicians.
"None of the bills in the House and Senate will get us where we need to go, but the recognition is there that primary care needs to be encouraged and function better if the entire health system is to be reformed," Heim added.
Other changes would increase scholarships and loan-forgiveness programs for primary-care providers serving in shortage areas, and medical-residency positions that go unfilled would be redistributed to primary-care and general-surgery slots, creating about 800 new slots.
But with the latest new class of U.S. medical students still fewer than 20,000, and few inclined toward primary care, "I don't see anything in the legislation that will greatly increase the primary-care pipeline," said Dr. Russell Robertson, chairman of the Council on Graduate Medical Education, which advises Congress on funding residency programs.
Earlier this year, Senate Democratic leader Harry Reid of Nevada proposed adding as many as 15,000 new primary-care training slots. But that suggestion didn't make it into either health bill drafted by two Senate committees because of cost concerns. And it's unlikely to be resurrected in the final Senate plan Reid is struggling to stitch together in the next few weeks.
"If this is all we do with health, we're still looking at a dysfunctional system and we're not going to be able to control costs unless we change how care is delivered and by whom," Heim said.
"We still have a health system that's in critical condition. With the legislation moved thus far, I'd have to say primary care is, at best, in guarded condition."
