One of the weaknesses of current U.S. health reform efforts is that they are counting on the idea that primary care doctors will continue to exist.
Witnesses delivered that message today in Washington at a hearing on the future of primary care that was organized by the Senate Health, Education, Labor and Pensions (HELP) primary health and aging subcommittee.
Dr. Claudia Fegan, chief medical officer at the John H. Stroger Jr. Hospital in Chicago, said she sees hundreds of people line up across the street at a walk-in clinic affiliated with the hospital every day.
Chicago residents "stand in line in the wee hours of the morning, hoping to be one of the 120-200 people who will be seen that day and, even better, hoping to be one of the 12 patients who will be assigned to a primary care physician and given an appointment so they won't have to come back," Fegan said, according to a written version of her remarks posted on the committee website.
The Patient Protection and Affordable Care Act of 2010 (PPACA) "promises to provide insurance coverage to more Americans, but I know there will still be 30 million people who will remain uninsured even after the Affordable Care Act is fully implemented," Fegan said. "So I know the need for the safety net and places like Cook County will remain."
There certainly still will not be enough primary care providers to care for all the patients who will need them, Fegan said.
The huge holes that already exist in the U.S. primary care network led to the current influenza epidemic flooding hospital emergency rooms with patients who should have been seeing primary care doctors, Fegan said.
Dr. Andrew Wilper, a medical school professor in Boise, Idaho, testified that the federal reimbursement formula system now pays primary care physicians about 30 percent to 60 percent less than it pays specialists.
In Massachusetts, a state that already has enacted a health insurance access expansion program, one result is that the coverage access program has led to an 82 percent in the length of time patients must wait to see primary care doctors, Wilper said.
"Without payment reform, it is unlikely that efforts targeting medical students and residents will succeed in bolstering the primary care workforce," Wilper said.
Uwe Reinhardt, a well-known Princeton University economist, said one solution would be for public and private health programs to make it easier for patients to see nurse practitioners for routine primary care needs.
Today, government programs often refuse to cover visits to nurse practitioners, or pay the nurse practitioners much less for the same services, and private insurers are often just as hostile to nurse practitioners, Reinhardt said.
When it comes to the primary care-specialist pay divide, "it can be asked...why private insurers have not led the way to raise the fees they pay primary-care physicians relative to those paid specialists," Reinhardt said. "Many and probably most of them simply have adopted the Medicare relative value scale underlying their fee schedules, although their absolute level of fees may be higher than Medicare fees."
Private insurers say Medicare must lead the way, because private insurers cannot act in unison to change the primary care-specialist pay gap without violating antitrust laws, Reinhardt said.
Dr. Fitzhugh Mullan, a public health professor at George Washington University, said the primary care shortage is likely to get worse because of the way the United States pays and trains doctors.
But public and private payers pay specialists more, and specialists tend to have more prestige, and many young doctors prefer to focus on practicing in specialties that will give them more control over their hours, Mullan said.
Meanwhile, hospitals run the residency programs that train recent medical school graduates, and "not surprisingly, hospitals recruit residents who fulfill the needs of the hospitals," Mullan said. "This tilts residency heavily toward medical and surgical specialties and subspecialties."
PPACA drafters tried to ease the primary care training gap by creating a Teaching Health Center Program to get more new physicians trained in primary care settings.
But the PPACA primary care teaching program is just demonstration program, and the money is set to run out in 2014, Mullan said.
"The absence of Medicare or Medicare-like permanent funding jeopardizes this small but enormously important new model of primary care education," Mullan said.