WASHINGTON, Feb. 19 (UPI) -- Family doctors are highly skilled, cost-effective -- and increasingly hard to find.
Faced with lower salaries, longer hours, high debt loads and high expectations, medical students are increasing eschewing general practice for better paid and more glamorous specialties. Between 2000 and 2005 alone, the percentage of U.S. medical students choosing family practice decreased from 14 percent to 8 percent.
Meanwhile, the aging population, an increase in chronic conditions, and skyrocketing healthcare costs are increasing demand for their services -- but not their pay -- because of the complicated formulas used to determine physician payment.
That shift is creating a deficit that could send shock waves through the entire health system, said Thomas Bodenheimer, author of a perspective appearing Tuesday in the Annals of Internal Medicine.
"There is going to be a real, terrible crisis where primary care is not available to a lot of the population," Bodenheimer told United Press International.
Though primary care physicians are well-paid compared to the average American, they earn a fraction of specialists' salaries. In 2005, the average dermatologist earned $308,855. The average family doctor earned $161,816.
Likewise, the reimbursement rate for a colonoscopy is at least twice that of an office visit, even though both take about half an hour.
The pay gap means many medical students, who graduate with a median debt of more than $100,000, feel they cannot afford to go into family practice, Bodenheimer said.
If they do choose the lower-paying field, they are also faced with a grueling work schedule that involves seeing dozens of patients, diagnosing and treating potentially hundreds of different conditions and struggling to coordinate patients' care with other doctors, he said, and much of that work is underpaid or completely unpaid.
The culprit, he writes in his article, is the payment formulas used to calculate reimbursement rates for various physician services. Procedures, like colonoscopies, are favored over more basic care like doctor's office visits.
In the Medicare program, when the number of procedures increases -- usually driven by increases in specialist services -- the reimbursement rate goes down for everyone, and that hurts general practitioners, he said.
To correct this, Medicare adopted the Resource-Based Relative Value Scale in 1992 and most private insurers followed suit. However, because the scale still favors procedures over preventive care and case management, it has done little to narrow the ever-widening pay gap.
Though general practitioners account for more than half of Medicare office visits, they only make up 15 percent of the committee that determines the relative value of procedures, known as the Relative Value Scale Update Committee, he said.
In the current payment system "there is only one pie," Bodenheimer said, "and primary care is getting a smaller and smaller share of that pie."
Ironically, primary care physicians' services have been shown to help drive down healthcare costs by emphasizing early, low-cost interventions instead of later complicated medical procedures, he added. "Specialty care drives cost -- not primary care."
The lack of general practitioners is felt even more acutely in rural areas, said Donald Frey, chairman of the Nebraska Rural Health Advisory Commission and of Creighton University's Department of Family Medicine.
"Even if there were no pay gap, it would still be difficult to get some physicians to go to rural areas," he told UPI; the income disparity "just makes the process more difficult."
The shortage fuels a cycle where rural doctors are more likely to retire early, burn out, or move to larger cities, he said, which increases the workload for doctors that remain.
"Fewer doctors are available to go (to rural areas) at any price."
Where healthcare services are few and far between, that impact is even greater, Frey said. "In some communities one doctor may determine whether or not a hospital stays open."
But the answer may not be simply pumping more money into the healthcare system, he added. Instead, it might be smarter to redistribute existing payments more rationally.
Changing the way medical school works could also help alleviate the problem, Frey said. Currently, the number of slots available for different specializations is not based on society's needs. The high number of specialists, in turn, creates more demand for expensive services.
"When the only tool you know how to use is a hammer," he said, "pretty soon everything starts to look like a nail."
But another factor that is much more difficult to quantify may simply be the changing times, Frey said.
"To go into family medicine in rural areas was viewed as a moral or even patriotic thing to do -- that's gone.
"Now people come to medical school with different ideas about what it means to be a good physician or a successful physician."
"We know that primary care matters in the health of patients and the health of society," Rick Kellerman, president of the American Academy of Family Physicians, told UPI.
"The issue is what kind of problems this causes for the patients."
The solution, Kellerman said, is for Congress, employers and other stakeholders to realize the value of general practitioners and get involved.
"Congress needs to act on this," he said, "and we need insurers and employers to engage.
"They need to understand what they have to lose by continuing to disregard primary care."
