Where Will All the Doctors Be?

I’ve blogged about the staggering costs of medical school, the fact that most MD students have serious six figure loans, face very low pay until years after graduation because of required “residencies” and “fellowships” for most practices and the reality that we are going to be incredibly short of the doctors we are going to need not just for those now receiving new healthcare cover for a graying and “fattening” population. Half of Americans today suffer from some serious or chronic disease, and it’s getting worse as the years pass.

Today, I am going to examine how, by reconfiguring one of the early screening/contact elements in our medical care system – primary care – we can absorb some of the doctor shortfall we are facing. “According to the American Association of Medical Colleges, the United States will be short some 45,000 primary care physicians by 2020.

“The primary care physicians who do exist are badly distributed — 90 percent of internal medicine physicians, for example, work in urban areas. Some doctors go to work in rural areas or the poor parts of major cities, treating people who have Medicaid or no insurance. But they are few.

“In part it’s the money. Primary care doctors make less than specialists anywhere, but they take an even larger financial hit to treat the poor. Particularly in the countryside — even with programs that offer partial loan forgiveness, it’s very hard to pay off medical school debt treating Medicaid patients, much less those with no insurance at all.” New York Times, October 24, 2012. Add massive the above loan-load, the cost of malpractice insurance to this economic picture, and it seems pretty clear why this situation isn’t going to get better anytime in the foreseeable future.

Part of the answer is to move an increasing share of that primary care load out of the hands of the doctors and into the hands of nurse practitioners who hold at least a master’s degree in their profession. “It might seem that offering the rural poor a clinic staffed only by nurses is to give them second-class primary care. It is not. The alternative for residents of [many rural counties is] not first-class primary care, but none… When people got sick, they went to the emergency room [that’s an expensive solution!]. Or they waited it out — and then often landed in the emergency room anyway, now much sicker.” NY Times. But as doctors leave or will not accept Medicaid patients and hospitals close, the local can choices dwindle fast. Enter clinics supervised by nurse practitioners. One partial solution.

It’s clear that another initial touchpoint may be surfacing to help solve this issue. Pharmacies providing some basic care that may not need to go to a doctor unless the ailments are obviously more serious. For example, if you did get a flu shot this year, where did you get it? A pharmacy? Did you get your blood pressure tested there? Have you ever asked a pharmacist a question about what non-prescription drugs would work for your cold?

Look at how CVS, a pharmacy chain here in the United States, has moved into this void: “CVS has increasingly moved beyond its traditional role as a pharmacy in recent years, expanding its reach as a health-care provider. Its MinuteClinics services have allowed the company to increasingly enter into contracts with hospitals and health plans, often providing primary care services on the weekends and evenings, when doctors' offices tend to be closed… CVS chief medical officer Troyen A. Brennan estimates that the company has between 30 and 40 partnerships with health-care systems across the country and is in talks with a similar number about starting additional arrangements.” Washington Post, February 5^th.

To make the point that they are in the healthcare, not the health killing, business, CVS also announced that as of October 1 of this year, they will stop selling tobacco products entirely. CVS’s CEO, Larry Merlo, appeared on CBS This Morning program (February 5^th), saying that his company was willing to take the annual hit of billions of dollars to make a clear point of the new role his company intends to play in the primary care arena. With tobacco holding the dubious status of being the number one cause of preventable death, Merlo felt he needed to make a clear statement to those looking to new directions for American healthcare.

“A recent report from the U.S. Surgeon General estimates that the country spends $132 billion annually treating smoking-related disease. Despite steep declines in the smoking rate over the past five decades -- and in the 50 years since the Surgeon General's Office issued its first report warning of tobacco's health risks -- tobacco use still remains the leading preventable cause of premature death in the United States. Eighteen percent of American adults are cigarette smokers, down from 42 percent in 1964.” The Post.

President Obama immediately praised the CVS decision as “powerful example… [that will] help advance my Administration’s efforts to reduce tobacco-related deaths, cancer, and heart disease, as well as bring down health care costs -- ultimately saving lives and protecting untold numbers of families from pain and heartbreak for years to come."

We’ve just begun to address the huge number of issues all across our healthcare system. We’ve hit too many big bumps down this road and some rather significant pot holes loom for years to come. But there are answers even as some experiments show “improvement needed.” The alternative could easily be that wealthy segments get primary care, the poor get nothing, and the middle class struggles for answers. Or maybe we can fix this beast.

I’m Peter Dekom, but the “one true thing” we all face is that there are big changes in the future of American healthcare… perhaps we actually might get a better system…