The DoubleTree Hotel in Bethesda, Md., is an odd place to get beyond the utter irrelevance of much of the health-care debate. Yet on Apr. 22 and 23, as Bloomberg Businessweek went to press, the Council on Graduate Medical Education, a little-known federal panel, was set to recommend a dramatic change in the doctor workforce that treats Americans of all political parties.
The council was created—and statutorily mandated—in 1981. It's made up of a cross section of physicians, including representatives from the private sector, academe, the Veterans Affairs Dept., and Medicare. The council's reports are taken seriously by the private sector and government; in 1997 its members suggested a cap on the overall number of medical residents as part of federal cost cuts. And so it was done. Its 2010 recommendation could have just as much impact: Increase the number of primary-care physicians—and pay them a whole lot more.
To understand why this makes sense, I followed the council chairman, Dr. Russell Robertson, during his volunteer rounds at CommunityHealth, the largest free clinic in Illinois. It serves a poor, uninsured clientele of mostly Latinos and Poles—many undocumented, nobody asks—in a diverse working-class section of Chicago.
Robertson, the chairman of family and community medicine at the Feinberg School of Medicine at Northwestern University, spent 2½ hours treating five patients with chronic multisystem diseases: hypertension, diabetes, high cholesterol, obesity, and depression. A rotten economy spawned a 33% surge in patients last year, for a total of 22,000 visits. The wait for an appointment with one of the clinic's 300 volunteer doctors is six weeks.
One thirtysomething man needed antidepressants and a social worker. Another patient was off her medication for high blood pressure. A third had constipation tied to a thyroid condition. A 19-year-old woman was panicked by a sister with multiple sclerosis and, after her father's death from a heart attack, became convinced she also had heart problems and MS. Robertson gave her an electrocardiogram, antidepressants, and reassurance.
None of these conditions is imminently life-threatening or makes for particularly sexy medicine. Yet when the Obama health plan kicks in and a wave of newly insured patients goes for treatment, the system will be congested with these kinds of rudimentary ailments. Primary-care doctors comprise 32% of the physician workforce. Factor out pediatricians and just over 23% of doctors deal with adults, and that number is shrinking, says the Altarum Institute, a nonprofit health-care consultancy.
Why doctors choose to practice general medicine or specialize is a personal matter. Some dermatologists just love skin diseases. Others may like money. A family physician or general internist averages about $160,000 a year, according to the nonprofit Robert Graham Center, which researches primary care. A specialist averages $267,000. That means the general practitioner will earn about $3.5 million less over a lifetime.
Medicare determines the baseline for doctors' pay, and since most medical students elect to train in the non-primary-care jobs generating the majority of charges, procedure-oriented specialists end up the winners. Medicare finances the system via direct subsidies to pay residents' salaries and indirect payments to hospitals for tests and other duties fulfilled by residents. There's no inherent logic to the payments. Some New York City hospitals get over $200,000 per resident. Robertson's gets $60,000.
Other factors affect the general practitioner shortage, from a med school culture that considers it more glamorous to be an orthopedic surgeon or anesthesiologist—not to mention more advantageous to pay back student loans—to the media's fascination with obscure diseases. (Goodbye Marcus Welby, M.D., hello House.) The result is a system ill suited to our needs.
The panel is calling for a 40% hike in the number of primary-care doctors—and a 40% income increase for those entering the field. That should get general practitioners to within 70% of the median income of specialty physicians. "Policy changes should be dramatic to remedy these legacy biases and have immediate effect," states a council draft.
I talked to Robertson again on a day when he saw four more patients. He personifies selflessness, yet at the end of the day he admitted his frustration. "Primary care is the bargain of the century, given that prevention and maintenance is a whole lot cheaper than intervention," said Robertson. It should be "like motherhood and apple pie."