[NPInfo] Answer to Wall Street Journal

[David Mittman]

Patti: I posted earlier also.
Dave
THE DOCTOR'S OFFICE
By BENJAMIN BREWER, M.D.


Primary Health Care Needs Fixing
Before Universal Care Can Work
March 26, 2008
Who will take care of the estimated 47 million uninsured Americans if  
they get health coverage promised by politicians?

Few people seem concerned about whether the supply of primary care  
doctors is up to the task. But they should be.

Even without health-care reform, the demand for family physicians is  
expected to surge by 2020, when the nation will need 140,000 family  
physicians, according to the American Academy of Family Physician's  
2006 Physician Workforce Report. That's a 40% increase over the  
100,000 family doctors at work in 2006.
Low payments to primary care doctors are discouraging those of us in  
practice and are dissuading new doctors from entering the field.  
Medicare's proposed 0.5% fee increase to family doctors like me for  
the remainder of 2008 is well below inflation. None of my office  
expenses will rise less than 0.5% this year.

To me, universal coverage looks like an empty promise. Just  
nationalizing health insurance by declaring Medicare for all isn't  
going to get the job done. Medical insurance coverage without a  
doctor to see is another big health problem -- not a solution.

An expanded insurance program based on Medicare or state Medicaid,  
another stingy payer, will prompt many doctors to opt out if they  
can. If doctors are forced to participate in a program with fees  
lower than their cost of doing business, I expect primary care  
doctors in private practices like mine will close up shop.

Once displaced, they'll probably work in ERs, continuing to provide  
high-cost care for diseases that a properly designed and financed  
health system would have prevented or nipped earlier and more cheaply.

Massachusetts, the state with mandated insurance coverage most like  
Sen. Hillary Clinton's health plan, has suffered a painful shortage  
of family doctors the last two years. More people signed up than  
predicted and higher costs have led to premium increases. It's  
apparent to me there is no increased access to care with this plan in  
many areas and no cost savings have materialized.

That tells me that physicians in any universal coverage program will  
have to weigh the personal and financial risk of an access crunch.  
When a bad outcome arises, I expect lawyers will come after the  
overburdened primary care docs instead of the politicians who  
promised more than could be delivered.

We won't see better health outcomes or any cost savings from  
improvements in quality unless there are broadly trained primary care  
doctors available and willing to practice where they're needed. Some  
would advocate using nurse practitioners or physician assistants to  
fill this role, but I don't see that working as well. A family  
doctor's set of skills is much broader. In this case, you get what  
you pay for.

If we add large numbers of patients to the underfunded, understaffed  
primary care system we have now, things won't improve. That approach  
will look good on TV for 15 minutes and then health care as most  
Americans experience it will continue to stink, just more expensively.

Until we adequately fund primary care, we're not going to get the  
health system Americans expect.

Right now the U.S. is graduating about half the family physicians  
we'll need in the coming years, and the government proposes to cut  
funding to train more. The 2009 federal budget would abolish funding  
for training programs under Title VII of the Public Health Service  
Act, including Section 747 of the act, which provides the only  
federal grants for training primary care physicians.

To fill the primary care gap, we could flood the U.S. with foreign  
trained doctors. In fact, we're pretty much already doing that in our  
training programs. Fifty-six percent of doctors starting family  
medicine residencies this summer are foreign graduates. Foreign grads  
practice mainly in larger cities so that doesn't help overall  
distribution of doctors to smaller communities.

Only 65 more U.S. medical students chose family medicine for their  
residency this year than last year for a total of 1,172. (See a chart  
on the primary care trends here.) Compared with the bleak decline of  
the last 10 years, a 2% increase in family practice residents is  
cause for celebration among family doctors. "We're extremely pleased  
with this year's match," said AAFP President Jim King, M.D., of  
Selmer, Tenn.

Still, I would be happier if every one of those doctors had a  
sustainable practice to grow into. The fact is that costs are too  
high for an economically viable practice in many areas. Payments from  
the government and large insurance companies don't adequately cover  
expenses and the burden of educational debt. The cost of malpractice  
insurance to practice the full range of primary care medicine,  
including obstetrics, is untenable for most.

How can anyone rationally expect to build up the nation's health on  
that crumbling foundation?

Family physicians could meet the needs of the uninsured, the  
underinsured and the baby boomers, but not without some fundamental  
changes in the way they are paid.

Due to his schedule and the volume of email he receives, Dr. Brewer  
may not be able to respond to all reader email. He does participate  
in his forum, where readers are urged to post. His email address is  
thedoctorsoffice at wsj.com.__
On Mar 26, 2008, at 6:41 PM, <pattinp at verizon.net> wrote:

> Dave,
>
> First, thank you for taking the time to write such a fabulous  
> response. You definitely have a way with words! Thank you too for  
> your tireless advocacy for our professions.
>
> Do you have a link to the article?  What was Dr. Brewer's first  
> name?  I am wondering if it is the same Dr. Brewer I once worked  
> for in MD.
>
> Patti Robertson
>
>> From: David Mittman <dmittman at comcast.net>
>> Date: 2008/03/26 Wed AM 11:11:42 CDT
>> To: ACC Circle Circle <ACC-Circle at listserve.com>, NPinfo  
>> <NPinfo at nurse.net>,
> 	PA Forum <PAForum at mc.duke.edu>
>> Subject: [NPInfo] Answer to Wall Street Journal
>
>> Sent to Dr. Brewer and Letters to the Editor and posted as a comment.
>>
>> Dear Dr. Brewer:
>> I read your article on the future of primary care in today's Wall
>> Street Journal with interest.
>> As a physician assistant (PA) with 33 years experience, I take
>> umbrage with a number of comments you made. Please let me explain.
>> You assertion that the primary care provided by NPs and PAs is
>> inferior to that of any other group of professionals who provide
>> primary care is biased, unfair and unable to be substantiated. Can
>> you show one study to back your opinion up? Do you have any idea how
>> much professional opinions based on anecdotal information hurt
>> people? To say that "you get what you pay for"regarding PA and NP
>> care smacks of the type of words used in turf battles without much
>> thought being given to the harm your statement can produce. The same
>> was said by the internal medicine physicians about the first family
>> physicians and your first residencies. Their graduates were also
>> looked at with less than the proper respect and understanding they
>> deserved. I am amazed you would do the same to others.
>> I think few would argue that a cardiologist is both trained better
>> and more broadly to treat cardiac problems than a family doctor. So
>> using your logic, in the case of treating hypertension or CHF, family
>> doctors also provide inferior treatment. Clearly the poor patient who
>> gets their CHF treated by a family physician rather than a
>> cardiologist would also" get what they pay for". That thinking is
>> absurd. To think that I would treat bronchitis, or otitis, or tinea,
>> or hypertension or most other problems differently than all others
>> who encounter them, is the same as thinking that you are not equipped
>> to treat hypertension. Of course you are, of course we are.
>>
>> Dr. Brewer there are close to 200,000 PAs and NPs in practice across
>> America, and the care we provide is excellent. Many work with your FP
>> colleagues whom I would guess are also allowing their patients to
>> receive inferior care. Much of the primary care delivered to our
>> servicemen and their dependents is provided by NPs and PAs, as is
>> much care in the much improved VA system. I suppose all of these
>> people receive poor care also. Even the President and Vice-President
>> have a PA treating them. The US Army's Flight Surgeon of the Year in
>> 2007 was a PA!
>> We deserve a place in any system designed to bring more healthcare to
>> the people of our country.
>>
>> As another professional, I would respectfully ask that you do two
>> things; one realize your comments can malign and hurt other
>> professionals who are out there working hard to provide care to many
>> who need it across our great country and secondly, as a man of
>> science, be able to back up your assertions with at least one or two
>> scientific studies.
>>
>> Yours for a healthier America
>> Dave Mittman, PA
>> Secretary,
>> American College of Clinicians
>> Natick, MA
>>
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