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Pay unhealthy, physicians say

Could hurt future of primary care.


GOLDSMITH: Sees difficult times.
  • GOLDSMITH: Sees difficult times.

In January, the American College of Physicians, which represents internal medicine doctors, issued the alarming assessment that “primary care is on the verge of collapse.”

The report said that more doctors are retiring than new primary care doctors are entering the workforce. “Very few young physicians are going into primary care and those already in practice are under such stress that they are looking for an exit strategy,” the organization said.

In Arkansas, however, more than half the graduates of the University of Arkansas go into primary care, and 80 percent of those stay in Arkansas. Collapse is not imminent here, though there are enough underserved parts of Arkansas that its physician-to-population ranking is one of the lowest in the country.

But the ACP report pointed out a problem that Arkansas shares with the nation: “Inadequate and dysfunctional payment policies.”

Most people look at doctors’ salaries and see big numbers, said Dr. Geoffrey Goldsmith, professor of family and community health at UAMS. In fact, the average before-tax pay for a family physician in our region is $169,000, according to the American Academy of Family Physicians. In rural areas it’s lower, at $130,000. Women’s pay averages at $117,000 to men’s $150,000.

What people don’t see, however, is that doctors don’t begin to earn until they’re out of school at age 30, and owe an average $120,000 in school loans by the time they can start earning. Their pay must also cover the overhead — office, staff, supplies — of running their practice. And their compensation is less than that of specialists.

For example, Goldsmith said: Say a patient comes in to see his family practice doctor with a complaint. His is a complex case, with several things going wrong at once. His doctor could spend up to 45 minutes on the case, talking to the patient, choosing a course of action, making sure the various meds he might prescribe are compatible. There’s paperwork to be done in the front office. Because of reimbursement rates, the family practice doctor might be paid only about $35, the mean pay for an established patient visit.

But say a patient is wheeled into surgery, and spends 45 minutes under the knife. The surgeon — who has no overhead — will be paid $500 or $1,000 for the same time, depending on the surgery.

The overhead can eat up 50 percent of what the primary care doctor makes, Goldsmith said.

“We’ve got to increase the fee schedule.”

The AAFP, like the internists group, sounded an alarm in 2004 that the future of family practice (which is more comprehensive than internal medicine) is threatened by inequitable reimbursement.

What should change? Medicare reimbursement, the doctors’ groups say; in the next couple of decades, one fifth of Americans will be over the age 65. Primary care doctors will be treating an enormous number of patients with multiple chronic conditions.

According to the AAFP, only intervention by Congress has kept family practice doctors from cuts in Medicare reimbursements, amounts that are based on formula meant to account for growth. It suggests Medicare should spend more for preventive health care, and save money on expensive procedures requiring specialists.

Goldsmith noted that the cost of running a practice “has outstripped the increase in revenues for the last five years. … It’s very difficult times in this regard.”

The ACP report said administrative hassles and high patient loads are other problems keep graduating doctors from pursuing careers in primary care. It cited American Medical Association figures that said only 27 percent of internal medicine residents actually planned to practice internal medicine.

The Association of American Medical Colleges anticipates a shortage of doctors in all areas of medicine, and has called for a 15 percent increase in med school enrollment by 2015.

UAMS is increasing its fall enrollment to 160 for the first time, Richard Wheeler, dean of academic affairs, said. “Ten years from now, we’ll be up around 180,” he predicted.

In 2005, based on match figures, UAMS sent at least 70 new grads into primary care programs: 24 in family practice, 15 in internal medicine, 8 in medicine/pediatrics, 12 in ob/gyn and 11 in pediatrics. UAMS is ranked third in the nation in the percentage of its graduates choosing primary care.

The number is purposeful. In the 1970s, Arkansas was in crisis. Every county in the state was designated by the federal government as “medically underserved.” The legislature and UAMS instigated what Goldsmith describes as “one of the most ambitious programs in the United States” to improve care in Arkansas. The family practice model of doctoring — in which doctors treated adults and children, delivered babies and made hospital calls — became the norm. The training took three years after medical school, opposed to the general practitioner’s one, but the family practice doctor could better fill the gaps in rural health care.

When the 21st century arrived, the number of medically underserved areas had been reduced from every to about a third of the counties in Arkansas. The numbers of doctors going into primary care peaked in the 1990s (46 went into family practice alone in 1998). Numbers started to decline in 2000.

Still, Goldsmith says, Arkansas needs more primary care physicians. The ratio of doctors — specialists and primary care doctors alike — is “significantly below” the rest of the nation.

“If you look at surveys about the health of Arkansas, we rank between 45th and 48th among the states. Not only do we not have enough doctors, we have a sicker population,” he said.

“We gotta get the right doctors in the right place.”

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