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Shortage of Primary Care Doctors Seen as Problem for Health Care Law

By Emily Ethridge, CQ Roll Call

January 29, 2013 -- Congress should consider increased payments and other ways to bolster the primary care physician workforce before next year's expansion of health care insurance coverage, witnesses recently told a Senate panel.

The current shortage of primary care physicians will only increase as an estimated 30 million people join the ranks of the insured under the 2010 health care overhaul (PL 111-148, PL 111-152), the witnesses said. The law requires most Americans to buy insurance or pay a penalty.

Sen. Bernard Sanders, chairman of the Senate Health, Education, Labor, and Pensions Subcommittee on Primary Health and Aging, said expansion of insurance coverage is good news.

"The bad news is we don't know how we are going to be providing primary health care to those Americans who now will have health insurance," Sanders, I-Vt., said at the subcommittee hearing.

More than 52,000 additional primary care physicians will be needed by 2025 to meet the needs of the growing population and the expanded insured population, Sanders said.

Currently, about 16,000 additional primary care physicians are needed, according to the Health Resources and Service Administration at the U.S. Department of Health and Human Services.

Subcommittee ranking Republican Michael B. Enzi said it is important to ensure that providers work where they are most needed, including rural areas like his home state of Wyoming.

One of the biggest obstacles to expanding the primary care physician workforce, witnesses agreed, is the pay disparity between primary care providers and specialists.

"That is the driving force in this workforce problem that we're facing today," said Andrew Wilper, acting chief of medicine at the VA Medical Center in Boise, Idaho.

Sanders suggested that some of the problem may lie with how the Centers for Medicare and Medicaid Services (CMS) gets advice on payment rates from a committee of the American Medical Association (AMA).

The AMA/Specialty Society Relative Value Scale Update Committee, or RUC, "plays an enormously important role in determining how much specialists will make, how much primary care physicians will make," Sanders said. But he added that the group is "overloaded" with specialist members and does not have enough primary care physicians.

CMS usually adopts the committee's recommendations, and private insurers often base their payment rates on Medicare's payment rates, said Fitzhugh Mullan, a professor of medicine and health policy at the George Washington University School of Public Health.

"Managing the Medicare conundrum around the pay gap would be key to reforming the whole system, and the RUC is at the center of it," Mullan said.

Uwe Reinhardt, a professor of political economy and of economics and public affairs at Princeton University, said adding more primary care members on the board could be a good idea. He also encouraged lawmakers to look into a Medicare Payment Advisory Commission recommendation for an independent committee to review the RUC proposals.

Witnesses also suggested offering more loan forgiveness for medical students who choose to practice in underrepresented specialties or in underserved regions. Several suggested expanding the National Health Service Corps, which offers student loan repayments for primary care providers who serve in communities with limited access to health professionals.

"Compensation is clearly an issue," Reinhardt said. He proposed an incentive system under which the federal government would forgive a certain amount of student loans upfront if a medical student chose to go into primary care, with additional forgiveness for each year a student practices in a location that the government identifies as underserved.

Wilper also suggested increasing the amount of money given for graduate medical education that is set aside for primary care programs.
Another obstacle to recruiting more primary care physicians from medical students is a culture that devalues primary care physicians. Sen. Christopher S. Murphy, D-Conn., related tales from primary care physicians who were told as students that they were "too smart" to go into primary care.

"That culture is toxic," Mullan agreed.

Reinhardt that new models for delivering primary care, including medical homes and accountable care organizations, will enhance the professional power of primary care physicians and help them earn more money through shared savings.

"In those settings, their prestige will rise," he said.

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