By Josh Freeman, MD
Kansas City Star
Monday, Nov 10, 2008
National discussions about which system of universal health coverage — and yes, we need a system of universal health coverage — will be the best to adopt often miss the point. The goal is not simply to “cover everyone,” but to provide universal access to high-quality, cost-effective care.
We need health professionals to practice in the right locations and a payment system that reimburses for providing the care we want and need. We now have too few primary care physicians and not enough physicians practicing in rural and underserved urban areas. And the situation is getting worse.
The Journal of the American Medical Association recently reported that only 2 percent of senior medical students planned careers in general internal medicine. It is one of three specialties providing primary care; the other two are general pediatrics and family medicine. The number of students entering all types of primary care training is dropping rapidly. Because family medicine residencies are having more difficulty finding U.S. graduates to enter that specialty, half are currently international graduates.
These trends create tremendous problems. Massachusetts has too few primary care doctors to see all the people now insured under its new health plan. Many studies have demonstrated that health systems built around primary care provide higher quality care at lower cost. The Commonwealth Fund’s recent “health scorecard” shows the U.S. scores very poorly, and our worst score is for “efficiency,” the area where primary care has the greatest impact.
The main reason for the precipitous drop in primary care doctors is that they earn much less than sub-specialists. Students deep in debt are choosing higher-paid specialties. We need to pay primary care doctors more and pay them for what we want them to do: provide us a medical home and manage our health care. This can be done by a change in Medicare policy, because most payers base their reimbursement on Medicare. Students would choose specialties based on what kind of doctors they wanted to be, not salary expectations. We would begin to produce the primary care physicians we need. This can happen. For our health, and our pocketbooks, it has to happen.