My primary physician tells me it is difficult to recruit new doctors to his group practice in Eureka. Patients at the hospital where I work often say they don’t have a primary doctor. Recently a patient told me she lost hers when she got Medicare and Medi-Cal.
The doctor is a solo practitioner, and said that such a small office just can’t afford to treat any more patients for whom reimbursement rates are so low. The patient is diabetic, and was being seen in the emergency room for dangerously high blood sugar. That’s exactly what consistent primary care should help prevent.
According to a story in last week’s North Coast Journal, the Eureka VA clinic is struggling to find and keep doctors and nurse practitioners. In some cases, bad luck plays a part, such as a family emergency elsewhere. Often, spouses or domestic partners either don’t care for Humboldt County or can’t find a good job here.
The pay for primary care is universally low, and it’s even less lucrative in rural areas. Opening a private practice is incredibly expensive – out of reach for most young doctors just starting out. They are more likely to be attracted to group practices, or to clinics, where they earn a salary and don’t have to deal with the business side at all.
And if it is nonprofit clinic which can offer partial loan forgiveness, that’s even better. The typical graduate from medical school owes about $200,000 in educational loans, and faces another three to eight years of internship and residency, at salaries which barely cover living indoors. The whole time, interest is expanding the loan balance.
It’s small wonder that doctors are more likely to be white and come from affluent families. For minority high school students who will be the first in their family to attend college, the eight years of education by itself must seem daunting. When they realize the burden of debt that will be attached to the diploma, other careers start looking better.
I’m not convinced most doctors were ever as rich as some people assumed, but they used to be able to make a nice living. Now they need to be businesspeople as well as physicians, and few of them have even the slightest idea how to run a business. Being politically active is frustrating and time-consuming, but it’s the only way to push back against endless rounds of cuts that target fees without relieving costly record keeping and reporting.
The Affordable Care Act is adding to the provider crunch, because as more people have medical insurance, they will seek primary care. In the long run, that’s better for them and the system as a whole, because they’ll be less likely to end up in the emergency room with more serious – and expensive – conditions. But a big part of the problem is that nobody ever considers the system as a whole.
It’s made up of government programs, private for-profit businesses, nonprofit organizations and public-private partnerships. There is constant financial friction between the various elements, with the result that Americans pay more for health care than any other industrial nation, but get the worst results. Many countries pay for the cost of medical education for future doctors.
I know some of you are thinking that’s a terrible, independence-sapping idea. Americans are in love with the idea that everyone should emulate Horatio Alger, but wait until your doctor retires and you can’t get an appointment with another one. Then maybe you’ll reconsider.
From primary school to graduate school, government support to education has been slashed, slashed and slashed again. Public universities are now as expensive as the most elite private ones. Graduates are suffocated by debt that will take them decades to repay.
The Baby Boomer bulge cuts both ways. At the same time that the 55-and-older segment of our population is developing more medical problems that need treatment, that portion of the physician population is reaching retirement age. It doesn’t take a rocket scientist to figure out we need more doctors at the same time circumstances are conspiring to produce fewer.
A few medical schools and teaching hospitals are slightly increasing the number of slots they offer, but that doesn’t solve the financial problems. Encouraging more midlevel providers such as nurse practitioners and physician’s assistants can help, but only so much. If primary care was a bus, it would be careening toward a cliff with the brakes smoking.
We are fortunate to have the Open Door Community Heath Care clinic network to help bridge the gap in local primary care, but the physician shortage is still going to get worse before it gets better. It’s hard to see private enterprise stepping up to the plate. Some people would say it’s exactly the kind of situation which is best addressed by government.
(Elizabeth Alves sees the consequences of health care policy every night. Comments and suggestions are welcome care of the Press or to firstname.lastname@example.org)