America Needs More Primary Care Doctors
A new report from the U.S. Census Bureau reports that nearly 47 million people in America are uninsured — an increase of 600,000 people from 2007. This news comes as no surprise to Community Health Centers, which have seen a 62 percent increase in their uninsured patient population over the past nine years, the most significant patient growth in the program’s history. Health centers now serve one in seven uninsured people nationally, including one in five of the low-income. The economic recession has added fuel to the fire, and demand for health care is at an all time high — adding new pressures on health centers and other safety-net providers.
The National Association of Community Health Centers (NACHC) reports that, when taking into consideration the number of people who lack access to doctors and a regular source of primary health care — including some who have insurance — the total number of medically disenfranchised people stands at 60 million.
Recognizing this troubling uptick in the uninsured rate a few years ago and long before the recession hit, NACHC’s membership launched its ACCESS for All America (AAA) plan to reduce the ranks of America’s medically disenfranchised by preserving, strengthening and expanding health centers to reach a total of 30 million patients by the year 2015. To serve this number of people, the plan identifies a number of issues which must be addressed, including the need to grow and strengthen the nation’s primary care workforce, particularly to serve needs in medically underserved communities. The plan estimates that health centers will need nearly 16,000 primary care providers to reach its goals. How, then, can health centers — and indeed the nation — build as well as maintain a strong primary care workforce to meet today’s and tomorrow’s needs?
The shrinking supply
A recent New England Journal of Medicine article reports that in the eight-year period between 1998 and 2006, the number of pediatricians, obstetricians and internal medicine practitioners in the United States declined by eight percent, 16 percent and 18 percent respectively. At the same it says the number of anesthesiologists, pathologists and diagnostic radiologists rose by as much as 150 percent.
Most alarming, according to the article, the number of family practice physicians dropped by more than 50 percent. It is these types of doctors that make up the core of health center providers. As one example of the types of difficulties health centers face in finding the numbers of primary care doctors they need, Anita Monoian, the newly installed NACHC Chair of the Board of Directors and CEO of Yakima Neighborhood Health Services (YNHS) in rural Yakima, Wash., says, “Primary care providers are being siphoned off to be hospitalists,” an emerging type of practice with better pay, better hours and no overhead.
Earlier this year, the Josiah Macy Jr. Foundation held a conference in Washington, D.C. on “Developing a Strong Primary Care Workforce” to gain insight on these issues from organizations that have expertise and experience in primary care delivery. The meeting’s report summary noted that 30 percent or less of the 5,000 or so students who graduate from medical and osteopath schools each year in this country are going into primary care (as compared to 50 percent in the mid- twentieth century).
Monoian, who participated in the conference, says the situation is “truly a crisis,” and she believes the workforce challenge is “the number one issue facing Community Health Centers. The lack of primary care clinicians threatens to close down [health center] sites.”
In addition to competing for primary care physicians, health centers also must find ways to keep doctors once they do come on board. One retention problem they have to grapple with is that it is not uncommon for doctors who are working under a loan repayment agreement or J-1 Visa contract to leave the center once their service obligation in a medically underserved area is fulfilled.
Expanding the pipeline
The Macy Foundation report makes the practical point that “health care reform cannot succeed without commensurate workforce reform that reverses these trends.” Needless to say, the need for adequate numbers of primary care practitioners willing to serve in medically underserved areas is especially important. But with or without major health reform, primary care doctors will be needed. The greater challenge therefore will require fundamental changes – from how we work with the education system to nurture greater interest in math, science and the health care fields among students at all levels, to how we help to open the doors to medical schools and other health professions training programs for more students (particularly underrepresented minorities and low-income students), to how we revamp our health care system to place greater value on and thus greater rewards for quality care practices in community health.
Monoian says, “We do need to reduce the disparity of income between specialists and primary care doctors.” She also advocates “stronger ties between health centers and teaching hospitals with a real focus on primary and preventative care” and believes strongly that more medical school slots are needed.
For its part, the federal government made a “down payment” this year on building and investing in the workforce pipeline through $500 million in stimulus funding for primary care workforce training and medical school loan repayment. Of this amount, $300 million is targeted to expanding the National Health Service Corps – an important source of primary care clinicians for health centers; and $75 million for use through 2011 to extend the contracts of existing National Health Service Corps professionals working in underserved communities. Of the stimulus money, Monoian says that “at least for the next two years, we do see loan repayment as helping.”
Monoian is quick to add that the health center community's workforce “crisis” is not just the lack of doctors, but includes a need for nurses, pharmacists, social workers, and highly skilled health
care executives and financial managers because she says “the way our money flows is unique to the planet.”
As NACHC Chair, Monoian has identified “workforce” as one of her top priorities and recently announced the creation of a task force that will focus on the entire scope of primary care workforce needs and “move us to the next steps.”
Monoian’s predecessor Lil Anderson, CEO of RiverStone Health Clinic in Montana, also placed a high priority on this issue during her tenure. In her final address to the NACHC membership as NACHC’s Chair this past August, Anderson said that some progress has been made, citing the reauthorization of the National Health Service Corps (as called for in the ACCESS plan) and the establishment of a Primary Care Workforce Coalition, a body that includes 17 organizations, among them the American Academy of Family Physicians, the American Academy of Pediatrics and the Association of American Medical Colleges.
Monoian would also like to see a “national campaign focused on being a primary care provider” and says, “We need to sing out that primary care providers are the superheroes of medicine. I want other people to recognize this and celebrate it.” In reflecting on her 31-year health center career, she says, “There’s nothing more magical. I love it.”
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