American as baseball, apple pie and primary care doctors?

Harvard Medical School recently announced an anonymous gift of $30 million to create a center to “transform primary care medicine.” What I was hoping to read next was a vision for a metamorphosis of the role of primary care doctors. Instead the Boston Globe article went on to say the school hoped to “fix the nation’s shortage of primary care doctors by raising their status.”

The news story reignited a discussion– that I have been having with myself– over the reasons such a high importance has been placed on primary care doctors in the American health care system. In policy discussion after policy discussion, primary doctors might as well be lumped into the same camp as baseball and American pie, but why?

A recent Massachusetts Medical Society survey reported that primary care doctors are in short supply for the fifth year in a row, and wait times are up for internists. The report also found shortages in dermatology, emergency medicine, general surgery, neurology, orthopedics, psychiatry, urology, and vascular surgery. The primary driver of the shortage was the 2006 reform law. So how do we fix this locally, and where are 30 million newly insured patients going to turn under the federal law? I can assure you that the number of doctors and hospitals per capita are very different in MA compared to Mississippi or North Dakota, or anywhere else for that matter.

From a cost perspective what we are doing makes little sense. According to the Bureau of Labor Statistics, nurse practitioner (NP) and physician assistants (PA) salaries are roughly half that of a family practice doctor. In fact there is literature out there documenting some of the benefits of an increased use of nurse practitioners, physician assistants for many procedures that doctors still provide.

Two studies on the matter are Mundinger, et al. (2000) and Ettner, et al. (2005).

The Mundinger study, found that:

“There is no significant difference in patient health status, with the exception that in patients with hypertension, the diastolic value was statistically significantly lower for NP patients.

There were no significant differences in utilization rates between the two clinics.

There were no significant differences in patients satisfaction, with the exception that after 6 months, the patients rated physicians slightly higher in the category of provider attributes.”

One of the findings from Ettner, was that “Intervention costs were $1187 per patients but savings were $3331 per patient resulting in a net benefit per patient of $1484.”

Of course, the results should not be broadly applied given some design issues in the studies, however, they must not be written off either. The general findings have significant cost saving implications for both Massachusetts and the nation as a whole. While Massachusetts has taken some steps in the right direction, allowing more flexibility for NPs and PAs, there is still lots of work to be done there.

This discussion should leave taxpayers asking elected officials if it is in fact a good use of state funds to be spending roughly $400,000 annually on loan forgiveness for primary care doctors. Or why the federal government will be pouring in billions more for teaching hospitals and health centers to create general care residency programs. Perhaps finding the real answers to our health care cost issue lay in first questioning the premises of the current solutions.