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Is there a primary-care doctor in the house? Program aims to train more family physicians

This article first appeared in the St. Louis Beacon, Jan. 14, 2011 - St. Louis University Medical School is developing a new family medicine residency program that could address a critical element in recent health-reform legislation. The program -- a partnership between the medical school and St. Louis Family Health Care Centers -- would train more primary care doctors. It comes amid growing concern that a shortage of primary-care providers could undercut some medical services that are supposed to be offered through the health-reform legislation.

The Affordable Care Act offers new or expanded access to health care for millions of people nationwide. Some will be served by doctors willing, for the first time, to accept new Medicaid patients, because of the higher reimbursements. Still, there is no guarantee that enough doctors will be available in Missouri or nationally to accommodate the rising number of patients eligible for medical care.

"That's why we're starting a new family medicine residency program," says Dr. F. David Schneider, chair of family and community medicine at the medical school.

"Nurse practitioners and physician assistants are also part of the solution in that they work with family physicians and others to provide more primary care. But, again, it's not enough."

Schneider says the two parties are still developing the program. If the university's current primary-care initiatives are an indication, the number of doctors produced by the new program is likely to be small.

The university now partners with St. John's Mercy Medical Center in west St. Louis County and St. Elizabeth's Hospital in Belleville in two other primary-care programs. The partnership produces 20 physicians a year. Nearly two-thirds of them come from the Belleville program, which is a collaboration with Scott Air Force Base, and these doctors are likely to serve the military around the world instead of providing care for patients in the St. Louis region. By contrast, Schneider says the demand for new primary-care physicians would be in the hundreds if health reform remains on track. The House Republican leadership is trying to repeal the reform bill, which was passed last year.

"One thing that I've noticed is that there's a greater interest this year in primary care and family medicine, probably because of the political climate and the emphasis on primary care in the Affordable Care Act," he said.

The primary-care doctor shortage itself the reform legislation. Two years ago, Dr. Jack Colwill, a retired professor at the University of Missouri at Columbia, published a study showing that the nation would need more than 44,000 additional family physicians in the next 20 years due to population growth and aging.

The number is likely to be even higher now that the Affordable Care Act has become law and is likely to increase the number of insured. The shortage of primary-care doctors is due to a combination of factors, including the concerns of repaying medical school loans when receiving relatively low pay for primary-care work. That's one reason only 7 percent of medical students choose careers in primary care.

According to the Commonwealth Fund report, the median pretax compensation for specialists rose to $297,000 in 2004 from $215,978 in 1995. During the same period, compensation for primary-care providers rose to $133,329 from $61,816.

Schneider says doctors who began practicing last year had medical school debt averaging $156,000. He says a student could choose to remain in school an additional year and obtain certification for one of the higher-paying specialties.

"When you graduate with debt like that, which one would you choose? The people going into primary care are doing it because they truly have a passion for this type of medical care. They really want to do this. But we need more people who really want to do this."

Dr. Johnetta M. Craig, chief medical officer for Family Care Health Centers, says the health law should encourage more students to consider careers in primary care. Under the new law, part of a student's medical school loans is forgiven in exchange for pursuing primary care in underserved areas. In addition, the new health law sets aside $3.5 million for bonuses for primary-care providers from this year through 2016. Craig says the income subsidies will make it easier for practitioners to choose primary care over certain specialties "simply because the pay rate is better."

She adds that the program being developed with SLU will give students hands-on experience in working with the underserved and "hopefully it will encourage people to go into primary care and meet needs that are there."

One indication of what could happen under the new federal law is what happened in Massachusetts after it expanded the number of insured. Many people couldn't find primary-care doctors to treat them, or they experienced longer waits for service. That happened in spite of the fact that the ratio of primary-care doctors is said to be higher in Massachusetts than in other states.

On the other hand, Melinda Abrams, vice president for patient-centered coordinated care at the Commonwealth Fund, says the boost in Medicaid reimbursements is likely to expand greatly the number of doctors willing to treat patients they otherwise wouldn't accept. On average in 2008, for example, doctors who served a Medicaid patient for 15 minutes during an office visit was reimbursed $38, compared to $60 for a Medicare patient, according to a report Abrams and others did for the Commonwealth Fund. The low Medicaid reimbursement, she says, is the top reason doctors quit seeing Medicaid patients.

Under the health-reform law, the reimbursement rates for Medicaid will be equal with Medicare in 2013 and 2014. Bumping up Medicaid reimbursement, Abrams says, is "likely to help stabilize the primary-care physician workforce." She adds that the change will make a big difference in Missouri, where Medicaid reimbursement is about 65 percent of Medicare.

Even if primary-care physicians were plentiful here and nationwide, there is no guarantee that they would want to practice in underserved communities. Schneider acknowledges as much, saying, "We need good primary-care physicians everywhere," but he says one goal of the program is to "train people with passion for caring for people who don't have resources."

Funding for health reporting is provided in part by the Missouri Foundation for Health, a philanthropic organization whose vision is to improve the health of the people in the communities it serves.

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