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The Prescott Daily Courier | Prescott, Arizona

home : features : local health care series October 06, 2015

4/30/2008 9:48:00 PM
Why primary care deters doctors
Carol Galper, director of the Rural Health Professions Program at the University of Arizona, says lower pay and long hours drive doctors away from primary care practices.
Carol Galper, director of the Rural Health Professions Program at the University of Arizona, says lower pay and long hours drive doctors away from primary care practices.

The director of a training program that encourages medical students to practice in rural areas says debt load, pay and lifestyle issues are some of the factors that drive medical students - and even doctors in established practices - away from primary care.

Carol Galper, director of the Rural Health Professions Program at the University of Arizona, says heavy debt is the first thing facing a graduating doctor. It takes about a dozen years to train a primary care doctor: Four years of college, four years of medical school and then a residency - which for primary care doctors usually involves three to four years of post graduate training.

"This is a costly venture (that) leaves many students with loan amounts that resemble a mortgage," Galper said. Some estimates place the debt load at around a quarter of a million dollars. "A physician needs to somehow make enough money to pay these loans back and then do all the other things adults do, like make a house payment, start a family and get a reliable car."

The payment system of insurance companies, including Medicare and AHCCCS, Arizona's Medicaid program, also deters doctors from going into primary care.

"I think it is important for the population to understand how little insurance companies pay - which is one reason why physicians may only accept certain insurance," Galper said.

"As a country, we pay for things we value, and we have come to view medical specialists as more valuable than generalists," Galper continued. "(But) both play a valuable role. If our country chooses not to invest in primary care, we will have an even larger chasm between the haves and the have-nots (because) the wealthy will always have the care they need and want. (But) we will always have people in need of care, and most of us are one medical diagnosis away from being in that position."

Insurance payments favor specialty care and procedures, Galper continued.

"Not that procedures are not warranted at times, but sometimes the medical issue is not procedure-related and may take a tremendous amount of a primary care physicians' time. Imagine a family physician dealing with a new mother or an elderly person. The conversations may entail things like what to anticipate your child doing developmentally, how to get back into shape after having a baby, perhaps fears and concerns about how to parent or how to take care of an aging spouse or how to deal with a chronic illness. These conversations are important parts of the care a patient receives and expects from their primary care doctor, and these discussions take time - time that is not billable."

Insurance payments for office visits often don't come close to covering the costs the doctor invests in running an office. In addition to a doctor's own salary, he has to pay for nurses and medical assistants, malpractice insurance, and materials like syringes, medical waste disposal - even simple things like table paper cost money. And if the doctor accepts insurance, then he must have billing staff to deal with the many different documents and payment forms each insurance program has.

Another big issue is lifestyle.

After years of "deferred life," doctors want to spend time with their families, just like everyone else, Galper said.

"So this is another factor in the primary care equation - will I be able to have a life? We've seen a national increase in specialists like emergency medicine, anesthesiology and hospitalists - all specialties that may allow for set schedules," Galper said.

For example, cardio-thoracic surgeons not only receive more money for their services, they also have a very different type of practice, Galper continued. They deal with part of the person.

"They do the heart surgery, and then the patient is back to their primary care physician for all the rest of their health care - including addressing the risk factors that may have required having that heart surgery. And those are often complicated factors involving diet, smoking, and exercise - all complex issues for which there are no magic pills or procedures. (Patient) lifestyle issues are difficult to change and require lots of talking and encouragement and ongoing management by the primary care doctor," Galpen said.

Another big turnoff for doctors is the amount of time they spend filling out forms.

"Doctors want to care for patients ... not spend their time writing countless letters begging for approval for a medical device, or for authorization or medication approval from someone with less education and training.

"In the old days, the doctor and patient had a relationship. Today, the doctor and patient have an insurance provider in between their relationship."

Contact the reporter at tshultz@prescottaz.com

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Reader Comments

Posted: Thursday, July 10, 2008
Article comment by: nathanoyo

I am looking at going into medicine but I am equally looking at staying in the profession of teaching that I have already chosen. I love the idea of practicing primary care medicine, but all of these concerns like paperwork, arguing with insurance compaines, loan debt, and delayed family life are very depressing to me. And I haven't even experienced the matter first hand. Because of the dynamic nature of the medical field, I find it hard to judge if I'd enjoy myself. PresscottMD would you choose the health field again today were you given my opportunity? Do the pros out weigh the cons?

Posted: Tuesday, May 06, 2008
Article comment by: drcrutch

To Prescott MD: Thank you. Amen.

Posted: Thursday, May 01, 2008
Article comment by: Office nurse

As an office nurse I see the difficulty of both our patients and the worry our doctors have. I know there will be no easy answers. I see the cost of our supplies go up each month. I see lay offs of staff. I see the sadness on our doctors faces. We want to treat our medicare patients. Many are "family". Primary care doctors are the life line to all of us. They save lives daily.

Posted: Thursday, May 01, 2008
Article comment by: Prescott MD

I just want to thank you for the overall balanced nature of your articles on the problems faced by the primary care community in Prescott. A look at this subject is long overdue. A few thoughts: You may find it of interest, after talking with the CMS spokesman, that their beloved "participating provider list" includes physicians who do not accept assignment (therefore "non-participating" by definition) and docs in town that have retired. It simply has not been updated in years for accuracy. Of course the current Administration has a vested interest in spinning the numbers so they can pat themselves on the back. It's kinda like the Medicare D plan for prescriptions...a whole new level of bureaucracy was created (the pharmacy benefit managers) to try and apply draconian HMO rules to prescriptions. The Administration will toot from the hilltops that "it's a success"... in reality, it caused a whole new dimension of hassle and paperwork that is unreimbursed in my practice, and a whole legion of unhappy patients (who can't get their "purple pill" or whatever is advertised to them by the same pharmaceutical interests and insurance lobby that wrote the legislation). Another dirty little secret...that vaunted 0.5% "increase" we finally begged out of Congress 12/07 for 2008 as a "fix" was averaged across all billable codes. The everyday office visit codes actually decreased from 2007, meaning we actually got cut for the majority of the services we provide daily in primary care. The planned cuts totaling about 16% over 18 months will only make this worse. I know several primary providers that will be shutting practices this year just because of the cuts... they're good docs, and this is a shame. The government has said for 18 years that we must be "more efficient", while necessarily adding staff and purchasing expensive hardware just to cater to the burgeoning bureaucracy that eats up better than 50% of our healthcare dollars. My practice is as mean and lean as it can get, mostly by cutting services, laying off staff, and cutting mine own salary to the bone. Now they want more cuts... I do not have the answer to "fix" healthcare, but I do know that is unfair to legislatively limit any profession's charges in a free market economy. As a businessman, I should be able to get paid for my training, expertise, and time. I should be able to cover my office expenses and expect a reasonable profit (those who think any primary care doctor gets rich from this business are just plain uninformed). Our nemesis, the for-profit insurance industry, sees my practice as a drag on thier bottom line and sees patients as an income stream. They gleefully reduce costs(delaying and cutting payments to me) while increasing revenue(charging the patients more)- all good capitalism, just ask them. To think otherwise is believing their marketing hype and ignoring the millions their top executives make. Congress, on the other hand, is faced with an ever-growing pool of citizens it needs to care for who demand the best heathcare on the planet. Medicare was designed as a last-ditch safety net, not as the de facto "gold standard" of care. The government simply does not have the resources to do this and do it right. No elected official is ever going to propose the tax base necessary to provide good universal healthcare by the government...estimated at 70%+ conservatively! Hence the conflict in the paradigm: the best healtcare is demanded and 'somebody else' is needing to pay for it as an entitlement (with some of our fellow citizens actually believeing it is a RIGHT). What amazes me are the number of patients that expect to pay nothing for their healthcare, just because they have believed the tales told to them when they bought insurance. I have patients that live in expensive homes, drive luxury cars, and bitch to me about paying a legislatively mandated reduced fee up front at the time of service. Yet these same folks are paying at the gas station, the lawyer, the grocery store, or at the service facility for their luxury car. It just serves as a reminder how the paradigm of healthcare in this counrty is flawed to the core. Yes, there are truly poor patients in my practice for whom we make every effort to work with...usually by selectively accepting assignment and getting paid even less for our trouble (a "punishment" from Congress for not playing their game as a participating physician- damned if you do and damned more if you don't). When Jon Kyl tried to fix this back in '96, he was shot down by the then Administration and Medicare itself with claims his idea to allow "out of network" Medicare docs would ruin the system, mostly by costing more. Despite the opinion of one of your commentors yesterday, the Hippocratic oath has nothing to do with the business of medicine or accepting assignment; I know of no physician in this town that would not treat a gravely ill patient emergently and without thought of payment. However, I do have a business to run that needs to support me, my family, my employees, and service the mortgage-level educational debt I will pay for 30 years. I cannot treat all our seniors on the pittance Congress would prefer to pay me. Most primary physicians I know got into this business for the right reasons, from their hearts, to serve the patients we love and worry about. Nobody in their right mind would put up with 12+ years of expensive and difficult training if they didn't truly love it...and that is the worst tragedy in this. Those of us that have been, or are at risk of, being pushed out of the profession we love, have trained years for, and sacrificed our personal/family life for are the true victims of this mad farce our country uses as it's healthcare system. The IOM has predicted that primary care physicians will be extinct soon...coming up on just 12 years now... and that truly may be the future for Prescott. Pointing fingers and blaming everybody else will not solve this issue and obviates the basic truths that every American needs to be ultimately responsible for their healthcare and docs need to be fairly paid for their services.

Posted: Thursday, May 01, 2008
Article comment by: Brian Biggs

This is a superb article. People need to put the costs of becoming a primary care physician into perspective. One solution to increase the number of primary care physicians is to decrease the education and residency requirements for becoming primary care physicians. Perhaps six years of college and two years of residency would ease the burden on potential new doctors.

Posted: Thursday, May 01, 2008
Article comment by: Tom Steele

I don't like the idea of a government run health care system. However, I think all the costs of all the insurance companies, legal insurances, sales and advertising costs that are paid now; it may not be worse. If the bureauacy could be controlled to a fixed % of the medical costs it could work; maybe! I would rather see government subsidize basic doctor training than subsidize making alcohol from corn.

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