Fewer doctors, more waiting

Lack of primary care physicians boosting health costs, hassles

By peter korn

The Portland Tribune, Aug 7, 2008, Updated Oct 30, 2009 (4 Reader comments)

L.E. BASKOW / Portland Tribune

Dr. Gabrielle McGrew, examining patient Kathleen Hahn, bucked a nationwide trend when she chose to become a primary care physician. Only three residents who graduated with her from OHSU have become internists: most of the 31 other residents chose specialties in which they can earn more.

There were days last fall when Gabrielle McGrew felt she must be the most popular physician in Oregon – and she hadn’t even begun practicing.

McGrew, 32, was one of 31 residents who recently completed the Oregon Health & Science University Medical School’s internal medicine program. In years past, experts say, anywhere from half to three-quarters of the school’s internal medicine graduates now would be starting their careers as internists, providing primary care to a wide spectrum of patients.

Not anymore.

McGrew is one of only three graduating residents who are choosing to practice primary care medicine, and the only one in Portland. Most of the other 31 internal medicine residents are taking fellowships that likely will lead to careers as specialists.

Ten of the graduating residents are becoming hospitalists – working as hospital employees overseeing treatment of hospital patients, but without practices of their own. One of McGrew’s classmates is starting a career at a U.S. Navy medical clinic in California, and one will practice primary care for Kaiser Permanente in Beaverton.

But internists willing to practice primary care are the physicians in most demand.

“I could have worked in any neighborhood in the country,” says McGrew about her spring recruitment, which included letters every day from practices around the country hoping she would work there.

Physician search companies report that internists willing to practice primary care are the most difficult physicians for them to recruit, mainly because they make less money than most other physicians.

Supply dwindling as need rises

And the long-term implications of the growing shortage of primary care doctors could be a disaster, experts say, given the steadily growing number of senior citizens in Oregon who are going to need primary care internists more than ever in the years to come.

“It’s a problem, it’s serious, and it’s getting worse,” says Bart McMullan, president of Regence BlueCross BlueShield of Oregon, an internist himself.

The winner in the Gabrielle McGrew sweepstakes was Cascade Physicians, a group of 18 Portland internists. And those 18 internists are in great demand, just like every other internist in Portland.

Frank Kurz, president of Cascade Physicians, says the practice actually has two openings this year, and has filled only one, with McGrew. If Cascade Physicians hadn’t been able to find McGrew, Kurz says, the likelihood is that the practice would have had to turn more patients away, or tell patients they would have to wait longer before they could schedule an appointment.

Those waits already are long for many Portland patients, especially those with Medicare or Medicaid health insurance. Those providers don’t reimburse physicians at as high a rate as most private insurers.

About 45 percent of all Oregon physicians won’t even take new Medicare patients, according to McMullan. With a glut of patients and a lack of internists, McMullan says, they have begun rejecting the patients whose insurance won’t reimburse them as well.

And it’s getting worse. McMullan says that a few weeks ago a BlueCross member in Salem, fully insured, could not find a primary care physician willing to see her. BlueCross staff said they’d help, but found the task insurmountable.

“We spent three days and we couldn’t get anybody either,” McMullan says.

Jack Friedman, chief executive officer of Providence Health Plans, says the shortage of primary care providers is one of the reasons health care costs are escalating. Half of the visits to local emergency rooms, Friedman says, are from people not suffering emergencies, but in need of primary care.

Even those lucky enough to find a local primary care physician still have to deal with the shortage, Friedman says.

“Once you find one, getting in to see them for a routine visit can be months,” he says.

Supply and demand should dictate that McGrew and other physicians willing to practice primary care can command high salaries. But that’s not the way medicine is set up.

Big bucks not in primary care

Experts say the single greatest factor behind the primary care shortage is the fact that doctors such as McGrew are likely to make less money over the course of their careers than classmates who become specialists.

A study this year by Physician Search, a national physician recruiting firm, showed that for doctors in practice three or more years, primary care physicians overall make the least amount of money. While salaries for specialists such as ophthalmologists average $256,000 per year, and experienced heart surgeons average $558,000, primary care internists average $160,000.

In fact, a study by Merritt, Hawkins & Associates, a physician recruiting firm based in Dallas, Texas, showed that some nurses, specifically those trained in administering anesthesia, are paid more on average than primary care doctors.

“The money is in procedures, and family practice physicians and internists don’t do them as often,” says Kurt Mosley, vice president of business development for Merritt, Hawkins.

Graduating physicians on average leave OHSU medical school with a $155,000 debt, according to Donald Girard, associate dean for graduate medical education there. And that debt, he says, provides a huge incentive for new doctors to enter fields where they can make more money.

In addition to lower salaries, primary care physicians follow their own patients into hospitals, which means they are on call, with unpredictable hours.

But McGrew is looking forward to her time with patients. She says that is one of the reasons she entered medicine, and the main reason she has decided to practice primary care.

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