The healthcare reforms being debated by Congress don't address some major issues, such as the critical shortage of primary care physicians that could lessen the effectiveness of universal coverage, the president-elect of the Louisiana State Medical Society said.

 

"We need some innovative, out-of-the-box proposals to improve the compensation of primary care physicians, to recognize their important role in management of patients, particularly now that we're dealing with Baby Boomers," said Dr. Patrick Breaux, the society's president-elect.

 

The aging population of that demographic will bring with it chronic diseases – diabetes, cancer and heart disease, Breaux said. But there won't be enough primary care physicians to take care of the Boomers.

 

Healthcare reform also needs to address medical students' debt and the cost of medical malpractice insurance, Breaux said. The average student graduates from a public university owing around $100,000; for private university grads, the number is around $180,000.

 

Small wonder then that medical school graduates choose specialist training, such as cardiology or oncology, where the pay is better or the lifestyle is less arduous, Breaux said.

 

In 1997, 42 percent of those who completed an internal medical training program went into primary care, Breaux said. Last year, only 3 percent did.

 

The problem is particularly acute in rural areas.

 

"Primary care doctors in the rural areas are just being killed," Breaux said. "There are not enough of them. The demands are huge. They have large patient populations. They're underpaid. It's a meat grinder."

 

Add in the millions of Americans expected to gain coverage under healthcare reform, and the need for those doctors and the shortage of them, becomes even more critical.

 

Breaux said so far only one proposal has been made to increase Medicare reimbursements to primary care physicians by 5 percent. But that's not enough money to significantly affect primary care physicians.

 

The Medicare and Medicaid payment formulas do not, and have not for decades, placed much value on patient management, Breaux said. And primary care physicians spend 20 percent to 30 percent of their time on those sorts of uncompensated activities, making referrals, arranging tests, answering phone calls, and writing prescriptions.

 

Private insurance doesn't typically pay physicians for that work either, Breaux said.

 

In Louisiana, the shortage will be exacerbated as more and more physicians retire, he said. The average age of physicians statewide is now 55.

 

"I think we need to look at it differently," Breaux said. "For primary care, I think one solution … is certified medical homes."

 

Louisiana is one of the nation's leaders in this effort and has already has around a dozen medical homes certified by the National Committee for Quality Assurance, Breaux said.

 

Under this model, the primary care physician leads a team that takes collective responsibility for patient care. Care is coordinated across the healthcare system rather than episodically.

 

Breaux said the model could provide young doctors just starting to practice with a satisfactory and potentially better compensated career.

 

It may be that primary care physicians should be paid a per capita patient management fee, Breaux said. But something has to be done to better compensate them.

 

The Medical Society worries that improving primary care reimbursements will come at the expense of specialty care, Breaux said. Robbing Peter to pay Paul just shifts the problem to a different sector of healthcare; instead of a shortage of primary care, the country could end up without the needed access to specialist care.

 

It's a difficult situation, Breaux said.

 

Medical malpractice insurance costs will also have to be made part of reform efforts, Breaux said. Louisiana has some of the better malpractice laws in the country, but an obstetrician still pays around $80,000 a year for coverage, and the cost for neurosurgeons is around $100,000.

 

An obstetrician in New York is paying around $186,000 for malpractice insurance, he said.

 

"Without some sort of tort reform, I don't see that we can solve all the problems with healthcare delivery and its cost," Breaux said.

 

The estimates for the cost of medical malpractice insurance range from $70 billion to $170 billion a year, Breaux said. That's as much as 7 percent to 9 percent of the country's total healthcare costs.

 

"Medical malpractice is important. Student debt is important. Primary care is important, and none of that is included in the package," Breaux said.

 

The state medical society is also terribly concerned about the public option, Breaux said. The Society favors universal coverage but believes it should be provided through private insurance.

 

One of the reasons healthcare costs are spiraling is that hospitals and other providers break even or even lose money treating Medicare and Medicaid patients, Breaux said.

 

The providers have to shift those costs to patients who have private insurance, Breaux said, and that drives up costs.