They are primary-care residents at Children’s National Medical Center. A third of their class has more than $200,000 each in student loan debt. At the end of residency, they can stay in primary care and earn $29.58 an hour. Or they can specialize and make $74.45. Over a lifetime, a medical student who specializes can expect to earn $3.5 million more.
The Obama administration — and, arguably, the American health-care system — desperately needs them to choose primary care.
Decades of research have confirmed that more specialists leads to more specialty care, which leads to a more expensive system. Now, with the passage of the Affordable Care Act, tens of millions of previously uninsured Americans will be looking for a primary-care doctor. It is no exaggeration to say that the success of the health-care law rests on young doctors choosing to do something that is not in their economic self-interest.
The surprise of the health-care overhaul, at least thus far, is that so many young doctors are cooperating. The number of American medical students matching into primary care residencies jumped 20 percent between 2009 and 2011, according to the Association of American Medical Colleges.
“Regardless of what people think about the health reform legislation, or what side of the aisle people are on, the debate shone a significant light on the importance of primary care,” says Glen Stream, president of the American Academy of Family Physicians. “There was more attention paid to the importance of primary care, the cost-effectiveness of it and that we’re facing a worsening shortage.”
That worsening shortage, he says, has to do with the economics, with nearly every incentive working against going into primary care.
“No matter what speciality you’re going into, your medical education costs the same,” Stream says. “Think about a medical student who is sort of interested in primary care and has got $250,000 in debt. People are often driven by financial incentives, and you basically get the outcome that you incent. Health-care workforce is not different from any other sector in that regard.”
As with speciality doctors, specialty residents bring a hospital more lucrative business. A radiologist will earn a hospital $193 in Medicare reimbursements every hour, a primary-care doctor brings in $101, according to an analysis done for a congressional watchdog agency.
“What hospitals build, in terms of their residency training, has a lot to do with what business they’ll bring in,” says Robert Phillips, director of the Robert Graham Center, which studies health-care workforce issues. “If they have a choice between funding a primary-care residency or one in cardiology, the cardiology residency will make them a lot more money. It’s a perfect storm that aligns the incentives against everything other than primary care.”
Huge projected shortfall
The greatest threat to the health-care overhaul might not be the Supreme Court, which is scheduled to hear challenges to the law next month. Or the shifting alliances of an election year. In the end, it’s more likely to be a lack of medical providers. If the law succeeds in extending health insurance to 32 million more Americans, there won’t be enough doctors to see them. In fact, the anticipated shortfall of primary-care providers, by 2015, is staggering: 29,800.
The Obama administration’s options to address that threat are limited. It does have Medicare, which covers the lion’s share of the cost of training medical residents: In 2009, it spent $9.5 billion on residents’ stipends, teaching physicians’ salaries and related expenses. But when Congress passed the balanced budget amendment in 1996, it capped the number of residencies that Medicare can fund. Since then, hospitals’ slots have been tethered to 1996 levels.
The health overhaul, some hoped, would address that issue. But with the health insurance expansion’s $971 billion price tag — and the Obama administration goal to keep the law’s cost under $1 trillion — funds for more slots didn’t turn up.
In the context of a $1 trillion overhaul, the White House’s main effort on this front seems modest: a $167 million sliver of the $15 billion Prevention and Public Health Fund created as part of the health-care law.
“It’s good,” Stream says, “but it’s also a drop in the bucket.”
Last summer the White House launched the Primary Care Residency Expansion at 82 hospitals across the country, with two strings attached: The programs must train residents dedicated to primary care, and the residents must work in underserved areas.
Medical students see good reasons not to sign up, as primary-care doctors often find themselves at the bottom of the pecking order. Research published last month in the journal Family Medicine found that medical students, even those planning to pursue careers in primary care, viewed the work lives of primary-care doctors more negatively than those of other doctors.
“The income gap that stratifies much of society often stratifies the physician community as well,” a 2009 report on primary care from the Robert Graham Center concluded. “The ‘heart hospital’ side of a medical campus may have fountains and artwork, while the mental image of the primary-care offices is a necessarily full waiting room of a practice where physicians see 40 or more patients a day.”
Those differences help explain the country’s primary-care doctor shortage. They also make an impression on medical students like Reem Nubani, a 30-year-old student at Southern Illinois University interviewing for residency slots.
“It has this connotation that you don’t make much money or you’re not as smart,” says Nubani, who is considering primary care. “Sometimes I feel like it may be even harder in primary care because you still have to know a little bit about everything.”
When the White House launched its residency program, it wasn’t sure medical students would show up. In fact, they snapped up all 172 slots funded in its first year. “The thing we were really thrilled about is that all the positions were filled,” said Kathleen Klink of the Health Resources and Services Administration.
Children’s National Medical Center in the District is among 82 hospitals that were funded. Children’s grant is among the largest, at $3.8 million, and doubled the hospital’s community health residency to 24 students. Some of those new doctors are assigned to the Children’s community clinic on Martin Luther King Jr. Avenue SE, about two miles from the Capitol, where Congress passed the health-care overhaul in 2010.
The clinic’s patients are arguably among those who will benefit most from the law’s primary-care expansion. In 1993, the federal government declared the surrounding neighborhood, east of the Anacostia river, a health professional shortage area and, to this day, it has too few doctors to serve its residents.
The doctor shortage correlates with striking disparities between the health of its residents and those who live across the river. Ward 8 residents are eight times more likely to die of heart disease than residents of Washington’s tony upper Northwest neighborhoods in Ward 3, according to a 2008 Rand Corp. analysis. In Ward 8, 33.3 percent of adults are obese, compared with 9.3 percent in Ward 3.
The primary-care focus of the Children’s community clinic has attracted students such as Jacob Edwards, 34, who grew up in a low-income, predominantly African American neighborhood in Atlanta. Health-care specialists were hard to come by, he said. Edwards had asthma as a child and remembers his mother driving him 20 miles to see his doctor. “Especially in larger cities, you have higher rates of asthma and an inequality of medicine based on what community you come from,” he says. “I wanted to help bridge that gap.”
At Children’s, the care Edwards provides goes well behind medicine. “You end up referring patients to get assistance with basic needs, housing and basic bill paying,” Edwards says.
The health-care law bolstered Edwards’s confidence in his decision to join the front line of public health.
For “pediatricians,” he says, “I think there will definitely be a demand and a need for an increasing workforce.”
Atul Grover entertained such hopes nearly two decades ago as a young medical student who had watched President Bill Clinton and lawmakers battle over national health-care legislation.
Health management organizations — which emphasized primary care as a way to limit the use of expensive specialists — were booming. So were primary-care residencies: 40 percent of medical students pursued them in 1997, an all-time high.
“There was a very clear signal,” says Grover, who completed a primary-care residency at the University of California at San Francisco. “If you want to be employed, you need to go into primary care. If you want to drive a cab, take something in anesthesiology.”
Phillips, of the Robert Graham Center, graduated around the same time and remembers the era similarly. “There was this groundswell of energy that primary care would be the centerpiece for an effective health-care system,” he said. “We were obviously a bit naive and optimistic.”
The Clinton health-care plan failed. Consumers revolted against HMOs’ limited networks, and the insurance plans rapidly lost market share. As for family doctors? They now earn $150,000 less, on average, than anesthesiologists, according to the American Medical Group Association.
“In the early 1990s, there was a lot of potential,” Phillips says. “By time I was in residency, that was already waning.”
These days, Phillips, Grover and others say the current primary-care craze could end much the same way. The Prevention Fund’s residency financing runs out in 2015, and administration officials say there are no plans to extend the program.
“What I worry about is young physicians being told for a couple of years that this is totally worth it, and then it doesn’t pan out and then they get discouraged,” Grover says. “Unfortunately, I think we are moving in that direction.”
Kliff wrote this article with the assistance of the Dennis A. Hunt Fund for Health Journalism, which is administered by the California Endowment Health Journalism Fellowships, a program of the University of Southern California’s Annenberg School for Communication and Journalism.