Doctors are seething

Family doctors are mad. Who can blame them?

Primary-care physicians are the front line of medicine. They are the first stop for people who need care. They treat the patient as a whole person, not a body part or disease. They determine where to send the patient  for more care if necessary.

Their income essentially has stayed the same since the 1990s, while their practice expenses have steadily increased. After accounting for inflation, their average income fell 7 percent from 1995 to 2003. This obviously is an unsustainable business model.

Their workdays are brutal. A Philadelphia practice kept track of what its physicians did in a day’s time. The average doctor saw 18 patients, wrote 12 prescriptions, reviewed 14 consultation reports from specialists, studied 11 X-rays or other imaging reports, and wrote or answered 17 email messages.

Many patients do not get the recommended care. If everyone did, it would destabilize the U.S. primary-care system. A physician with a typical 2,000-patient base would have to spend more than 17 hours a day to meet all of the guidelines for preventive care and chronic-disease management.

Physicians have to fight for every dollar. Plumbers and attorneys do not have to call a third party to verify that they will be paid when they fix leaky faucets or draw up wills. Doctors must follow strict health-plan guidelines or they will not be reimbursed. State and federal health-insurance programs continue to squeeze the rates they pay physicians to compensate for rising costs. Many practices lose money when they treat Medicaid and Medicare patients.

Primary-care physicians’ share of the U.S. health-care dollar is only 7 cents. If payers cut reimbursement for physician services by 25 percent – certainly a doomsday scenario for doctors – the average rate of medical inflation would decrease from 6.2 percent to 5.7 percent.

However, primary-care doctors control 80 cents of every health-care dollar by sending their patients to hospitals, referring them to specialists and handing out prescriptions. This is a key paradox: Primary-care physicians arguably are the most powerful players in the health-care system but are underappreciated and comparatively undercompensated. In a 2006 survey, nearly 8 out of 10 characterized themselves as “junior partners” or “second-class citizens” in the health-care galaxy.

The threat of malpractice suits weighs heavily on physicians. Medical-liability system costs, including defensive medicine, represent less than 3 percent of total health-care spending. However, physician concerns are the same regardless of whether they live in states that have adopted medical malpractice reforms.

They are deeply suspicious of health reform. Two-thirds said their initial reaction to the law was negative. Almost 90 percent said primary care is on “shaky ground” or “is a dinosaur soon to go extinct.”

Lou Goodman, president of the Physicians Foundation and chief executive officer of the Texas Medical Association, predicts that physician practices will vanish because of market forces and the new law’s effects.

Health reform’s newly insured will be clamoring for physician services, which will become increasingly scarce because supply is not expanding with demand. The federal government soon will penalize physicians who do not use electronic health records, an expense and service disruption that many physicians cannot afford.  Many solo practitioners or small practices are banding together, selling themselves to hospitals or simply going away.

Some see primary care in a death spiral. Because it is so challenging and relatively underpaid, few medical students choose that route. This places greater pressure on existing practices, forcing even more to drop out. Primary-care doctors have little bargaining power. Their reimbursement from Medicare and Medicaid has remained relatively flat over the past decade, and private insurance plans have followed suit.

Even though the workload is expanding, physicians are slowing the speed of the treadmill. The average workweek decreased from 55 hours in 1996 to 51 hours in 2008. That is the equivalent of losing 36,000 doctors in a decade. The financial incentive to work harder, they say, is simply not there.

Only 1 out of 4 say that in three years, they will still work as hard as they always have. The remainder say they will cut back their hours, retire or seek nonclinical employment. The recession has prompted many to delay retirement. The health-care industry experience the largest decline in retirement rates  of all economic sectors. In 2009-2010, about 1.5 percent of full-time works retired, compared with 4 percent in 2004-2007.