The primary problem: Dwindling primary care doctors may mean worse health care for U.S., Utah

Editor's Note: This story was originally published November 25, 2007.
    MANTI - One of two family doctors in town, Robert Armstrong will tell you he's never really off the job.
    "If I'm at the grocery store, the plumber is going to ask me a medical question. That's fine with me," he said. "But I get to ask him about my pipes, too."
    Family medicine, rural style, is an intimate affair. Armstrong, who in 1985 took over the practice of the doctor who cared for him as a boy, gets to know generations of families.
    "It's fun for me to go to a high school game and count how many kids on the football team, basketball team, I've delivered," he said. "There are getting to be many, many families that I took care of grandma and now I'm taking care of great-grandkids."
    Those kinds of relationships mean Armstrong gets to know his patients well, from their family medical history to cholesterol level and blood pressure. And that, he said, yields better health care at a more reasonable cost.
    But doctors like Armstrong are disappearing in Utah and across the country, to the detriment of the nation's health care system, experts say. And it's easy to see why.
    Primary care doctors - including family medicine doctors, pediatricians and general internists - are paid far less than their colleagues who work in subspecialities.
    In Utah, for example, family doctors make an average $138,750 a year, and general internists, $129,119, according to a 2003 survey by the Utah Medical Education Council (UMEC).
    Radiologists, on the other hand, take home an average $286,552 a year, and orthopedic surgeons, $339,605.
    With medical students owing between $120,000 and $150,000 - sometimes more - at graduation, choosing a higher-paying career in a subspecialty is an obvious choice.
    Medicare, the single largest purchaser of health care in the U.S., discourages primary care by paying doctors too little - or nothing - to do work like checkups, cancer screenings or helping patients manage their asthma, The American College of Physicians says.
    Absent reform, the college warns, there will soon be too few primary care doctors to care for aging Americans amid the nation's increasing rates of obesity, diabetes and other chronic diseases.
    One benchmark is a ratio of 1,500 people to one primary care doctor. When that is exceeded, hospitalizations for illnesses that could have been prevented by timely care begin to increase, said executive director Andrew Bazemore, citing a study by Robert Graham Center for Policy Studies in Family Medicine and Primary Care.
    In Utah, 27 of 29 counties have population-to-doctor ratios that either exceed that - or, as is the case in Daggett County, do not have any primary care doctors at all, according to data provided by the state health department.
    Rewarding procedures over prevention is the problem, said Marc Babitz, director of the Utah Department of Health's Division of Health Systems Improvement.
    "Why do we pay somebody $1,000 for a half-hour of surgery and pay someone $100 for a half-hour of thinking?" he asked. "I do a preventative test on someone that keeps them from getting cancer - a pap smear, a colonoscopy, whatever - and I get my $50," he said. "But if I cut off a mole, I get $200."
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    The pipeline: At the University of Utah's School of Medicine, between 8 percent and 12 percent of students typically choose to go into family medicine, Babitz said. In recent years, however, that number has been as low as 6 percent.
    Residency training programs in family medicine also have shrunk by about 15 percent, he said, which hurts the state since most doctors who end up practicing in Utah have done residencies here.
     Conservative estimates show that Utah needs to recruit at least 35 family practitioners per year just to maintain its current capacity, according to the UMEC. But with the specter of a national physician shortage on the horizon - by some estimates, a deficit of 200,000 doctors by 2020 - that could be tough.
    "If this shortage actually molds itself and takes place, I don't believe we'll be able to draw physicians into this state as readily as we have in the past," said David Squire, executive director of the UMEC.
    That means Utah, which produces only 20 percent of its physician work force, could be hit disproportionately hard, especially in its rural areas, Squire said.
    The shortage is expected to hit all disciplines of medicine, general practitioners and subspecialists alike. The difference, Babitz said, is that while it may only take a few more subspecialists in a certain area to meet the state's need, it will take many more primary care doctors to serve the general population.
    "The relative shortage is severe," said Babitz, who is also on the U.'s medical school faculty. "But to fix it is huge, and then what it takes to recruit a family doctor when there are so few in training is a problem."
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    The mix: Experts say declining interest in primary care has also led to a ratio of too few primary care doctors to subspecialists - a skewed mix that can give Americans worse health outcomes at a higher price.
    Barbara Starfield, a researcher at Johns Hopkins University's Bloomberg School of Public Health, compared the U.S. with other developed countries.
    The U.S. ranked highest in health care spending. But it ranked lowest in its primary care services and health outcomes - such as healthy births and life expectancy.
    Most of the other developed countries, she points out, have primary care-subspecialist distributions that are closer to 50-50.
    In Utah, just 29 percent of physicians practice in generalist fields, while the rest, 71 percent, practice in subspecialty areas, according to a 2006 UMEC study.
    Studies have shown that the greater the supply of subspecialists, the more likely people are to pay one a visit. But when people seek primary care from a subspecialist, the results aren't as good.
    "We always fight against the attitude that you might as well go straight to the specialist because the specialist knows more about the problem," said Kim Bateman, a family physician and vice president of medical affairs at Health Insight.
    "The truth is, that's not always true," Bateman said. "If your problem cuts across all specialities, then you may not get the best care that way."
    In any solution, changing how doctors are paid will be key, Babitz said. However, he added, "It's political will. It has to be political will in this society to change the incentives."
    Reform suggested by the American Academy of Family Physicians is called "Patient Centered Medical Home." Primary care doctors would receive a monthly stipend to manage the health care of groups of patients. Continuous partnerships between primary care physicians and their patients would be nurtured.
    "The big problem is getting primary doctors better reimbursement, and getting patients interested in going back to primary care," Bateman said.
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    Another day in the office: Linda Gunderson, one of Armstrong's patients, is sold. Gunderson said her 13-year relationship with Armstrong has led to better management of her diabetes because of his familiarity with her case.
    "When I come in, I don't have to start from the beginning, or keep explaining things," said Gunderson, in Armstrong's office on a recent day to get her blood pressure checked and to go over some test results. She sees him at least once a year, she said.
    Armstrong also sees patient Joseph Pellegrino, who came in complaining of constant fatigue. Armstrong knew Pellegrino's late mother, who suffered from obstructive sleep apnea syndrome, or cessation of breath.
    It's likely, the doctor said, that Pellegrino suffers from the same problem.
    He schedules Pellegrino for an overnight polysomnography test and talks to him about using a C-PAP, or continuous positive airway pressure machine, that will blow air into his nose via a mask.
    "The chances are if we fix this, you won't feel groggy anymore," Armstrong said.
    About 90 percent of the time, Armstrong said he is prepared to treat the patients who walk through his door.
    Getting to know patients so intimately, he said - "heroic people who deal with the bad things that happen to us in life in incredible ways" - is gratifying.
    He plans to practice in Manti until he retires and another doctor - perhaps one of his own aspiring young patients - comes to take his place.
    lrosetta@sltrib.com