Doctors Wanted

A major decline in the number of primary care doctors in Michigan and the nation is impacting health care in urban and rural areas, with few remedies in sight.
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Christian Chagas drawing blood from a patient.
In Demand: Wayne State University is working to expand its medical programs to attract more students like Christian Chagas, seen here drawing blood from a patient. // Photographs by Hayden Stinebaugh

Michigan is facing a shortage of primary care doctors — a growing trend, especially in rural areas — that could lower the quality of patient care and even push up health care costs.

A new report by the Citizens Research Council of Michigan says population growth, aging baby boomers, the large number of new patients now insured under the Affordable Care Act, and physician retirement are contributing to shortages of primary care specialists —
doctors in internal medicine, family practice, and pediatrics — not only in the state, but coast-to-coast.

“If we were to only maintain the status quo (in Michigan), it is projected that we would need an additional 862 primary care physicians over the next decade,” says Dr. Tsveti Markova, associate dean for graduate medical education at Wayne State University in Detroit.

There are sizeable obstacles blocking the way to fixing the problem. Federal funding for training new doctors is stagnant. Recruiting them for primary care is difficult because their paychecks can be half that of other specialists, even though primary care specialties require a huge knowledge base, since any type of medical problem can walk through their door.

When you add in an enormous paperwork burden and government reimbursements that fall far short of costs, it’s no wonder the number of new primary care doctors dropped by half in the decade from 1998 to 2007. The result is an unmet need for primary care — the kind that treats and coordinates all of a patient’s health care needs — in some parts of the state, particularly in hard-to-fill urban and several rural locations.

Northern Michigan and the Upper Peninsula face the biggest shortages, but there are areas in the southern Lower Peninsula where obtaining primary care is challenging, too. Seven rural counties in the northern half of the Lower Peninsula also fall below suggested ratios in every primary care field except family practice.

“In Oakland County, we have more doctors than are needed,” says Dr. Paul Misch, chairman of the Family Medicine and Community Health department at the Oakland University William Beaumont School of Medicine in Rochester Hills. “Wayne County has lots of docs concentrated at the Detroit Medical Center or St. John or Henry Ford Hospital, and yet there’s these big pockets in the city where it’s difficult to find a doctor. Then we have the rural areas that are underserved.”

Dr. Tina Tanner, chair of the board for the Michigan Association of Family Physicians, says, “It’s a shortage of distribution. And the distribution is because of economics.”

The Citizens Research Council report includes a ranking of all Michigan counties, their number of primary care physicians, and the ratio of population-to-primary care physician. The findings show Oakland County tops the list for the number of primary care doctors at 1,836, with a ratio of 665-to-1; Wayne with 1,515-to-1; Macomb is at 1,698-to-1; and Washtenaw has the best ratio in the state at 598-to-1.

Three counties — Lake, Presque Isle, and Ontonagon — each have two primary care doctors, the lowest number, with ratios of 5,749-to-1, 6,565-to-1 and 3,207-to-1, respectively. Cass County has the lowest ratio, at one primary care doctor for every 7,463 residents.

The state average is 1,246-to-1, with 1,200-to-1 considered a “reasonable” ratio of population to primary care physician by the American Academy of Family Physicians.

The state’s medical schools are trying to solve the problem by expanding their programs and, in some cases, modifying their recruiting practices. Wayne State and Michigan State added to their medical schools’ class sizes, and both give slight preference on admission to students who intend to work in underserved areas in the state. Meanwhile, Oakland University’s new medical school graduated its first class of 47 students this year (13 went on to primary care residencies, six of them in Michigan), and Central Michigan University in Mount Pleasant and Western Michigan University in Kalamazoo have added medical schools.

The message to doctors in training is changing, too. “We really take the time to talk to our medical students to stress the importance of primary care,” says Oakland University’s Misch. “They’re the driving factor in making sure that the population, and their patient, is getting the right care.”

Some schools are responding to studies that show how the setting for a future doctor’s training influences his or her choice of specialty and work location. That’s one reason why, since 2010, Wayne State has sponsored the Robert R. Frank Student-Run Free Clinic, which provides primary care services to 50,000 uninsured patients in Detroit, and MSU has a rural physician-training program for up to 16 students a year that’s designed for those destined for primary care specialties.

If churning out more medical school graduates was the solution, the state might be well on its way to having the shortage solved. “But having more students that come through a school doesn’t change the number of practitioners,” says Dr. Aron Sousa, senior associate dean for academic affairs at MSU’s College of Human Medicine.

While medical schools like those at WSU and MSU can increase their number of graduates, those new doctors have to complete a residency. Right now, the number of resident positions — and funding for them — comes largely from Washington; currently there are about 500 more applicants than available residency positions.

Federal lawmakers have introduced legislation to increase funding to add to the number of positions. But Dr. Louis Saravolatz, governor of the Michigan chapter of the American College of Physicians in Troy, an organization for internal medicine doctors, doubts the measure will pass. “I have to tell you, I’m not overly optimistic that our Congress will do that as it should, (based on) the response I’ve gotten during lobbying,” he says of his yearly trips to Washington to engage lawmakers. “It hasn’t reached a high enough priority.”

Bridge the Gap

Given many other functions that have shifted to the states from a gridlocked federal government, Lansing is becoming more involved in overseeing graduate medical education. In January, a new consortium, MI-Docs, met for the first time to determine how to produce more physicians in those medical specialties most needed in underserved, rural communities, and how to keep them in the state after residency. The consortium has representatives from the Michigan Department of Health and Human Services and every Michigan medical school except Oakland University, which declined to join.

“The objective is to start new residency programs to bridge the gap, and to work on retention and incentives,” Markova says.

Elizabeth Hertel, director of health policy and innovation for the department, adds that the consortium may “identify potential savings and avenues for training outside of hospitals. I think the idea is that you could put people (residents) where primary care offices are.”

Hertel says the 2015 (FY) state budget includes $500,000 for the consortium. MI-Doc may first tap into the money for a detailed assessment, right down to the ZIP code level, of health care needs and accessibility in Michigan.

The trouble is, economic considerations make it hard to convince new doctors to specialize in primary care instead of more lucrative specialties when they’ve got student loan debts that can reach $250,000 or more. “Over the years, there has developed a significant gap in payment for primary care,” Misch says. “Internal medicine specialists can do a one- to two-year fellowship to become a cardiologist, a gastroenterologist, or another subspecialty, and can earn so much more.”

Mordechai Sadowski checks the blood pressure on a patient.
Primary Care: Wayne State medical student Mordechai Sadowski checks the blood pressure on a patient.

On the national level, Saravolatz’s group has advocated for more scholarships, while making it easier for new doctors to handle student loan repayments by deferring payback until after their residency. He says they also favor establishing a standard formulary — the group of drugs an insurer will pay for — and reimbursement paperwork to make doctors’ jobs more efficient. 

“The college is very committed to seeing what we can do to bring the joy back to medicine,” Saravolatz says.

Meanwhile, MidMichigan Medical Center – Gratiot, a 79-bed hospital in Alma and a part of MSU, plans to start a rural practice-focused family medicine residency program with four positions in 2016. In turn, Beaumont Health System has added more family medicine residency positions in recent years — but, with the cost to fund one resident for a year hovering around $100,000, it doesn’t plan to add more.In the meantime, primary care doctors are tweaking their business models to maximize their time with patients or reserve their appointments for more complex problems, while other health care professionals step in for more routine patient needs.

In Ann Arbor, at the primary care clinics at the University of Michigan in Ann Arbor, for example, patients with medication-controllable conditions like high blood pressure, high cholesterol, diabetes, or asthma, as well as people who take lots of different medications or use generic offerings, see doctorate-level pharmacists.

Maximize Care

While the program wasn’t meant to address a physician shortage, it does free up primary care doctors to address more complex medical problems. Once a patient’s condition is under control, he or she is discharged from the care of the pharmacist and back to the primary care doctor.

Money for the U-M pharmacists comes from Blue Cross Blue Shield of Michigan, Priority Health, and the government. The insurers pay the U-M Faculty Group Practice based on the number of visits patients make to pharmacists. The group practice, in turn, pays the pharmacists a salary.

Blue Cross has other ways to maximize primary care physicians’ time via certified patient-centered medical homes and care managers. In the Patient Centered Medical Home model, an insurer pays doctors an added 10 percent of their salary to be leaders of a health care team that delegates some patient care to nurses, social workers, pharmacists, and others.

“There’s a lot of discussion about physicians becoming team leaders, and us seeing very complex patients and co-managing with specialists, and helping to coordinate with a team of people,” says Dr. Connie Standiford, executive medical director of Ambulatory Care Services at U-M. “I think patients benefit from getting these different perspectives.”

Doctors’ practices get an extra 5 percent from Blue Cross for having care managers, often registered nurses, who work toward treating patients in the proper setting. The goal is to reduce unnecessary, costly hospitalizations and emergency visits.

“What they do is they help take care of patients in between visits with the physician,” says Dr. Jean Malouin, medical director of value partnerships for Blue Cross. “They address needs like coordinating care and visits with specialists, transportation, resources in the home, things like that.”

Since 2009, Blue Cross has paid $152 million in fee uplifts to physician practices that have changed to the Patient Centered Medical Home model, and who employ care managers, according to figures from the insurer. In addition, Blue Cross has helped get 430 care managers in practices throughout Michigan in a three-year demonstration project that’s been extended two more years, Malouin says. The program saved Medicare $148 per beneficiary in its first year, she says.

The Family Medicine department at Beaumont Hospital in Troy, which Misch heads, uses a time-saver to boost efficiency. It schedules group appointments that help streamline physicians’ time so they can see up to eight patients for complete physicals, for example, in two hours versus taking up a half to a full day. What’s more, insurance-mandated patient education about cancer prevention and a healthy lifestyle is done in a group, but patients are examined individually and in private. “It clearly pays for itself, and our patient satisfaction numbers are very high for this,” Misch says.

Beaumont’s family medicine doctors also use scribes to record notes from patient visits, which eliminates the practice of a physician looking at a computer screen instead of the patient during a visit.

Primary Care Alternatives

The primary care shortage could soon lead to new rules that allow other health care professionals and commercial ventures to help fill the void.

For example, legislation that is pending in Lansing that would enable physical therapists to independently treat back pain. Another bill would grant autonomy to nurse practitioners, who now must practice under the supervision of a physician.

If the latter legislation passes, patients could be treated by a nurse practitioner for any condition that would otherwise lead them to see a primary care doctor, says Dr. Ann Sheehan, president of the Michigan Council of Nurse Practitioners in Canton Township.

“Over 40 years of research demonstrates that nurse practitioners provide safe, quality, cost-effective care, and increase access to health care,” says Sheehan, a doctorate-level, 28-year pediatric nurse practitioner who works in Kalamazoo.

However, almost every doctor interviewed for this story opposes the pending legislation.

Tanner, who practices family medicine out of an office in North Muskegon, and has worked with nurse practitioners, is concerned autonomy measures for various specialists like nurse practitioners and physician assistants would encourage further fragmentation of the health care system. “Everybody has a place on this team, but we have to bring the team together,” she says.

Dr. Jeffrey Sanfield, chairman of Internal Medicine at St. Joseph Mercy Ann Arbor, embraces the legislation. “I support it as an option for primary care,” he says. “It addresses an unmet need the primary care community has not been able to meet.”

Private companies are also moving to close the gap. One example is the MinuteClinic concept at CVS stores.   Besides offering services like flu shots and care for minor illnesses, it provides health screenings for cholesterol, blood pressure, weight, and blood sugar. Beaumont also recently set up a clinic at a Meijer store in Royal Oak.

Only time will tell if the medical establishment can work fast enough to cure the shortage and distribution problems of primary care in Michigan and across the country, or if minute clinics and non-physician specialties will try and meet the unmet need.

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