U.S. Incentives for More Family Doctors Weighed

As part of its long-term vision for health care reform, the Clinton Administration may create a set of financial incentives to reverse the nation’s lopsided ratio of general practice physicians to specialists, according to knowledgeable sources.

Although final decisions have not yet been made by the health reform task force headed by First Lady Hillary Rodham Clinton, sources said options under consideration include government-sponsored low-interest loans and bonuses or scholarships to medical students who choose general practice over the currently more lucrative specialties.

In addition, the Administration is weighing a plan that would limit the number of specialty residency slots in the nation’s teaching hospitals, sources said.

The positions are funded by the federal government through Medicare, which spends about $5 billion a year on them--believed to be the largest federal expenditure for medical education.

Many experts say they believe that health care reform will be impossible without relieving the severe shortage of generalists and family doctors, and reducing the surplus of specialists.

The Administration’s vision of universal coverage and “managed competition” will require more general-practice physicians who can dispense primary care, particularly in underserved areas such as inner cities and rural communities.

“The key question is, if tomorrow we had (such a system), would we have the right physicians to staff it?” one source said. “Right now, the answer is no.”

Only about a third of all doctors today are generalists. In 1931, 87% of the physician work force was made up of family doctors and other general practitioners. By 1949, the number had dropped to 59%; by 1961, to 50%. By 1962, the balance had begun to shift in the other direction, toward specialists.

Often, future doctors are discouraged from choosing general practice because the pay can be significantly less, the hours longer and the administrative burdens considerably more than in specialties.

Generalists earn an average of about $100,000 a year. In contrast, specialists’ salaries can average as much as $220,000, according to the American Academy of Family Physicians.

Members of the health care work force development group, the working group that is advising the White House health care reform task force, believe that initially the problem should be addressed at the educational level--in medical schools and residency programs--before doctors actually launch their medical careers, sources said.

Currently, only a sixth of all medical school graduates are choosing to be generalists.

The aim of the proposals under deliberation is to increase to at least 50% the number of medical school graduates who complete a training program in family medicine, general internal medicine and general pediatrics and begin a generalist practice, sources said.

“A major force that will bring about this change is going to be the health care system itself,” one source said. “Generalist physicians and family doctors will play a fundamental role at the entry point to the system as the personal physician, the first-line provider.”

The working group is expected to place a heavy emphasis on incentives, such as scholarships and loans, for minority medical students in an attempt to double the number of entering students by the year 2000, sources said.

The hope is that these students will choose to work in underserved areas, such as rural communities and inner cities.

Furthermore, the group has suggested that the government add a bonus to Medicare and Medicaid reimbursement for those who practice in these shortage areas, and that the National Health Service Corps earmark scholarships and loans to physicians who agree to serve there, sources said.

Many of the working group’s proposals originated with a report released last fall by the Council on Graduate Medical Education, a group created by Congress in 1986 to advise the secretary of health and human services and Congress on ways to improve the physician work force.

The report recommended that a national plan be drafted that would include the creation of national and state commissions to determine local, regional and national physician needs. Under the plan, physician-training positions and funding would be based on the types of doctors needed.

Medical industry representatives, told of the proposals under consideration by the task force, had mixed reactions.

Dr. Alan Nelson, executive vice president of the American Society of Internal Medicine, said the proposals at the education level “made good sense” but placed too great an emphasis on “quotas.” Also, they did little to address a physician’s practice beyond education and training, he said.

“Changing graduate medical education is very important, but it’s not enough,” Nelson said. “Medical students look . . . to whether their services are going to be valued (after they begin their practices) and right now those services are undervalued.”

He suggested that the plan should include ways to close the salary gap and ease the administration burdens.

“If doctors think they are going to be working for much less--not just income but in terms of how hard they have to work--they won’t select primary care, no matter what you do,” he said. “And if you relegate primary care to a last resort role by forcing them into it, they won’t be happy. If you haven’t got a happy doctor, you won’t get good care.”

But Dr. Robert Graham, executive vice president of the American Academy of Family Physicians, predicted that most of these concerns would be corrected by the marketplace.

Under “global budgeting” (in which health care spending ceilings are set) and “managed competition” (in which health insurance groups negotiate rates with providers), the demand for primary care physicians is expected to increase, while pressures are expected to grow on specialists to perform fewer services, he said.

“The system will be structured to say you’ve got to deal with your personal physician,” Graham said. “There will be correcting tendencies within the market that will increase family physicians’ income and, at the same time, decrease the numbers of procedures or salaries available to the sub-specialties.”

Sources within the working group said they were encouraged by reports last week that the percentage of medical students seeking residencies in family medicine--and being matched with their choice--had increased from 67% last year to 77% this year after a five-year decline.

“It still needs to become much higher, but it’s the first sign that changes in the needs of the health care system are being heard by the students,” one source said.