Primary care or a specialty? Overhaul may provide answer

VIRGINIA BEACH

In a quiet suburban office, Dr. Mitchell Miller sifts through charts and discusses earaches and cholesterol levels with his medical student daughter.

It's a typical day in the life of a family physician and a ground zero of sorts in the national discussion of the health-care system.

Simply put, there aren't enough primary-care doctors like Miller to meet the demand of America now, much less the 46 million uninsured people - 1 million in Virginia - who could be added to the rolls.

Part of the reason for the shortage is that medical students are passing over general care for specialty work. Those fields pay more, an important factor when medical students can face $200,000 in debt by the time they're ready to practice.

The national situation is dire enough that federal officials and legislators are proposing solutions, including: granting medical-school debt relief to students entering primary care; retooling the insurance system to better compensate primary-care doctors; and expanding the National Health Service Corps, which funds doctors and nurses in rural areas and poor neighborhoods.

Miller's daughter, Devin, just finished her first year of med school at Virginia Commonwealth University, and she can tell you that the loan payments that await her and her colleagues are not far from their minds.

"Debt is a daily conversation; it's everyday banter," she said. "It's hard, because we want to be part of the solution, we're excited about that, but at the same time, we want to pay off our debt and still have money to start families and have lives."

Devin has not yet made a decision on whether she'll choose primary care over a specialty; in fact she's spending time in her father's practice this summer to get a sense of primary care.

The debate on health care arises at an interesting juncture in the Millers' lives. The 55-year-old parent has spent 27 years in the trenches of primary care, and sees himself in the last decade or so of his career.

His daughter is getting ready to embark on her career, one that will be colored both by what unfolds before Congress and what she has experienced firsthand with her father.

Miller is a genial bear of a doctor who enjoys chatting with patients. He's going against the current right now in that he's an independent doc, while a growing number of physicians are migrating to group practices.

The reason for the shift is apparent in Miller's workload:

He treats 20 to 25 patients a day. Makes decisions about equipment and his office budget, which his wife, Karen, manages. Supervises a staff of 12 people, three or four of whom spend most of their time filling out insurance documentation, authorization forms, appeals of denials.

"It's incredible the hoops you have to jump through to advocate for your patient."

That's one of the biggest changes in medicine since he finished his residency at VCU in 1982, a time when he worried more about the practice of medicine than the bureaucracy of reimbursements.

"I remember worrying about passing my anatomy exam and not wanting to harm anyone, but I guess somehow we felt the system would take care of us."

He set up practice in Pungo - his office is in the Strawbridge area now - at a time when government insurance like Medicare and Medicaid reimbursed doctors for the cost of the care. It wasn't long, though, before spiraling health-care costs led government to shift to a more managed care system in the late 1980s.

Even though his older patients are some of his favorites - he enjoys the complexity of their health issues - he started restricting his Medicare patient caseload a decade ago.

The reimbursement the federal government insurance provides to doctors for people 65 and older fell short of the cost to treat them. Thirty percent of his practice used to be Medicare patients, compared with 20 to 25 percent now.

"I did not go into medicine to turn people away - that's the worst part of my day - but you have to meet your expenses to maintain a viable business."

He supports everyone having a basic insurance package but worries that if legislators choose another public insurance option, it will be so much like Medicare that doctors won't want to accept those patients.

"We have not done anything to improve access if we take those folks and inject them into a broken system."

Currently, Medicare tends to pay more to doctors who perform procedures, such as MRIs, surgeries, colon-oscopies, than to those who do the lower-tech evaluation of patients and coordinating of care.

"The system reimburses intervention," said Dr. Christine Matson, chair of the Department of Family and Community Medicine at Eastern Virginia Medical School.

"It's perverse in that it rewards doctors for doing more."

She and others in the primary-care arena said the reimbursement system needs to be retooled to provide better payment for coordination of care, evaluating patients and preventing disease.

She said about 10 percent of EVMS graduates currently leave the school headed for primary care, a drop from 24 percent in the late 1990s.

Yet, "If you can go to a primary-care physician and not to the emergency room where care costs more, that's better for you and the health-care system."

For Miller, national efforts could make his work more complicated with another layer of government insurance, but it also could improve pay for doctors like himself who diagnose and coordinate care. For his daughter and her generation, debt-reduction incentives and changes in reimbursements could move them from one field of interest to another.

Miller said he hopes reform will allow medical students to pursue what they're good at and enjoy, rather than be influenced by reimbursements.

Devin Miller is exploring her options. She loves women's health issues, as well as the public health arena, and appreciates her father's work.

"I haven't ruled anything out."

She said she expects balancing work and family to play a role. She and many other med students - an increasing percentage are women - are not only delaying their earning power to become doctors but also are delaying decisions such as marriage and having children.

That ratchets up the pressure to hit the ground running when they graduate, and to find niches that let them balance work and home. What Congress decides on, whether it's debt forgiveness, retooling the reimbursement system, or putting more funds into underserved areas, could make a difference in where she lands.

Both Millers heard President Barack Obama speak at the American Medical Academy convention in Chicago last month - Devin is a medical school delegate and her father is one of seven Virginia AMA delegates - and both are cautiously optimistic about possibilities for change.

Devin said it's an exciting time for medical students, being at a crossroads in their careers and in the nation's health-care debate. "A lot of people are skeptical it will ever change, but I think it will," she said.

Her father, meanwhile, appreciates the attention primary care has picked up, and he hopes more medical students will consider the field.

While he understands some students' desire to do high-tech, procedure-related work, he said the relationships he's built over time with patients have been rewarding. He has seen some families for several generations. He attended the births of babies he now treats as adults.

"I've never had a lawsuit against me, knock on wood."

Devin may be keeping a close eye on changes government makes, but she's also influenced by the work her father does as he moves from one exam room to the other, a boy with an earache here, a man with a heart problem there.

He's the reason she entered the field in the first place:

"I'd see my dad come home and even though he was constantly dealing with different issues, he was always happy," Devin said.

"I knew I needed to do something I was that excited about."

Elizabeth Simpson, (757) 446-2635, elizabeth.simpson@pilotonline.com