Redução de médicos de atenção primária nos Estados Unidos
Autor: Paulo Lotufo | Publicado: 2008-06-04T17:18:00-03:00

Shortage of Doctors in Primary Care May Harm Health of Nation: More U.S. Physicians Educated OverseasPosted 05/23/2008With new federal findings bolstering concerns about shrinking ranks of primary care physicians, advocates are looking to critically underbudgeted programs that — if properly funded — could help prevent a widening of the health care gap.According to research released by the U.S. Government Accountability Office in February, U.S. medical school graduates enrolled in primary care residency programs, such as family medicine and pediatrics, fell from 23,800 in 1995 to just more than 22,100 in 2006. While there are many reasons behind the declining primary care numbers, GAO pointed to an "undervaluing" of the field within the health care marketplace as well as an over-reliance on specialty services as main contributing factors. The widening income gap between primary care physicians and those in specialty fields warrants more federal attention, GAO reported, especially as access to primary care is often associated with better health outcomes and less health care costs. A. Bruce Steinwald, director of GAO's health care team, presented the agency's findings in testimony during a Feb. 12 Senate Committee on Health, Education, Labor and Pensions hearing on the "Crisis in the Primary Care Physician Workforce.""A paradox commonly cited about the U.S. health care system is that the nation spends more per capita than all other industrialized nations but ranks consistently low in such quality and access measures as life expectancy, infant mortality, preventable deaths and percentage of population with health insurance," Steinwald reported.GAO's testimony comes as Congress considers the future of the federal effort known as Title VII, a program administered via the U.S. Health Resources and Services Administration and created to shore up the nation's supply of primary care medicine and dentistry professionals as well as to improve diversity among medical students. Title VII supports primary care education and training through a variety of means, including scholarships and loans, and plays a critical role in bringing primary care to under-served and disadvantaged communities. Unlike specialty fields, primary care is an "essential foundation of a well-performing health system" and often serves as the "patient's door into the health care system and the patient's guide through the system," according to hearing testimony submitted by Kevin Grumbach, MD, co-director of the Center for Excellence in Primary Care at the University of California-San Francisco.But despite support from those in the field, Title VII health professions training — like many public health-related efforts — often lands on the budgetary chopping block. In spite of years of cuts and flat funding, President Bush's fiscal year 2009 federal budget proposal, which was released in early February, recommends slashing HRSA's budget by about $1 billion, including a 70 percent cut to the agency's overall health professions training programs and a proposed elimination of Title VII funding."Title VII funding is essential for us," said James King, MD, president of the American Academy of Family Physicians. "Everybody knows that we don't have enough primary care physicians and yet we go through this every year."Even though Congress is expected to provide Title VII funding in the 2009 budget, King noted that tighter budgets and competing national priorities are making it more and more difficult to secure needed funds. Policy-makers acknowledge that a primary care system based on prevention works, and yet they are not making decisions to support that, he said.One way to begin strengthening that support, King told The Nation's Health, is to start closing the income gap between primary care physicians and those in the specialty fields. Most times, medical students graduate with debts in the hundreds of thousands of dollars, and primary care services simply don't bring in the dollars that specialty services do — and that needs to change, King said. While there will always be a fee-for-service component, health payers should also reward primary care physicians for the substantial amounts of time they spend managing patients' health, he said. On a daily basis in his own practice, King said he spends up to 40 percent of his time working with patients on sustaining good health, such as helping patients manage chronic illnesses. Unlike many specialists who serve patients who are already sick, King added, primary care physicians focus heavily on preserving health."We need to turn around the way we pay for prevention," he said. "In geographic areas with more primary care (professionals), health is better and costs are less."And in areas with primary cares shortages, it is often already under-served communities facing health care access problems and health disparities that suffer worst, King noted. As part of a solution, U.S. policy recruits medical graduates trained abroad to come to the United States and practice in communities with low health access. In fact, according to GAO's findings, the decline in U.S. medical school graduates choosing primary care residencies is being offset by incoming international medical graduates. However, the ethics and practicalities of recruiting international medical providers to make up for domestic gaps have been questioned for some time, and many advocates are calling for a stop to the practice. In fact, a recent editorial published in the Feb. 23 issue of the Lancet discussed whether actively recruiting health workers from developing regions such as sub-Saharan Africa should be seen as a crime."The quick fix has been to recruit internationally... but we're being pushed to look at what that means globally in stripping resource-poor countries of resources they desperately need," said Kristine Gebbie, DrPH, RN, director of the Center for Health Policy at Columbia University's School of Nursing.Besides helping to deplete primary care numbers in developing regions, physicians trained abroad aren't necessarily equipped to help the U.S. communities they are recruited to serve, said Gebbie. For example, she said, there is no requirement that such providers be trained in the cultural competencies often needed to overcome health disparities affecting ethnic, racial and rural communities. One way to better address such disparities and gaps in U.S.-trained primary care workers is to stop talking about primary care physicians "as if they live in a vacuum...We know from research and experience that primary care can be done by quite a range of people," such as physician assistants and nurse practitioners, Gebbie told The Nation's Health."I'm not saying that these groups are exactly interchangeable, but there are many overlapping skills with those of physicians," she said.Gebbie also noted that shortages in the primary care work force inevitably spill over into the public health arena, where public health workers often do their best to fill in the service gaps — even though such work diverts much-needed resources from public health's broader mission and adds extra strain to already tight budgets."I remain absolutely astonished by our federal government's inability to grasp that there is real pay-off in investing in health care work force development," she said. "We go through occasional spasms where we put some money in, but we don't sustain it and therefore we don't develop the cadre of people that we need."For more information on primary care shortages, visit www.aafp.org. For a copy of the GAO testimony, visit www.gao.gov and search for GAO-08-472T. For more news from The Nation's Health, visit www.thenationshealth.org.