The Baltimore City Health Department held a public hearing last week to address the shortage of primary health care in Baltimore.
The event, held at the Bloomberg School of Public Health on April 21, was in response to a report compiled by the RAND Health Corporation which indicated that the number of preventable hospitalizations in Baltimore city is significantly higher than in Washington D.C. and other areas of Maryland. The report linked the number of hospitalizations with the efficacy of available primary health care.
According to Jennifer Monti, Special Assistant to the Health Commissioner, the Baltimore primary care shortage has been longstanding. The RAND Corporation was commissioned to study Baltimore's health care system in order to quantify the shortage.
According to Monti, there is a shortage of about 150,000 primary care visits per year in Baltimore. However this shortage does not correspond with a shortage of doctors.
Jonathan Weiner, professor of Health Policy and Management at the Bloomberg School of Public Health, explained that Maryland is among the states with the highest number of doctors.
"We have enough doctors," Weiner said. "The problem is that they are not in the right place doing the right thing. There are many doctors involved in government and academia, and too few [involved] in primary care."
Hearing attendees included three representatives from the state, including the Secretary of Health, and about 85 physicians, health center representatives and students.
"The idea of the hearing was to get enough information on the public record," Monti said. "The information can then be used by legislators to make policies to address the shortage."
The main issues discussed at the hearing were the reasons for the gap in primary care access in Baltimore, the consequences of this gap and specific programs and policies that could be enacted to close it.
Monti explained that the shortage of primary care is a result of the decision by most doctors in Baltimore to specialize.
"Doctors in Baltimore are not paid enough," Monti said. "Specialists make more money than general physicians, so [doctors] feel the need to specialize."
According to Joseph Zebley, a family physician in Baltimore, the majority of all medical services have a fixed price for patients, but insurance companies can decide how much they will reimburse doctors for these services.
Zebley also noted that levels of physician pay in Maryland are low, and that Baltimore is the lowest payment jurisdiction for insurance companies in the nation.
The market for insurance in Maryland is dominated by two companies: United Health Care and the Blue Cross Blue Shield companies. According to Zebley, these two companies own so much of the market that no other insurance companies have been able to gain a foothold in Maryland. They have been able to lower the reimbursement payments to doctors with no competition.
As a result, most doctors in Baltimore choose to specialize in order to earn more pay. In addition, many doctors who train in Baltimore move to other areas to practice, where they will receive better payment.
Zebley also explained that teaching institutions limit the number of doctors they train in general medicine because it not as financially viable as training specialists. Residency slots at medical schools like Hopkins are funded by the federal government and Medicare, and institutions make more money by offering residency positions for specialized medicine than they do for general practice.
According to Zebley, Hopkins does not have a department of family medicine. Although the University of Maryland School of Medicine does have a residency program in family care, Zebley explained that it only graduates about 12 people per year.
"There are not an adequate number of family physicians trained to supply for the generation of physicians who are retiring," Zebley said. "Most practicing physicians are part of the baby boomer age group, and they are going to retire soon."
The low retention rate of doctors, the lack of emphasis on training primary care physicians at teaching institutions and the low payment by insurance companies in Maryland have all contributed to the lacking primary care system in Baltimore, according to Zebley.
Monti explained that the shortage of primary care physicians in Baltimore has costly consequences.
"When a person can't see a doctor, what might have been a mild case of bronchitis becomes pneumonia," Monti said. "Patients get more severe and then end up in the hospital which is much more expensive than outpatient treatment."
According to Monti, one thing that the state is considering is shifting funds to doctors who choose to stay in primary care.
"Currently the state offers about half a million dollars of loan forgiveness to doctors to pay off medical school loans," Monti said. "But that amount of money is only enough to help about eight doctors. The state needs to invest more money to keep doctors in primary care."
Other policy changes discussed at the hearing included changes in reimbursement formulas by insurance companies and the need for electronic medical records (EMRs).
Weiner explained that the implementation of EMRs would strengthen communication between doctors and coordinate care better.
"The advantage of a primary care doctor is that he or she serves as a gatekeeper," Weiner said. "They serve as the coordinator among all of a patient's doctors. But without a primary care physician, such communication is lacking."
According to Weiner, only about five percent of doctors currently use EMRs frequently.
"One day, we will be interoperable, meaning that your doctor can look at the records from all your other doctors," Weiner said.
Although EMR implementation would not solve the primary health care shortage, it would improve the function of the health system without general physicians.
Monti explained that the record from the hearing will remain open to contributions from the public into May. The information will then be taken to the legislature to help them formulate policies regarding the primary care shortage by early summer.
