Editor's note: This is the final article in a four-part series discussing aspects of a state and national shortage of primary care physicians. With the political season in full swing, we have heard discussion of a variety of issues, including implementation a universal health care plan. While more than half of U.S. doctors are in favor of switching to a national health care plan, according to a recent report in the Annals of Internal Medicine, many are also concerned about placing even greater demands on primary care physicians. "Universal Health Care would increase demand on services we provide, which is good in that people who don't have health care now would have the opportunity," says John Brandon, MD, a family medicine physician in Gordo, Alabama, and Medical Director of the Rural Medical Scholars Program at the University of Alabama School of Medicine. "However, it would create a tremendous burden because there are not enough primary care physicians to provide the services. We are working as hard as we can now. If we had 10-12 more patients per day, I'm not sure what we would do." Michael Harrington, MD, Professor and Chairman in the Department of Family and Community Medicine at UAB, points to Massachusetts, which implemented a universal health care plan several years ago. Today, many of its citizens are waiting months to see a primary care physician. "We can all guess and predict what would happen with universal health care, but we can look at Massachusetts and see what's happening," Harrington says. "Everyone has coverage, but there are not enough primary care doctors to provide services, so there are long waits. If politicians say they will cover everybody, that's great but it's not enough. Who's going to take care of them? It doesn't solve the problem. It just creates another bottleneck."

Health Care for Everyone

Wally Retan, MD, a Birmingham internist and state coordinator for Health Care for Everyone, says that shortages of physicians are going to exist. He adds that the problems in Massachusetts are not widespread. "It's all a matter of considered speculation," he says. "Should we decide on universal coverage based on the number of primary care physicians? That says your moral right to health care must wait until we have enough physicians. That's a difficult position to defend." Retan and proponents of Health Care for Everyone want to cut administrative health care costs by eliminating private insurance companies. They also want to extend coverage like Medicare to everyone in the nation and eliminate premiums, copayments and other out-of-pocket costs. "It could be paid for with an employer tax of about 5.8 percent, which is less than what employers now pay for the insurance they provide for employees, coupled with an income tax of 2.9 percent, which is less than most people spend on out-of-pocket expenses for insurance that is available today," he says.

Universal Access vs. Mandated Coverage

Leonard J. Nelson III, a professor at Cumberland Law School at Samford University, prefers a plan that provides universal access, without mandating participation. "Universal health care could exacerbate the shortage of primary care physicians, with more patients stressing the system." He wonders what a free plan would look like. "Is it a system like England's or Canada?" he asks. "Is it expanding existing government programs? I'm concerned that if we expand government programs and everybody is on Medicare, for example, how will we ration care? Will it be through pricing or some bureaucratic mechanism? Medicare is already having problems, and future cost projections are staggering. If you add everybody, it's a looming disaster." Nelson adds that an expanded government program could also impact physician compensation. "They're already talking about cutting physician compensation in the current Medicare program," he says. "That might make medicine less attractive, leading to fewer doctors. If a state pays for education, like Canada does, it's a possibility it will work, but you're still talking about a big expense." John Wheat, MD, professor of community and rural medicine at the University of Alabama's College of Community Health Sciences and School of Medicine, and director of the Rural Medical Scholars Program at the University of Alabama School of Medicine, thinks a universal health plan might improve physician compensation in rural Alabama. "If everyone has coverage, it should create a more level playing field, where it is more financially feasible to practice in rural areas," Wheat says. "But of course, that won't help the problem with the supply of doctors."

A Solution to the Access Issue?

Jim McMinn, MD, of Total Wellness in Homewood, is addressing the access issue with the novel idea of shared appointments. Because most of his patients see him for hormone therapy, McMinn finds himself repeating the same information over and over each day to different patients. Also, he says that the women talk to each other in the waiting room. "The patients seem to find comfort in sharing experiences, so we tried to be creative and come up with a way to make the doctor visits more efficient for everyone," he says. McMinn emphasizes that the shared appointment is a true medical visit for each patient. He takes vital signs and examines each one, so each patient has individual time with him in addition to the group session, where McMinn discusses a topic of interest to all. An added bonus for the patients is that the shared appointments cost less that a traditional doctor visit. "The shared visit is billed at a lower rate, and it is more efficient for us," McMinn says. "Each patient gets more time with me for less money, so it's a win-win for everyone." With or without universal access, the shortage of primary care physicians is only going to get worse, creating the need for more out-of-the-box solutions, like McMinn's.