Is there a doctor in the house?
Georgia has fewer doctors per 100,000 population than the vast majority of states. Massachusetts has the highest concentration of doctors --- 415 physicians per 100,000 residents. Georgia has only half that number. Mississippi has the lowest rate at 176 doctors per 100,000 residents.
Georgia is facing a critical doctor shortage, as a generation of physicians prepares to retire just as aging baby boomers and the federal health care law create a surge in demand for medical care.
Knowing a shortage was coming, the state's medical schools have boosted enrollments by 50 percent over the last decade. But the crisis still looms.
While there are more medical students, there aren't enough residencies --- the final phase of training required to become a full-fledged doctor. The bottleneck in the doctor pipeline persists as medical schools and elected officials struggle to find a way to pay for more residency slots at teaching hospitals across the country.
Some people want the federal government to fix the problem by paying to train more doctors. Some in Washington, however, argue that the federal government is already paying too much for residency training programs.
Plus, they say the programs often don't produce the kinds of doctors the American public needs --- especially the internists, family physicians and pediatricians who are on the front lines of health care.
Georgia faces one of the toughest challenges. Already, most of its new med school graduates are packing their bags and heading out of state for their residencies, unlikely to ever return. The state ranks 41st nationally for residency slots per 100,000 population. Georgia currently has about 2,000 slots and would need to add about 1,500 slots just to be on par with the national average.
The inevitable result, experts say, is that getting in to see a doctor in Georgia will no longer be as easy as making an appointment and handing over an insurance card. Longer waits or difficulty finding a good doctor who is accepting new patients may become a norm.
"We have an expectation as a society of getting care when we want care, " said Dr. Robert Jansen, president of the WellStar Medical Group, which employs 385 doctors in metro Atlanta. "If you go to Canada and you go to Europe, you're going to find that expectations are different and people are accustomed to waiting. It's going to be very hard to impose that in the United States."
And yet, many fear that's exactly what's coming.
"It will be longer waits, " said U.S. Rep. Tom Price, R-Roswell, who is a doctor. "It will be services that are not available and are more inconvenient. Anything you can imagine that would be a consequence of not having the number of doctors we need will occur."
Rural areas hit hardest
Those studying the numbers project that by 2020, the nation will need 90,000 more doctors than it will have. Georgia, which currently has about 20,000 doctors, will be short about 2,500 by 2020. Just a decade later, the physician shortage here will have doubled. The shortage is expected to be most pronounced in the state's rural areas.
Georgia currently has about 2,400 students enrolled in medical school, with plans to reach 3,200 by 2020. About 1 in 4 stay in Georgia for their residencies.
What worries health care experts the most is the shortage of primary care doctors. It's a problem nationally as high-paying specialties have attracted more medical students than lower-paying internal medicine, family practice and pediatrics.
Georgia ranks 45th nationally for its number of primary care doctors per 100,000 residents.
Dr. Tom Bat runs one of the largest primary care practices in the state, with offices across metro Atlanta. He said Georgia's primary care doctors whose practices are already busy can't absorb hundreds of thousands of new patients.
"Our rhetoric out there is you can give people health insurance cards --- but can you actually give them health care?" Bat said.
The demand is also increasing as those in the massive baby boom generation are reaching an age where they need to see a doctor more often.
Bat and many other physicians say the doctor shortage will be compounded by the retirement of a generation of doctors who were trained to work around the clock. Younger doctors, they say, want a more predictable schedule that allows them to leave work in time for dinner or a child's soccer game.
State dollars are helping
Gov. Nathan Deal knows the problem is serious. He found $1.2 million in a tight budget to help hospitals start new residency programs. His goal: create 400 additional residency slots. The state dollars are seed money to help hospitals get a program off the ground with the goal of getting federal dollars to pay for the slots over the long haul. It's currently possible to get more federal money for slots created through brand new residency programs.
The strategy is to try to bring residencies to parts of Georgia where the physician shortage is the most severe.
"The value of developing residency programs in hospitals that can do so --- more sprinkled throughout Georgia --- is that doctors who go there for their training are more likely to stay there afterward if they like the environment, " said Dr. Peter Buckley, dean of the Medical College of Georgia at Georgia Health Sciences University.
Even if Georgia pulls off the complicated task of setting up new teaching programs, getting federal money may be tricky.
In 1997, as part of an effort to balance the budget, Congress froze the number of residency spots it would fund. The federal government primarily helps pay for the slots through Medicare. Even though the Affordable Care Act will extend insurance to millions of people, the law did not lift the caps or support the sort of massive expansion of residency slots that many in health care believe is urgently needed.
Every residency slots costs about $100,000 to $150,000 a year. While there is a bill pending in Congress to increase the number of Medicare-funded slots, the current residency program is also being targeted for cuts.
"We see a contradiction right now in federal policy, " said Christiane Mitchell of the Association of American Medical Colleges. "We see an enormous effort to make sure as many Americans as possible have access to health care while we also see 1 in 3 physicians retiring, with more physicians over age 60 than under age 40. These retiring physicians are not being replaced."
Questions about training
While medical colleges want the federal government to lift the cap to ease the bottleneck, many in Washington say it's time to take a hard look at how doctors are trained and who pays for it.
Medical school graduates get on-the-job training as residents. They see patients, but only under the supervision of a more seasoned physician.
Through Medicare, the federal government already spends more than $9 billion a year to support residency spots across the country. The support is based on the idea that the massive health plan should help bear the cost of training new doctors because its patients benefit. While the payments average more than $100,000 per year for each residency, the money is supposed to cover not just the direct costs of the residencies, but also the greater costs of running a teaching hospital that include everything from treating sicker patients and using cutting-edge technologies, to covering the extra time it takes to care for patients in a hospital where the residents are learning by doing.
A study for Congress from the Medicare Payment Advisory Commission found that the current system produces "superbly skilled clinicians." But it doesn't demand accountability from teaching hospitals to make sure that they are training doctors in a way that will best serve the public, such as making sure doctors are learning how to work in teams and use treatments that have been proven to be the most effective. The commission also concluded that Medicare overpays teaching hospitals for the indirect costs of running residency programs.
Price, the Georgia Congressman, said he believes the nation's approach to paying for residencies needs to change so that the system is less reliant on Medicare and more on private support. "Everybody benefits from the doctors of this land and everybody ought to have a hand in their training and education, " Price said.
The current system, he said, is a holdover from Medicare's more solvent days. "Medicare is going broke, Medicaid is going broke, the country is going broke, " Price said.
But it's such a long process to train physicians, said Dr. Wright Caughman, Emory University's executive vice president for health affairs, that alternative ways to pay for residencies need to be secured before Congress considers reducing funding already viewed as inadequate.
If residency programs are forced to make cuts, there will be fewer physicians at a time when the nation is trying to offer greater access to health care, Caughman said. "The math doesn't work."
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