CAPE GIRARDEAU — Practicing primary care isn't glamorous. There's nothing sexy about treating a sore throat.
There are no reality television shows about family physicians like there are about plastic surgeons.
Fewer medical students are choosing to go into primary care at a time when demand for their services is expected to increase as more people gain access to care through federal health care reform.
Eighty percent of Missouri, including all of Southeast Missouri, has already been designated a Health Provider Shortage Area by the U.S. Department of Health and Human Services. That means one in five Missourians is without access to primary health care, according to the Missouri Foundation for Health. The problem is worse in rural areas than in urban centers, said Thomas McAuliffe, policy analyst with the foundation.
Only about 12 percent of Missouri medical school graduates went into family medicine in 2009, according to the Missouri Primary Care Association.
"Being a primary care physician is not an easy job," said Danette Miller, a primary care physician with Southeast Primary Care-West in Cape Girardeau. "When compared to various other specialties, family practice is not as glamorous and not nearly the moneymaker."
Declining reimbursements from insurance companies and the hundreds of thousands of dollars in medical school debt doctors graduate with are both contributing to the shortage of primary care physicians, she said.
Primary care doctors earn about half what specialists do, according to the Medical Group Management Association.
Miller said she chose primary care because she enjoys taking care of newborn babies just as much as she enjoys taking care of their grandparents.
A Bootheel native, she graduated from the University of Missouri-Kansas City medical school in 2007 and completed her residency last year in South Carolina.
She and her husband wanted to move home, and the position she was offered at Southeast Primary Care-West, operated by SoutheastHEALTH, allowed her to do that.
Miller is the kind of homegrown physician Joe Pierle, CEO of the Missouri Primary Care Association, said Missouri needs more of.
"We've got to get children while they're in their high school years and gear them toward primary care. We need to focus on getting them scholarships, so they don't come out of school with huge amounts of debt," Pierle said. "Then we need to give them opportunities to train here."
Miller was offered help paying back her student loans as part of her contract with SoutheastHEALTH, something Jim Limbaugh, executive vice president of planning and business development, said is typical of physician employment packages.
Both SoutheastHEALTH and Saint Francis Medical Center say they are actively recruiting primary care physicians to the area.
"The more demographics change, as baby boomers age, the more need there will be for primary care providers," Limbaugh said. "The ability to motivate and convince folks to want to stay as a family practitioner will be a real challenge not only for community hospitals but for the whole country."
Saint Francis Medical Center CEO Steven Bjelich said federal health care reform makes the recruitment and retention of physicians more important than ever.
"Growing demand for physician services, especially primary care, will make today's existing physician shortage more acute," Bjelich said.
The U.S. Department of Health and Human Services estimates more than 16,000 primary care physicians are needed immediately, and the Association of American Medical Colleges estimates a shortage of 21,000 primary care physicians by 2015.
Both hospitals have reached outside Cape Girardeau County, partnering with practices in rural areas of Southeast Missouri.
There are components of the federal health care reform law intended to address the primary care shortage, specifically in rural areas.
"More people in rural areas have trouble getting into see physicians, and we know unless they're willing to drive to a metro area, they can't get in to see a specialist," McAuliffe said.
In an effort to make rural practices as lucrative as urban ones, physicians will see a 10 percent bonus applied to reimbursements for seeing Medicare patients beginning in 2014. The individual insurance mandate will also, in theory, increase reimbursements to physicians, McAuliffe said.
"When the state-run (health insurance) exchanges get up and running in 2014, people who are uninsured now will have insurance, so the incentive now to go to the city where people have insurance will no longer be an incentive," he said.
The health care reform law provides $1.5 billion over five years to expand the National Health Service Corps, a program that repays educational loans and provides scholarships to primary care health care doctors, nurse practitioners and nurses who practice in areas of the country with provider shortages.
Miller said programs like that will help encourage more physicians like her to practice in rural areas.
"Medical school loans are significant and many doctors graduate with $200,000-plus in loans. I believe any type of forgiveness and aid, whether through the government or hospitals, will help place doctors in shortage areas."
Loan debt makes it difficult for doctors to own private practices, she said, leading many, like herself, to become employed by hospitals.
A total of $168 million in the federal health care reform law will go toward training more than 500 primary care physicians by 2015.
Providing more opportunities for physicians to train in rural communities, and in Missouri specifically, will help recruit students to work in those areas when they graduate, McAuliffe and Pierle said.
"The biggest obstacle to health care reform, besides the political noise you hear every day, is the lack of providers," Pierle said. "What's the point of giving someone insurance if they don't have anywhere to go? In rural Missouri, you're going to face that. You can give everyone an insurance card, but if they can't go use it, it's meaningless."
Research shows people who don't have access to primary care physicians put off needed treatments and enter the health care system sicker. The primary care shortage is driving more people to the emergency room — the most expensive place to get health care.
Problems such as heart disease, diabetes and obesity get worse — and can be deadly — without routinely seeing a primary care physician.
"If people don't see doctors regularly and have these chronic medical conditions, their morbidity and mortality is much worse than if they do have a primary doctor caring for them," Miller said.