It is well known that primary care is in peril. A recent analysis quantifies that peril and shines some light on the reasons for the problem, perhaps pointing the way to possible solutions.
Mark Schwartz, of New York University, and colleagues report in Archives of Internal Medicine that the United States faces a “troubling shortage in its primary care workforce.” They found that the proportion of medical students planning to practice general internal medicine dropped from 9 percent in 1990 to 2 percent in 2007. General internal medicine is but one aspect of primary care—others being pediatrics and family medicine– but this trend is indicative of a looming crisis that will only be exacerbated as 30 to 40 million more people obtain health insurance as a result of last year’s health care reform.
According to a 2010 report, Advancing Primary Care by the Council on Graduate Medical Education, only about 32 percent of physicians in the U.S. today are primary care providers. The council estimates that only 16 percent to 18 percent of medical students who matched into National Resident Matching Program residencies in 2010 were likely to practice primary care. Given an increasing demand (an aging population suffering from chronic conditions and an impending obesity epidemic) and decreasing supply (retiring physicians, accelerating attrition, and fewer clinical hours) in primary care, major shortages in primary care are to be expected. Although more medical students view internal medicine as a meaningful career today than they did in 1990, students have higher debt, more negative perceptions of workload and stress, and less career interest in internal medicine. Furthermore, Schwartz and colleagues report that the income gap between generalist and subspecialty physicians has grown to nearly threefold, or an income disparity of $3.5 million throughout a 40-year career.
The Council on Graduate Medical Education report offers a series of recommendations to address some of these problems. It suggests, among other things, the implementation of policies that raise the percentage of primary care physicians to at least 40 percent of the physician workforce; increasing the average incomes of primary care physicians to at least 70 percent of median incomes of all other physicians; encouraging premedical and medical schools to emphasize the importance of primary care; and creating financial and career incentives to practice primary care in health workforce shortage areas, so as to address socioeconomic and geographic misdistribution of primary care.
The Affordable Care Act (ACA) has the potential to set some of these changes into motion. In September 2010, the Department of Health and Human Services announced that $253 million dollars would go to improve and expand the primary care workforce and provide community-based prevention under the Prevention and Public Health Fund of ACA. From this grant, $167.3 million was designated to establish the Primary Care Residency Expansion (PCRE) program. The program promises to fund 82 accredited primary care residency training programs in general pediatrics, general internal medicine, and family medicine. By 2015, the program is expected to support the training of 889 new primary care residents, 500 of which will have completed their training.
In November 2010, the Department of Health and Human Services announced the reauthorization of the National Health Services Corps Loan Repayment Program, which provides up to $60,000 to repay loans for primary care medical, nursing, dental and mental health clinicians who commit two years of service at health care facilities in medically underserved areas. The program received $290 million from ACA to address shortages in the primary care workforce and provide greater access to health care for all Americans. More than 16,000 primary care professionals could be trained and practicing as a result of Corps funding by 2015.
The Affordable Care Act makes a series of other efforts to strengthen the breadth and practice of primary care. As of 2011, primary care practitioners participating in Medicare are eligible for a 10 percent payment bonus, available for five years. The bonus targets primary care service billing codes for office visits, nursing facility visits, and home visits payable to physicians, nurse practitioners, clinical nurse specialists, and physician assistants if 60 percent of their annual revenue is from primary care services. Between 2011 and 2016, ACA invests nearly $3.5 billion in the primary care provider bonus program. To encourage physicians who already accept Medicaid to continue accepting it, as well as to persuade new physicians to begin accepting it, ACA stipulates that Medicaid payment rates for primary care physicians will be raised to the level of Medicare payment rates in 2013 and 2014.
In addition to these provisions that seek to increase the supply of primary care providers, ACA also attempts to alter the delivery of primary care services by expanding the federally qualified health center program; encouraging patients to seek preventive care; creating incentives for states and insurers to experiment with comprehensive patient-centered medical homes; and promoting Medicare and Medicaid pilot programs to test new delivery and payment models. A shift toward more primary care would benefit physicians and patients alike by reducing costs and improving the quality of health care.
The Dartmouth Atlas of Health Care, which reported great variation in per capita Medicare spending across regions, found that lower spending regions had a much larger proportion of care delivered at the primary care level, with little or no diminished quality of outcomes. Research suggests that when more specialists are available, primary care physicians will come to rely on specialists because it may seem more efficient, given the current payment system and lack of support for primary care. This can in turn lead to higher utilization rates, greater costs, and worse quality of care and outcomes due to fragmentation of care. For this reason, placing more emphasis on primary care could reduce costs, improve quality, and increase access to the health care system.
These changes brought about by ACA already seem to be having an impact on medical students’ decisions to enter primary care. This year, family medicine residency programs saw a 94 percent enrollment rate and attracted 1,317 students, 133 more than in 2010. This is an encouraging trend, but more work needs to be done. The United States still has much to learn from other countries. Health care systems, such as Germany and France, in which upwards of half of the physician workforce practices primary care, tend to be the highest performing. Ensuring a commitment to the successful implementation of ACA and other programs designed to increase the primary care workforce will bring the U.S. one step closer to a sustainable health care system better equipped to provide cost-effective, high quality health care to an increasing population of Americans.
Ross White is a research assistant at The Hastings Center.