Radical Primary Care Changes Needed to Meet Coming Demand for Health Care

In testimony recently submitted to the Senate’s Health, Education, Labor and Pensions (HELP) Subcommittee on Health, the AAFP urged the public and private sectors to work on sustaining and strengthening the nation’s primary care physician infrastructure. Policies and programs to support the practice of primary care and increase the supply of primary care physicians are needed, said the AAFP.

“Health delivery reform requires considering how our dysfunctional health care system can become one that serves the patient by coordinating care over time to prevent disease, managing chronic conditions, and providing immediate and targeted care for an acute condition when it arises,” said the AAFP in written testimony. “The availability of an adequate primary care physician workforce is essential to achieving these aims.”

The AAFP identified specific steps the public and private sectors could take to increase the number of primary care physicians, and noted that the need to enact such policies is acute because the Patient Protection and Affordable Care Act will extend health care coverage to millions more individuals during the next few years.

The percentage of primary care physicians in the United States needs to increase from the current 32% of the physician workforce to at least 40%, said the AAFP. “Decreased medical student interest in primary care is caused by multiple factors, including heavy workload, insufficient reimbursement, the subtle persuasion in medical school away from primary care and a lack of strong primary care role models.”

To help boost interest in primary care, the average income of physicians actually practicing primary care must increase to at least 70% of the median income of all physicians, an increase of about 20%, said the AAFP. “If primary care physicians are paid differently and better, in the context of the physician-led, patient-centered medical home (PCMH), costs should decline.”

Medical schools and academic health centers also can take steps to help increase the primary care physician work force by

• increasing and sustaining the involvement of primary care physicians through all levels of medical training

• supporting primary care student interest groups

• recruiting, developing and supporting community physician faculty members; and

• reforming admission procedures to increase the number of students likely to go into primary care

These institutions also should require student participation in rural, underserved, and global health experiences and require block and longitudinal experiences that demonstrate the essential functions of primary care and the PCMH.

Federal and state governments can support an expansion in primary care by providing increased incentives for physicians who practice primary care or other critical specialties in designated health workforce shortage areas and by increasing funding for scholarship, loan, loan repayment, and tuition waiver programs to lower financial obligations for students who plan and pursue careers in primary care, said the AAFP. Primary care physicians should also receive preferential increases in fee-for-service payments for primary care.

In response to the testimony of the AAFP and other groups, the chair of the HELP Subcommittee on Primary Health and Aging issued a report that noted the growing shortage of primary care physicians has forced millions of Americans to seek care from emergency rooms and to delay or forgo needed care in some instances, which has resulted in higher rates of preventable illnesses and even deaths.

“When people delay or fail to receive primary care and preventive services, everyone pays the price,” says the report, which was issued by Senator Bernard Sanders, I-Vt, chair of the Senate HELP subcommittee. “It is not only our moral responsibility to ensure primary care access now and into the future, but it is fiscally sensible to act quickly to expand this critical workforce.”

According to the report, the “evidence is clear that access to primary health care results in better health outcomes, reduced health disparities and lower spending, including on avoidable emergency room visits and hospital care…. Primary care is intended to be, and should be, the foundation of the US health care system.”

Yet, the shortage of primary care physicians and other primary care health professionals has reached critical mass, says the report. Nearly 57 million people in the United States—1 in 5 Americans—now live in areas that lack adequate access to primary care. As a consequence, millions of Americans use the emergency room for care that could have been provided by a primary care physician. Specifically, one-half of emergency room patients could have obtained care from a primary care physician if they had been able to obtain an appointment when care was needed, according to the report.

“Visits to emergency rooms are not only more expensive, but the lack of continuity in care can result in extra tests, limited follow-up care and an increased risk for medical errors,” says the report. “Also, acute, nonurgent cases can crowd emergency rooms, making it more challenging for emergency room physicians to provide care to the most serious cases.”

The need for primary care physicians will become even more severe as the Patient Protection and Affordable Care Act extends health care coverage to millions more people during the next few years. According to the report, the nation will need 52,000 primary care physicians by 2025, a demand that will not be met based on current trends.

“In 2011, about 17,000 doctors graduated from American medical schools,” the report says. “Despite the fact that over half of patient visits are for primary care, only 7% of the nation’s medical school graduates now choose a primary care career.”

Additionally, the average primary care physician in the United States is 47 years old, and one-quarter are nearing retirement, a trend that will further exacerbate the growing shortage.

The report cites other reasons for the growing shortage of primary care physicians, as well, including the wide income disparity between subspecialists and primary care physicians that acts as a disincentive to pursuing primary care.

The report also discusses the AMA/Specialty Society Relative Value Scale Update Committee (RUC). It describes the 31-member committee as dominated by subspecialists and largely responsible for setting physician payment rates. “Therefore, it should come as no surprise that it (the RUC) has accelerated higher payments—larger paychecks—to (sub)specialists over primary care doctors,” says the report.

Medicare, meanwhile, encourages the growth of subspecialty residencies by providing about $10 billion a year to teaching hospitals “without requiring any emphasis on training primary care doctors. Because of the strong financial incentives to train (sub)specialists, many hospitals have shifted away from training primary care doctors over time,” the report says.

There are various ways of addressing the ongoing shortage of primary care physicians and other primary care health professionals, says the report. It recommends increasing primary care scholarship and loan repayment programs and opportunities in education and residencies for primary care training in community settings. For example, the Affordable Care Act has created the Teaching Health Centers program to move training outside of hospitals and into communities, where most health care is delivered.

The Affordable Care Act provides $230 million for the Teaching Health Centers program from 2011–2015, which is a small percentage of overall graduate medical education spending and is enough to produce 600 new primary care residents by 2015, according to the report. “Although these physicians will serve thousands of patients, the scope of the need in this country is so great that this program must be dramatically expanded.”

• © 2013 Annals of Family Medicine, Inc.