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JAMA Forum Archive, 2012-2019: Health policy commentary from leaders in the field
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Primary Care: Rebuilding a Foundation for Reforming Health Care Delivery

Observers of the US health care system have noted the withering primary care physician workforce and the declining interest among US medical students for careers in primary care. Primary care physicians constitute less than a third of the US physician workforce, according to a report from the Council on Graduate Medical Education, a number that is lower than is found in most other industrialized nations. Meanwhile, the demand for primary care is expected to grow as a result of the expansion of coverage under the Affordable Care Act (ACA) and—more significantly—as the baby boomers become the elderly, with an increasing need for health care services.

Andrew Bindman, MD

There is some disagreement, with apparent differences across political party lines, as to whether this constitutes a problem worthy of government intervention. Democrats demonstrated their interest in supporting primary care through several provisions of the ACA, which (along with almost every other aspect of the law) were generally opposed by Republicans. The ACA includes a 10% payment increase per year in Medicare for primary care physicians for 5 years that began in 2011 and a 2-year payment increase in Medicaid that requires states to pay primary care physicians at least Medicare rates that will start in 2013. There are also funds to test primary care medical home models of care and to expand primary care clinics and training programs.

A strong case can be made that the government has a compelling interest in strengthening the primary care workforce. Research suggests that health care delivery systems that invest more of their resources in primary care have lower costs and better outcomes. There’s evidence that large integrated delivery systems, including Kaiser Health Plan and Group Health Care, which are recognized as models of high quality and low cost, tend to employ as a part of their workforce a lower overall supply of physicians and a higher percentage of primary care physicians than is represented in the US population as a whole. Although it is unclear whether it is the overall supply of primary care physicians available for a population, the percentage of primary care physicians present in the workforce, or some combination that triggers these benefits, delivery systems that rely more heavily on primary care achieve better outcomes, make more efficient and appropriate use of higher-cost specialized services, and reduce a substantial amount of unnecessary care.1

No one should question the remarkable benefits available through a wide range of specialized medical care services, but this should not be interpreted to mean that this is the best approach for the population’s health as a whole. There’s ample evidence that despite having the most expensive and one of the most, if not the most, specialized health care systems in the world, the United States has distressingly poor health outcomes that are getting relatively worse over time in comparison with other countries. Thus, redirecting limited resources that are overinvested in specialty care toward primary care would seem to make good sense from a societal perspective, but it has been difficult to muster the political will in the United States to fully untangle the complicated web that incentivizes the production of specialist rather than primary care physicians. Those who profit under current policies, including teaching hospitals and specialist physicians, believe that they are best prepared to address patients’ needs and that the government should not be involved in picking physician specialty winners and losers.

It is also a false argument for anyone to suggest that the US government should not be involved in shaping the specialty mix of the physician workforce. It is already deeply involved, so it is really just a matter of whether the government acting on behalf of society is encouraging the mix of physician specialties that returns the most value for its investment.

One example is the Medicare graduate medical education (GME) program, which is the main source of support for resident and fellowship training. The program’s funds—approximately $10 billion per year—are distributed to teaching hospitals with few requirements on how hospitals allocate them among different specialty programs. Left on their own, teaching hospitals are able to redirect their fixed number of positions away from primary care and toward highly specialized areas within the hospital that are seen as higher-revenue generators, such as organ transplantation, neurosurgery, and critical care. Although this serves an obvious short-term need for a teaching hospital, it undermines the overall production of a physician workforce that meets society’s needs. MedPAC, which advises Congress about the Medicare program, has recommended that the government increase the requirements for use of GME funds by hospitals, with a specific emphasis on training more primary care physicians.

Another long-standing government policy that contributes toward the overspecialized physician workforce is the Medicare physician fee schedule. Many agree that Medicare’s reimbursement for office-based primary care visits is relatively low compared with its payments for specialty care, which often includes billing for procedures. Although it would seem reasonably simple to correct this, to do so requires a redistribution of physician reimbursement away from specialists. But experts have pointed out that the government’s stakeholder process includes a majority representation of specialist physicians, who tend to overwhelm the minority interests of primary care physicians in promoting the status quo.

Even when efforts such as the ACA occasionally succeed in increasing payments for primary care physicians, it can be difficult to implement the policy to ensure that the funds are targeted to primary care physicians. Societies for specialty physicians who are not traditionally considered primary care providers are quick to characterize their members as fulfilling the role of primary care physicians, lobbying policy makers to include them in the list of physicians eligible for new pools of funds. Their success can siphon funds away from those who are truly prepared to fulfill roles as highly accessible, first-contact health care professionals who are able to deliver and coordinate a comprehensive range of services.

In the next few weeks, the Supreme Court is expected to issue a decision that will clarify the future of the ACA. If the court completely strikes down the law, this will deliver a major blow not only against coverage expansion, but also to a set of reforms that are built on a foundation of primary care. Clearly, it will take more than the ACA’s provisions for primary care to overcome policies set in motion long ago that promoted excessive physician specialization in the United States. Since the passage of the ACA, medical students have started to show a small but noticeable increase in their interest in primary care training. This suggests that given signals of hope and opportunity, medical students in the United States are no different from their counterparts in other countries where there remains a strong interest in being a primary care doctor.

About the author: Andrew Bindman, MD, is Professor of Medicine, Health Policy, Epidemiology and Biostatistics at University of California, San Francisco (UCSF). He is the founder and Director of the University of California Medicaid Research Institute, a multicampus research program that supports the translation of research into policy.
Starfield B. Primary Care: Balancing Health Needs, Services, and Technology. New York, NY: Oxford University Press; 1998.
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