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Invited Commentary
February 18, 2019

The Future of Primary Care in the United States Depends on Payment Reform

Author Affiliations
  • 1Division of General Internal Medicine and Clinical Innovation, Department of Medicine, New York University School of Medicine, New York
  • 2NYC Health + Hospitals/Bellevue, New York
JAMA Intern Med. Published online February 18, 2019. doi:10.1001/jamainternmed.2018.7623

In this issue of JAMA Internal Medicine, Basu and colleagues1 report that greater density of primary care physicians is associated with better population health in the United States. Their findings are consistent with an extensive body of literature linking access to primary care with better individual- and population-level health outcomes. Unfortunately, their study also confirms that the primary care workforce is maldistributed, with many rural communities having no primary care physicians. To increase access to primary care, especially in underserved areas, we must align incentives to attract individuals into primary care practice, innovate primary care training, and greatly improve the primary care practice model. Physician payment reform is a key to making all of this happen.

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    4 Comments for this article
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    A more effective way to increase the number of primary care doctors would be to make their training more practical
    Edward Volpintesta, BA,MD | bethel medical group
    February 18, 2019
    JAMA Internal Medicine [comment]

    I disagree that payment reform is the answer to attracting more students to primary care.1

    A more effective way to increase the number of primary care doctors would be to make training more practical.
    Primary care changed dramatically over the past two decades and medical educators did not take notice. Most primary care doctors no longer take care of hospital or nursing home patients. Their days are filled with treating common illnesses, doing physicals, and taking care of patients who are referred back  after having seen a specialist.
    /> Primary care doctors don’t need 11 years of training to do what is required of them today. Training could be shortened to almost one-half the length. This would put more primary care doctors into the workforce sooner and help reduce the shortage.

    But it is doubtful that medical educators would make the drastic changes necessary.

    Edward Volpintesta MD



    1. Zabar S, Wallach A, Kalet A. The future of primary care in the United States depends on payment reform. JAMA Intern Med published online February 18, 2019.
    CONFLICT OF INTEREST: None Reported
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    Glass half empty
    Neal Devitt, M.D. | Community Health Center
    One could as well say that areas with a preponderance of non-primary care specialty physicians have a lower life expectancy.
    CONFLICT OF INTEREST: None Reported
    A Dream
    Mark Scapini |
    Payment reform for primary care has been talked about for years and years. It will never happen to a significant degree unless internists unite, that is unionize. That is unlikely to happen. We are always willing to discuss the problem but never act on it.

    The model for primary care is to increase the use of physician extenders such as physicians assistants and nurse practitioners. They will provide most primary care and refer to specialists. Insurers are happy with this as costs will not increase. Concierge medicine will fill the gap for patients who want traditional care.
    /> Happily I am at the end of my 35 year career as a general internist. However, I do worry about who will take care of me.

    Someone needs to take a true leadership role to create a physician union (no, I am not a left wing liberal).
    CONFLICT OF INTEREST: None Reported
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    Same Old Story, New Wrapping
    Stephen Cavalieri, MD | Retired
    When I started practice in the 1980’s, there were calls for improved primary care compensation. RBRVS was going to solve that and did not. Subsequent payment reform also failed. There are too many vested interests that maintain reimbursement for PCPs where it is- hospitals, pharmaceutical companies, device manufacturers, specialists. As to the latter, the AMA has done almost nothing for primary care during my entire career and the ACP, my representative in this quagmire, subsumed the ASIM and promptly forgot about PCPs. It is an academically focused organization. PCPs have insufficient representation in Congress and insufficient income to lobby strongly. No one should hold their breath.
    CONFLICT OF INTEREST: None Reported
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