It’s Time We Face the Primary Care Shortage

From reimbursement rates to public policy and medical schools, a UCLA professor emeritus offers a step-by-step solution

January 6, 2010 -- Fifty years ago over half of medical school graduates became general practitioners, general internists or general pediatricians. Today subspecialty training dominates by a ratio of almost 7:1.
 
Research comparing the U.S. healthcare to other industrialized countries indicates the desirability of a primary care-based healthcare system. Data show better health outcomes, lower costs, increased patient satisfaction and less use of medications.
 
As Congress debates new health reform laws and the Oregon Health Authority ponders workforce shortages, here’s what can be done to change the current pattern of behavior common in today’s academic medical centers and put healthcare on the path to improved access and reduced costs.
  1. Reduce training openings for already overcrowded specialties. Limit the choices of medical graduates choosing a specialtyupon graduation by reducing the number of selected specialty training positions. We should aim to achieve the nearly 1:1 ratio that has proved desirable and advantageous for other wealthy countries. Such policies are in place in Canada, the United Kingdom and many Western European countries. Government involvement will be needed. Entreaties have failed.
  2.  Voters must urge their elected officials to reestablish the pre-eminence of the primary care specialties in medical school graduating classes and post-graduate programs. Legislators could start byfunding more medical education and developing loan forgiveness programs for physicians who both train and practice as generalists. In several European countries, medical student education is supported by public funds and some provide free tuition. Creating more funded public health positions has had little effect on the supply of generalists, and few legislators are aware that primary care is struggling to survive.
  3. While reimbursement rates are determined to a large extent by physicians who are not generalists, the financial incentive should not be the only determinant of physician career choices. Improving the financial picture of primary care physicians will surely be helpful, but limiting some subspecialty training positions will be quicker and perhaps decrease the importation of non-U.S. graduates to fill available primary care positions (non-U.S. graduates were 53.8 per cent in the 2008 NRMP match for primary care).
  4. Reestablish the rotating internship for all graduates, allowing them to experience the full spectrum of medicine and its many practice options. This step could change the dubious practice of top students vying for less demanding, high-paying medical careers.
  5. Replace or reconstitute the membership of the Resource-Based Relative Value Scalegroup (RUC) that updates physician payments and is currently dominated by specialists.
Changing the physician specialty mix through implementation of the above policies will be a slow process. The current situation developed gradually over nearly 40 years. What seemed in the 1970s to be a chance to reduce reliance on state taxes and public funds has developed into a norm for medical education that has cost Americans trillions of dollars in added costs since the trend began. By comparison, some increase in public funding to achieve a primary care-based system through state legislative measures would be a bargain.
 
Over the years both medical training and practice have changed and so has the financing of medical education. The training of physicians became increasingly expensive at all schools but the state medical schools have experienced the greatest change in sources of funding. When supported largely by state legislatures, these schools had a clearly stated mandate to train doctors to serve the needs of their citizens. But as that mission became increasingly expensive, taxpayers and their legislators balked. Tuition and student indebtedness rose together. For at least the past 15 years many medical graduates have needed or have been attracted to higher-paying specialties to pay off debt incurred in school.
 
The U.S. population has experienced lower overall health status as measured by international standards. Health economists have identified various explanations for the stubborn rise in what Americans spend for health care compared to other industrialized countries. Surely there are many factors, but I propose one that’s been widely discussed but largely left out of serious debate -- changes in the funding of medical education.
 
In 1994, pediatrician Barbara Starfield of Johns Hopkins University pointed out that industrialized countries with a much larger proportion of primary care physicians enjoy safer, cheaper, more effective care than Americans, and also have better access to services. Her conclusions have been borne out by more recent studies. Countries that spend less and have better outcomes have a large base of primary care physicians.
 
Meanwhile U.S. state medical schools are essentially trapped in the current pattern by decisions resulting from anti-tax measures of 35 years ago. And few graduates avail themselves of rotating internships that would allow them to experience the professional and personal contacts and the non-monetary rewards of generalist practice.
 
We need more primary care physicians to fill this void: they are the workforce infrastructure of health care systems that function far better than ours. They are in critically short supply and open the possibility of cost savings resulting from the “wait and observe” option provided by continuity of care.
 
We need to begin by educating the public and our elected officials of the need for more state funding of primary care physicians and shut off the training of excess specialists who wield power over the payment process.
 
Dr. Fred Matthies is professor emeritus of UCLA’s medical school and active in the Portland City Club.

Comments

Well-stated, Dr. Matthies. The struggle necessary to break out of a subspecialty-driven medical education system began long before the last 15 years, however, as I can personally testify. It really began more than 30 years ago, as the funding changes for medical schools and the money available for specialized practice both took hold in the 1970s. The extreme debt loads of the last two decades' medical graduates just accelerated the problem and made it more intractable. Loan forgiveness, favorable treatment in underserved markets, and other key policy changes are needed. We don't need higher incomes (though those are needed for some fields) as much as we need lower barriers to making the choice of a primary care career: faculty who actually value, respect and encourage entry into those fields, lower debt loads through loan forgiveness and other support for education costs, and indeed a more appropriate allocation of residency slots that is less related to the financial goals of the academic medical center doing the educating, and more related to the needs of the community it should be serving.

Your suggestions will be of minimal help. The major problem is that the current practice of primary care is a nightmare. Correcting the financial imbalance would be nice but not enough to attract medical students. I retired from a primary care practice two years ago and have been smiling ever since. The amount of knowledge required to be a good primary care doctor is enormous but the medical group I worked for only valued my production. My chart notes were critiqued not for the quality of care I provided but for whether my coding maximized the reimbursement the group could achieve. And our much praised electronic medical record system led to a steadily increasing number of tasks that needed to be accomplished during each 15 minute visit. Any medical student who spends the time working with a primary care doctor will quickly realize that not only is the reimbursement inadequate but so is the quality of life. Perhaps the solution is to accept that the bottom line for a primary care doctor should be quality of care provided and not production. But this is the United States. It can't happen here.

Dr, Matthies raises some important points. I would add that some of them are especially important for Oregon over the next decade. Oregon needs to help OHSU and the newest Oregon Medical School Western University provide scholarship, loan forgiveness and other financial incentives for our current and future medical students if they spend 5 years after graduation in primary care. Oregon either needs to realign financial and non financial incentives to increase the percent of physicians into primary care and/or needs to expand the skill base and scope of practice for qualified nurse practitioner and PA's to rectify our current situation. I trust that our state health leaders and legislature will address this issue in the 2011 legislature and we Oregonians should support legislative candidates who will pledge to make this happen.

Interesting insight...do you think that by limiting the options of students and attempting to funnel them towards the primary care role will deter student from practicing medicine in the first place. Although monetary or financial gain should not be the primary reason to choose a career path, it certainly plays a major role. Also, what effect an online medical schoo has with these trends?