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.
- 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.
- 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.
- 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).
- 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.
- 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.
Jan 6 2010