ACP: How to fix the primary care problem in health care

The following is part of a series of original guest columns by the American College of Physicians.

by Steven Weinberger, MD, FACP

ACP: How to fix the primary care problem in health care Many would argue that lack of universal coverage is the primary problem with health care in the United States, accompanied by the logistical and financial difficulties of obtaining coverage for someone with a pre-existing medical condition. Others would argue that the primary problem with health care is financial, i.e. the fact that it represents one-sixth of the entire American economy, with projections that its share of the economy is only going to increase. I cannot argue with either of these positions; they both clearly represent major problems that must be addressed, as the Obama administration has continually stressed.

We must, however, remember another “primary problem” that is critical for access to high quality, well-coordinated care. The “primary problem” to which I am referring is the shortage of primary care physicians, a challenge that has been well-recognized by advocates for health care reform and reinforced in Massachusetts, where mandated coverage has uncovered a shortage of primary care physicians to care for the state’s residents. It is particularly apropos to emphasize this problem at the present time, since October 19-23 was designated National Primary Care Week.

Rather than focusing on the statistics documenting the need for more primary care physicians, I would like to concentrate on “the fix.” Unfortunately, no single magic bullet will correct the problem, and approaching a solution will require a multifaceted approach. Even if all of these strategies were used to maximal effectiveness, we would not see an overnight fix, based on the length of the pipeline to train and produce new physicians.

I believe there are three overarching strategies for fixing the “primary problem” and the associated access to care: 1) increasing the overall number of physicians trained; 2) increasing the percentage of physicians who enter primary care; and 3) increasing the number of alternative providers besides traditional primary care physicians. At the same time, we must avoid exacerbating the problem by losing physicians who are currently in primary care practice. Recognizing their importance and improving their lot is essential for their retention.

Increasing the number of physicians trained.

The Association of American Medical Colleges (AAMC) has called for a 30 percent increase in the number of medical students. Although creation of new medical schools and increases in enrollment at existing medical schools are making progress along these lines, the number of available residency training positions continues to be a bottleneck. Unless more positions are funded (ideally by commercial payers in addition to federal funding sources), more students in American medical schools will not increase the number of physicians trained, but rather only squeeze out international medical graduates from residency training positions.

Increasing the percentage of physicians who enter primary care.

The oft-quoted figure of 2 percent of medical students intending to enter general internal medicine is a wake-up call for the need to make primary care more attractive to medical students and residents. This requires not only modifying the reimbursement system for primary care and “patient-centered medical homes,” but also changing models for practice that ultimately result in fewer hassles, more time to spend with each patient, and greater professional satisfaction. We must also change the culture of training environments to elevate the prestige of a primary care career and avoid the oft-provided message to students and residents discouraging them from entering primary care.

Increasing the number of alternative providers.

Medicine needs to become more of a “team sport,” with primary care physicians leading teams that include greater numbers of non-physician providers. We need to generalize successful “best practice” models in which each team member can focus on providing types of care appropriate for his or her level of training and experience. Additionally, it is reasonable for some subspecialists to expand their responsibilities by taking on a broader, primary care role for many of their patients who have a chronic illness within their subspecialty.

As health care reform proceeds, it is incumbent upon legislators, physician leaders and practitioners, and those responsible for training the next generation of physicians to address the “primary problem” and avoid its becoming the Achilles’ heel of our health care system.

Steven Weinberger is Deputy Executive Vice President and Senior Vice President, Medical Education and Publishing, of the American College of Physicians. His statements do not necessarily reflect official policies of ACP.

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  • jsmith

    This analysis misses the point. Here is a better analysis: The main cause of the PCP shortage is the salary discrepancy. If that is not ameliorated, increasing residency slots or improving quality of professional life will be ineffective. The second most important cause of the PCP shortage is poor working conditions. This is important to address, but will be insufficient without more money for PCPs.
    Readers interested in a sophisticated analysis for the PCP shortage should read the white on the physician workforce published 3-1-09 by the Robert Graham Center. It’s available on the internet.

  • anonymous

    disagree that the main cause of the shortage is the salary discrepancy. it is certainly one cause, but it is joined by many other items which (to me) are more insulting than making $100k.

    the other factos are paperwork hell, preauthorization hell, prescription hell, lack of respect from patients, perhaps related to not having enough time to spend with patients while still performing quality measures whether or not those are problems for the patient in front of you.


  • R Watkins

    Jsmith is correct. 99% of the problem is inadequate payment for services; 99% of the solution is payment reform.

  • Rezmed09

    Subspecialists taking on Primary Care responsibilities only occurs when it is to their advantage : Ease of patient management or good insurance. I am afraid the patients not pickup for primary care by subspecialists will merely be the poor, complicated, time consuming and less lucrative.

  • anonymous

    I agree that fixing the salary discrepancy will go a long way to increasing primary care numbers. Many PMDs in my area have given up on primary care (or reduced their primary care hours) and started doing botox and laser (I know because I am one of these “sell-outs”). I can’t speak for others, but I personally might be persuaded to increase my hours again if this is fixed.

  • Tom

    This is about what I would expect from the ACP, i.e., that if they are just allowed a free hand in academia, everything will be better. To fix primary care, there are two things that need to happen:
    1. Pay PCPs enough to incentivize them to take the time to see a patient as a person, not a problem.
    2. Let PCPs practice medicine, not social work. Patients bear the responsibility to take care of themselves. It is not an efficient use of resources to use a physician to fill out paperwork for no charge.

  • anonymous

    to those who think fixing the salary discrepancy, how much do you think the salary would have to average to be ‘right’?

    secondly, does it have to be right where you want to live? iow, people who stay in MA and earn 80k when they could be in Louisiana and make let’s say 170k. Is that something the system has to fix or is that a decision made by the MA residents to make less money and deal with the tradeoffs?

  • jsmith

    Anon,The right salary level must be determined empirically. It is that level that will result in an adequate number of PCPs. That number will of course vary by community and job specification. Most areas of the US seem to be quite under that number at the moment.

  • anonymous

    ballpark the appropriate primary care salary for me. most areas are underserved with specialists, according to studies, despite the claims that their salaries are too high.

    maybe we should control the distribution rather than the income. if we mandate jobs by government allocation to geographical regions, we might get the most effective ‘bang for the buck’ in health care cost controls.

  • Tom

    Anonymous, hate to disappoint you, but there is no number, not even a ball park. My recommendation, for you, would be to stop trying to control the uncontrollable. Let the market work. It is the most efficient distributor of talent, if there are no distorting influences. What you are suggesting comes down to population control, and I don’t think you want to go there. Telling people where they can live and work has been tried before, and it didn’t go well. Centralized planning sucks for those under its control. The question for you is, do you see yourself as the party under control, or as the controlling party? No thanks, commisar.

  • anonymous

    respectfully, how can there not be a ballpark ‘right’ income if the argument is that income is not appropriate?

    “1. Pay PCPs enough to incentivize them to take the time to see a patient as a person, not a problem.” i don’t know how you can say that, and then say there is no ballpark figure that would achieve this, at least as a policy level consideration.

  • John Ryan

    There is nothing fair about how primary care (or physician) salaries are determined. My payments for each encounter is regulated by Medicare & the insurers. I am forbidden to charge the patient more, no matter how much more service I give the patient, how complex their condition is, or how few doctors provide that service. Combine that with the tendency for insurers and our government to balance their wasteful management expenses by cutting payments further, and the smart incoming medical graduates avoid primary care. What is a fair income? — what the market will bear. Primary care in short supply? You’ve got to pay more until the shortage corrects itself. In most medium sized communities with a tight supply of IMs and FPs, patients would probably pay at least 50% above what Medicare and the PPO insurers have forced down the price down to.

  • Aestivate99

    I’m sorta behind the person who said let the market work. Speaking of working conditions, I have also wondered why some PCPs are in their own practice with nice offices, spacious exam rooms, not lavish but welcoming waiting rooms, while others work under contract to someone else with no office just a tiny little stand up space in the hall with a computer, teeny tiny obviously cost cutting exam rooms, barren waiting room and often surly staff? As a patient I have experienced both and I got the hell out of the second situation as fast as I could. I know both are subject to Medicare and insurers but how did the first group achieve autonomy and why would anyone want to work in the second environment? Made me lose respect for them.

  • Aestivate99

    One more comment. I’m from Texas and we haven’t got any docs in a lot of rural areas, much less PCPs. I don’t think a big salary will change that.

  • Coalition for Patients’ Rights

    Thank you for recognizing that healthcare professionals, who are not doctors of medicine (MDs) or osteopathy (DOs), play a large role in addressing our nation’s “primary care problem.” The Coalition for Patients’ Rights™ (CPR) represents more than three million licensed healthcare professionals committed to ensuring comprehensive healthcare choices for all patients.

    Unfortunately, there is a concerted effort led by the AMA’s Scope of Practice Partnership (SOPP) to limit the care that healthcare professionals (who are not MDs or DOs) are properly educated, legally licensed and/or fully certified to provide.

    We hope that divisive efforts among healthcare professionals will be eschewed in favor of efforts to meet the growing needs of our nation’s patient population for safe and reliable care. Dr. Weinberger gets it right when he recognizes the role of non-MDs or DOs in filling the gaps that exist.

    If you would like to learn more about CPR’s providers, visit CPR’s Web site at
    - The Coalition for Patients’ Rights™

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