Address the primary care shortage and make the AMA more relevant

It saddens me to proclaim that the American Medical Association (AMA), the once-venerable organization that has advocated for the interests of physicians and patients alike since its founding in 1847, is on the precipice of irrelevancy.  Membership has dwindled such that only 1/4 of physicians now belong to its ranks.

The attendant decrease in social and political influence that accompanies this decrease in membership arguably compromises the ability of the AMA to execute its mission statement: “To promote the art and science of medicine and the betterment of public health.”

Now more than ever, as we witness the transformation of healthcare delivery in the United States, there exists a need for a strong voice to represent the collective wisdom and experience of physicians in this country.  Sadly, this is lacking at this pivotal time.

Regardless of one’s political leanings, there appears to have developed a broad consensus among stakeholders that:

  • the cost of healthcare in the United States is too high
  • there are not enough primary care physicians in the United States
  • relatively low compensation is one factor motivating medical students to choose more lucrative specialties as careers

If our goal, as a society, is to increase the number of medical students who choose primary care then we must commit to paying these physicians fairly.

The AMA’s Specialty Society Relative Value Scale Update Committee (RUC) is advertised as representing the entire medical profession.  It consists of 31 members, with 21 of these appointed by medical specialty societies.  At any one time, no more than 5 of its members (at most) represent primary care.  It is this committee that is tasked with allocating a work relative value unit to every professional activity performed by physicians.  These recommendations, which are made annually, are then forwarded  to the Center for Medicare and Medicaid Services (CMS) and also serve as the template for Physician reimbursement by commercial payers.

Since every committee is a reflection of its membership, the recommendations of the RUC (not surprisingly) allocate a higher value to the activities performed by specialists and subspecialists compared to those performed by their primary care counterparts.  The downstream effect is reduced reimbursement to primary care physicians by both CMS as well as private insurers.  To begin to address this significant differential in compensation between specialists and primary care physicians, the composition of the RUC must change.  Otherwise the AMA risks being indelibly tarnished as an organization that serves as a lobby for specialists and subspecialists to the exclusion of our primary care brethren in the trenches.

Revamping the membership of the RUC so that half of its voting members represent primary care would represent a bold attempt at acknowledging that primary care physicians have been under appreciated (and under compensated) for far too long in our current healthcare system.  So as not to silence the voice of any specialty society that is currently privileged to serve on the RUC, the committee can instead be enlarged via the addition of positions that would be reserved exclusively for primary care physicians.  The consequences of such a restructuring of the RUC would be clear: as greater value is placed on activities performed by primary care physicians compensation would increase, followed by an increase in the number of medical students who choose to enter primary care.  In time, the shortage of primary care physicians in the United States would be alleviated.

Such a change would demonstrate that the AMA (both its leadership as well as membership) is serious about addressing the dearth of primary care physicians in the United States for “the betterment of public health” (as per its mission statement).

Such a change would also secure the AMA a continued place at the table of stakeholders as our healthcare delivery system undergoes dramatic transformation in the 21st century.

James M. Pritsiolas is a nephrologist and can be reached on Twitter @Nephro_Doc.

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  • Steven Reznick

    The authors suggestions of enlarging the RUC to give primary care significantly more votes is a solid one. While I have supported my state and county medical society I will not give the AMA money until they address the primary care issues fairly. The RUC has been dominated by specialty lobbying for years and frankly with no representation most independent internists will not give the AMA $500 plus contributions to their political action committees which vote against primary care interests .

  • Dr. Drake Ramoray

    Family medicine doesn’t fill. In 2013 96 % of open FP slots filled. In 1998 there were about 3200 residemcy slots that have now decreased to 2555 by 2009 because programs closed secomdary to lack of demand. Furthermore most schools and statistics count IM positions as primary care yet most of them specialize.

    Our system undervalues and underplays primary care, so new doctors specialize. In the same time frame above anesthesia spots have quadrupled.

    In the citation below the IM categorical doesn’t count the docs like myself that chose to specialize. Some statistics and medical schools also count OB/Gyn as primary care and pediatrics as primary care.

  • PoliticallyIncorrectMD

    What are you smoking? Assigning economic values to different activities is deciding who gets how much money. PCP residencies do not fill, and of those initially enrolled many go streight to specialization after graduation, mainly because of financial incentives.

    • VKA

      See my comment above. There were over 4000 applicants in Family Medicine alone for 3000 positions. Pediatrics is similar.

      Many IM doctors do go straight into specialties- but relatively few FM doctors.

      Compensation may be unfair- but raising compensation will do relatively little to push more doctors towards Primary Care (outside of the admittedly large case of internal medicine doctors choosing general practice or specialization). Adding an extra 1000 residency spots in Family Medicine will immediately and definitely boost the number of PCPs in 4 years.

      • Dr. Drake Ramoray

        I teach medical students and residents. Almost none of them want to go into primary care. This has been my experience both personally when I was a med student over 10 years ago, now when I teach students and residents, as well as across multiple states. None of them want to go into Endocrine either (the pay isn’t that much different) and the chronic management of diabetes is the burden we bear (especially with the transition to pay for performance).

        There is no DOMESTIC demand for primary care amongst medical students and residents. More headaches, more red tape, more prior authorizations, worse hours, less pay. It really isn’t that hard to figure out. As above I don’t dispute that a lot of FMG’s want spots to practice in the US but this creates a system not very different from the H1b visa issues that the techies in computer science/engineering that you have to deal he foreign trained docs would do just about anything to practice in the US. They will also take a lot less pay, of course they don’t carry the debt burden that US grads do either.

        Primary care is the red headed step child of medicine, that without changes will be run by PA’s, NP’s, or if you have your way FMG’s. US trained doctors won’t do it, I see them every day. If you spent 5 minutes with a 3rd year medical student class you would see it too.

      • NewMexicoRam

        Some of those applicants to FP residencies are students who actually want to match with a specialty, but include a primary care spot to fall back on, “just in case.”

  • NewMexicoRam

    Uh, primary care is at least 85-90% in the Evaluation and Management section of the CPT book. Specialists vary, but most would be in the 60-70% procedure range. It only takes weighting the values towards procedures and you have given the favor towards the specialists.
    So, it’s easy. Lower the procedure values, increase the E&M values, and voila, you have a fairer reimbursed position for primary care.
    But, that’s like trying to get Congress to vote for malpractice reform, considering 80% of Congressional members are attorneys.

  • VKA

    In 1997 there were too many physicians entering the field- specifically, there were too many specialists. There arguably still are in some cases. The supply of general surgeons at the time was way more than what was needed, especially as medications took away a significant part of their business (surgical volumes have fallen steadily for much of the past two decades).

    1997 was 17 years ago. The AMA got burned when Congress acted stupidly (big surprise) and froze the GME slots in their current ratios (rather than acting logically and cutting specialist slots while retaining Primary Care ones).

    Right now, the AMA is in full swing with it’s SaveGME campaign, to bring them back and undo it’s mistake. It’s been pushing for more GME slots for at least the last 5 years.

  • Dr. Drake Ramoray

    FMG’s. I believe it is called the American Medical Association. Snarkiness aside, no America doctors want to do primary care. Only 9/144 UVA grads went into FP in 2013. That’s over a 50% reduction. Hardly any American trained physicians want to go into FP or Primary Care. Grads from UA can do just about anything, it’s a top notch school but hardly any want to go into primary care.

    America is still a great place to be, of course foreign docs want to come, they will depress wages further, just like the H1b visas in tech companies.

  • NewMexicoRam

    No, I knew fellow students who wanted a specialty, but put a FP residency somewhere down the list, so as to not look too disinterested, but keeping their top choices for the specialty at the top.

    • brettmd

      Why did they rank FP residencies if they didn’t think such a job would be good for them or their families? If some applies and interviews at a program then it appears they want to go there, regardless of whether it is their first choice. Some probably wanted to be NBA players but weren’t drafted so they went to medical school. Does that mean they are not interested in becoming a doctor. It appears that you are promoting a narcissitic philosophy by suggesting that only a first choice is acceptable and interesting.

      • NewMexicoRam

        Back in the day, you could start in a FP residency and transfer to a different specialty after one year. That’s not possible anymore.

  • PoliticallyIncorrectMD

    Why would you join the group that only claims to represent physicians’ interests while doing completely opposite in practice?

    • Doug

      Because how can you hope to ever exert any modicum of change on a system if all you do is throw comments from outside the house instead of going in and sitting at the table?

      • PoliticallyIncorrectMD

        I am interested in changing the system, not the corrupt organization that only serves its own financial interests ( and this is not just my opinion). Why can’t we sit at our own table?

        • Margalit Gur-Arie

          You can, but you will have to build the table, and shove it into the room, because there is none offered on a silver platter.
          I know I sound like a broken record, but you guys need to organize, or Doug is right….

          • PoliticallyIncorrectMD

            Building sound like fun!!!! Have any blueprints in mind?

          • Margalit Gur-Arie

            Well, yes, as I have said here many times, but nobody seems to think that this is a worthwhile endeavor…
            You have to create a grassroots movement; leave the politics out; leave the money out; leave everything divisive out; define the one common ground that most everybody can rally behind; use the web; use word of mouth; use the media; get people excited; build critical mass; and when the table is all built and ready, don’t be afraid to stand up and pound your fist on it….. There is no other way.

  • heartdoc345

    IM residencies fill only because it is a stepping stone to more lucrative subspecialty training. Read “the Dean’s lie.”

  • Deceased MD

    Do you work for the AMA?

    • Guest

      No, but why would it matter if I did? My arguments are my own- not paid for by anyone else. Trying to tear me down with ad hominem attacks is an indication that you find my logic difficult to argue with.

  • Deceased MD

    I would not say there is a shortage. We are systematically being killed off. There is a difference.

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