The United States spends more on health care per capita than any other country in the world — yet health outcomes continue to fall short. In order to close the spending gap with other countries, United States health care policy must focus on reducing costs. While a variety of suggestions have been put forth by economists and medical professionals on how to cut spending and improve health, one recommendation by Dr. Suneel Dhand addresses both problems simultaneously — strengthening the primary care workforce.
Primary care providers are a critical part of the United States health care system and play a unique and significant role in supporting patient health. They offer comprehensive, continuous care at a depth not possible with other medical providers who see patients less consistently. Being treated by a primary care provider has been proven to be positively associated with more effective preventive and diagnostic care and a range of better health outcomes, including less premature mortality, longer lifespans and an overall more equitable distribution of health in populations.
The advantages of seeing a primary care physician go beyond better health outcomes. Studies have shown that there is a significant association between regular primary care visits and less utilization of more expensive health care services, including visits to the emergency room and hospitalization. An illustrative study amongst Colorado Medicaid patients found that those who were enrolled in a program where they regularly visited a primary care physician saw a 15 percent decrease in health care costs compared to patients without the same provider access. There is strong evidence that access to and visits with a primary care provider can lower the costs of the United States health care system and significantly impact patient and population health.
While improving the primary care workforce will have both economic and health benefits, the United States has actually been experiencing a shortage of primary care physicians for many years because of increasing provider demand and decreasing salaries relative to other health care professions. The problem is further exacerbated by increases in health care needs due to population growth and aging Baby Boomers and increases in health care utilization due to insurance expansion. This has led researchers to predict a primary care physician deficit of approximately 50,000 by 2025.
One of the reasons primary care is a less attractive path for health care professionals is because wages are notably lower than in other fields of medicine. This salary disparity is even more acute in rural and low-income areas. Primary care providers make less in rural areas compared to urban ones And they are paid less to treat patients with Medicaid, both of which disincentive primary care physicians to work in these settings. Lower wages are of particular concern for physicians who graduate from medical school with debt and require salaries that will help them adequately pay off their loans.
Another important consideration is the significant lack of racial and ethnic diversity among primary care providers and the medical profession in general. If we are to improve our primary care workforce, we need to do so in a way that benefits all patients and is reflective of the people being served. Currently, people of color represent over 25 percent of the United States population but only 10 percent of the health care workforce. This disparity is important not just for inclusivity but also because people of color in the medical field are more likely to become primary care physicians and practice in medically underserved communities (typically low-income and rural areas). Perhaps if we diversify the primary care workforce, we will also increase the number of primary care physicians in these areas.
To drive down health care costs by creating a more robust and diverse primary care workforce nationally, there needs to be an increase in federal policies that institutionalize pathways from medical school to primary care and a shift in federal spending to support communities with high medical need and low primary care access. One suggestion is to create financial incentives that encourage medical students to select primary care practice. This could be in the form of federally funded stipend programs that provide monetary support with the stipulation that recipients continue careers in primary care. Such stipends could also help diversify the workforce by decreasing the economic burden of medical school and making it more accessible for low-income people of color. Linking scholarships to desired outcomes through education/profession pipelines have increased the robustness and diversity of other industries. The California Social Work Education Center’s Title IV-E stipend for California master of social work students is a federally funded program that requires graduates to dedicate two years of post-graduation employment to a public child welfare agency. The stipend has infused public child welfare agencies with hundreds of new workers annually, and almost 70 percent of stipend graduates are students of color.
Another possible solution is to increase stable funding for institutions that provide primary care services to high need populations. Medically underserved urban and rural areas are largely serviced by primary care physicians in community health centers, and federal funding for these centers is cyclical and uncertain. Establishing a permanent funding stream would support continuity of care for patients and potentially recruit new primary care providers with guaranteed, sustainable salaries.
Strengthening our primary care workforce will have important financial and health benefits for individual patients and the United States economy as a whole; therefore it is necessary that we reverse the decline in primary care physicians before the shortage becomes more severe. Policy solutions must make primary care careers feasible for doctors, service more consistent and sustainable in urban and rural areas, and foster a more diverse and inclusive workforce.
Nicole Liner-Jigamian is a social worker and public health student.
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