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

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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