Need for Primary Care Physicians Increases with Health Care Reform

Oversight of patients by primary care physician to provide preventive care and coordinate care is essential in improving quality and controlling costs, according to an article in JS Online. Recent studies, however, continue to show a shortage of primary care physicians. What is contributing to the shortage of primary care physicians and what can be done to encourage medical students to pursue primary care? Researchers have provided some answers to those questions.

The Current Demand for Primary Care Physicians

For the sixth consecutive year, primary care physicians are at the top of the list for most hospitals, medical groups and other health care organizations recruiting physicians, according to a recent study by Merritt Hawkins. The most sought after primary care physicians were family physicians, general internists, and pediatricians. General internists play a key role in managing the care of middle-aged to elderly patients. Merritt Hawkins explains that in 1950, 50 percent of physicians were engaged in primary care and the other 50 percent were engaged in a handful of medical specialities. Today, however, only 32 percent of physicians are engaged in primary care, while 68 percent are engaged in one of more than 200 specialties. The study attributes this to (1) technical advances in medicine and payment models that reward procedures over consultations producing a system that is largely specialty driven, and (2) the imbalance in earnings between primary care physicians and specialists. Demand has increased due to population growth and aging, Merritt Hawkins said adding the current number of general internists being trained is insufficient to meet the demand generated by the aging population. In addition, many internists are choosing to practice as hospitalists or sub-specialize, further limiting supply.

Current Residents’ Career Paths

As reported in HealthDay, a study in the December issue of the Journal of the American Medical Association found that fewer medical students are choosing primary care and instead are choosing to become specialists. Of nearly 17,000 third-year residents surveyed, the researchers found that only 21.5 percent were planning on a career as an internal medicine doctor, including about 40 percent of students in a primary-care residency program and about 20 percent in a categorical residency program. The study also found that women were more likely to choose internal medicine than men, and U.S. medical school graduates were slightly more likely to opt for a career in internal medicine than international graduates. The researchers stated that the current medical training models in the United States are unlikely to produce sufficient numbers of general internists and primary care physicians.

Encouraging Medical Students to Choose Primary Care

Health Day provided insights from a number of physicians that provided suggestions for enticing medical students to choose primary-care careers. Dr. Colin West of the Mayo Clinic said “This may involve getting rid of some of the non-care-related demands of the job, such as paperwork and the routine time spent haggling with insurers about reimbursement.” Dr. Cynthia Smith, senior medical associate for content development at the American College of Physicians, noted that reimbursement is an issue. She said “Today’s primary-care physicians spend 60 percent of their time doing activities that are not currently reimbursed.” This includes following up with patients and other specialists and performing clerical duties. Dr. Martha Grayson, senior associate dean of medical education and a professor of clinical medicine at Albert Einstein College of Medicine in New York City, said debt forgiveness may help boost interest in primary care as many medical students have significant debt. Another issue is lifestyle. Many medical students are choosing careers with set boundaries on their time, such as the hospitalist track.

Another obstacle to encouraging medical students to opt into primary care is that over the course of their careers, primary care doctors make millions of dollars less than their counterparts in other specialties, JS Online reported. Although the income gap between primary physicians and specialists won’t lessen quickly and repaying student loans is an obstacle in drawing more medical students primary care, many primary care doctors may receive loan forgiveness when recruited by a practice of health system and primary care doctors have a better chance of finding a job, JS Online noted.

Medical School and Insurance Companies’ Actions

JS Online also reported that two Wisconsin medical schools are attempting to increase the number of primary care physicians. The Medical College of Wisconsin plans to open campuses in Green Bay and central Wisconsin in part to increase the number of students who want to practice in smaller cities and rural areas. The University of Wisconsin School of Medicine and Public created the Wisconsin Academy for Rural Medicine to recruit students from rural areas. In addition, many health insurers are taking steps toward increasing fees for primary care physicians. Wellpoint, Inc., the parent of Anthem Blue Cross and Blue Shield in Wisconsin announced an initiative to increase payments to primary care physicians for specific services and pay bonuses for meeting specific quality goals and reducing costs, JS Online said. Other health insurers such as United Healthcare are rewarding primary care physicians for meeting quality goals.

Forbes reported that Dr. Shalini Reddy, Associate Professor of Medicine at the University of Chicago and her colleague Dr. Julie Oyler, a University of Chicago interist, said that graduate medical education programs are working to make internal medicine more attractive. For example, starting in July of 2013, the University of Chicago internal medicine residency will begin a more concentrated outpatient experience by separating the inpatient experience from the outpatient.  Doctors will have four weeks of “inpatient only training” and two weeks of “outpatient and only outpatient so they have the experince of only that of a primary care doctor without the stress of the inpatient side,” Oyer said.

PPACA Provisions and Physician Fee Schedule

The Patient Protection and Affordable Care Act (PPACA) (P.L. 111-148) also has created incentives for medical students and primary care physicians. First, PPACA redistributed unused, Medicare funded residency slots to teaching hospitals that agree to use them with the most spots designated for primary care. In addition, beginning in 2011, qualifying primary care physicians will have a 10 percent increase in Medicare reimbursement and a two-year increase in Medicaid that requires states to pay primary care physicians that provide care to Medicaid patients at least Medicare rates beginning in 2013. Finally, under the Medicare Shared Savings Program (MSSP), accountable care organizations (ACOs) must show that they have a sufficient number of primary care physicians as part of the delivery system and have more control over care coördination, quality, and cost, the Merrick Hawkins study explained. In addition, the payment rates announced in the Physician Fee Schedule for calendar year 2013, provided for an increase in reimbursement for primary care physicians, while other physicians would see cuts in reimbursement.