Health Care 2009
A Lifeline for Primary Care
N Engl J Med 2009; 360:2693-2696June 25, 2009DOI: 10.1056/NEJMp0902909
Primary care in the United States needs a lifeline. In 2009, for the 12th straight year, the number of graduating U.S. medical students choosing primary care residencies reached dismally low levels.1 Overloaded primary care practices, whose doctors are aptly compared to hamsters on a treadmill, struggle to provide prompt access and high-quality care. Three major factors contribute to this crisis. First, primary care physicians earn far lower incomes than procedural specialists, reducing career attractiveness for medical students with high debt burdens. Second, the work-related stresses felt by primary care physicians tags primary care as the career with more work at less pay. Third, medical education favors training in non–primary care fields. Rescuing primary care requires national policies that address all three issues.
Growing clamor that primary care's plight may undermine important goals of health care reform has Washington policymakers concerned. Primary care has featured prominently in recent hearings held by Senate and House committees, and the New York Times has quoted President Barack Obama as saying that “we're not producing enough primary care physicians.” The administration and Congress understand that after Massachusetts expanded health insurance in 2006, many newly insured adults were unable to find a primary care physician, raising the specter of theoretically universal access to care but no primary care to which to have access. Policymakers are also familiar with studies showing that health systems anchored in primary care have lower costs and better quality.2
A bold federal initiative to revitalize primary care is urgently needed as part of health care reform legislation. This initiative must be comprehensive, simultaneously addressing three interrelated issues: physician payment, practice infrastructure and organization, and the training pipeline (see tableRevitalizing Primary Care.).
For the first of these, physician payment, Medicare and most private insurers currently use the resource-based relative value scale, which was purportedly designed to reduce the payment gap between primary care physicians and procedural specialists. That gap, however, continues to widen. Under Medicare's sustainable-growth-rate approach to containing expenditures, spending on physicians' services remains a zero-sum game: if expenditures for all physicians' services exceed a congressionally set target, physicians' fees are supposed to decline. Because of disproportionately large increases in spending growth for advanced imaging, tests, and minor procedures, physicians whose income depends on evaluation and management (cognitive) services, especially primary care physicians, have seen a relative reduction in Medicare revenues.3 And commercial health plans frequently amplify this gap between primary care and specialty payment.
Congress is considering options for reducing the Medicare payment gap. For the short term, the Medicare Payment Advisory Commission (MedPAC) has recommended that Medicare primary care evaluation and management services receive an increase of 5 to 10% next year.4 Congress is exploring such an increase, perhaps also for additional years. To close the income gap, annual increases of this magnitude would need to compound for several years, and private payers would have to follow suit. Medicare would also have to split physicians' services into separate buckets so that primary care payments would not be reduced as a result of rapid growth in expenditures for procedures and imaging.
An additional strategy to make primary care financially attractive would be providing more relief from medical education debt for clinicians entering primary care. The stimulus package — the American Recovery and Reinvestment Act of 2009 (ARRA) — included expanded funding for the National Health Service Corps, which provides debt-relief opportunities for primary care physicians. Congress is considering further growth of the corps.
For the longer term, Congress is weighing alternatives to fee-for-service compensation of physicians. Currently, reimbursement for office visits does not capture many activities that primary care practices must perform for their patients, especially those with chronic conditions. Under the Medicare Patient-Centered Medical Home demonstration, additional payments would be made to qualifying practices for care-coordination activities, including communication with patients and families by telephone and secure e-mail. Even more ambitiously, Congress may expand the modestly successful Physician Group Practice Demonstration for primary care–oriented integrated care systems, such as the Geisinger Health System and Kaiser Permanente. Under this approach, groups would be rewarded for improved performance on quality measures and assessments of patients' experience by being allowed to share in the savings if costs for their Medicare patients were lower than projected. Under both of these approaches, primary care physicians should receive higher incomes. Moreover, these models provide resources and incentives for enhanced practice capabilities and team orientation to make primary care practice more satisfying and manageable.
Payment reform is a necessary but not sufficient measure for revitalizing primary care, which also requires a modernization program for the second piece of the puzzle — practice infrastructure and organization — akin to federal infrastructure investments to shore up aging bridges and outmoded electrical grids. Most primary care physicians practice in small offices and clinics and cannot afford major capital improvements.
The most pressing infrastructure need is health information technology (HIT). Governments in several European countries equip all primary care practices with interoperable, ambulatory care–focused electronic health records that allow information to flow across settings to enhance the continuity and coordination of care. The ARRA included $19 billion for HIT but did not specify how these funds should be apportioned; it is essential that a substantial share be channeled toward primary care electronic health records.
Yet primary care needs more than computer chips and keyboards. Primary care clinicians require technical assistance to reorganize their practices into modernized medical homes, which will entail the formation of teams to assist physicians in providing proactive preventive and chronic care, the institution of same-day appointment scheduling, the substitution of e-mail and telephone encounters for face-to-face visits when clinically appropriate, and improvement of the coordination of care with specialists, hospitals, and other service providers. Recognizing these needs, Congress included a section in the ARRA calling for the creation of HIT regional extension centers to assist practices and hospitals in implementing HIT. This model draws from the Department of Agriculture's Cooperative Extension Service, a collaboration among federal and state governments, agricultural experts at land-grant universities, and farmers. Extension field agents in every county provide technical assistance to local farmers, spreading agricultural innovations. Believing that what worked for family farmers may also work for family doctors, Congress is considering broadening the scope of a health-oriented extension program beyond HIT to facilitate more profound reorganization of primary care.
The final area requiring action is federal funding of medical education. Medicare spends $8.8 billion annually on graduate medical education (GME), almost all of which flows to hospitals rather than directly to residency programs. Appreciating that this payment mechanism inhibits training in nonhospital ambulatory care settings, which is critical for the development of primary care skills, MedPAC and the Council on Graduate Medical Education are calling for more flexible approaches to Medicare GME payment.5 Advocacy groups for family medicine have gone further and proposed that Medicare GME funding for primary care residency training be wrested from hospital control and paid directly to residency programs, raising the politically charged question of whether GME funding should fundamentally be payment for medical education or a subsidy to hospitals.
The federal government also administers smaller but strategically important programs supporting primary care education under the Public Health Service Act: Title VII (for physicians, physician assistants, and dentists) and Title VIII (for nurses). Despite research documenting these programs' effectiveness, Title VII training funds were reduced from $88.8 million in 2005 to $41.3 million in 2006. The ARRA provided $200 million in one-time funding for Title VII and Title VIII programs, and Congress may increase the base level of funding in the 2010 appropriations bill. Far-reaching medical-education reform would redirect a substantial portion of Medicare's GME billions to strengthening primary care residencies and preparing residents to lead the implementation of innovative models of primary care.
This triad of reforms to primary care policy would result in a comprehensive and interlocking solution to the causes of distress in primary care. Reducing the payment gap would help to refill the pipeline of physicians going into primary care, as would reform of training programs. Changes in reimbursement would pave the way for practice reorganization and be symbiotic with a technical-assistance program. Practice reorganization, in turn, would improve the satisfaction, performance, and productivity of the primary care workforce.
As it writes health care reform legislation, Congress is deliberating over measures that would offer a three-stranded lifeline to rescue primary care. Successfully weaving these strands together is a political challenge, particularly if shifting resources to primary care is viewed by specialists and teaching hospitals as coming at their expense. But for health care reform to succeed in improving access, quality, and affordability, Congress and the Obama administration must make the primary care lifeline strong; otherwise, they risk watching primary care go under.
No potential conflict of interest relevant to this article was reported.
Dr. Bodenheimer is a professor at the Center for Excellence in Primary Care in the Department of Family and Community Medicine, and Dr. Grumbach a professor and chair of the Department of Family and Community Medicine at the University of California, San Francisco, School of Medicine, San Francisco. Dr. Berenson is an institute fellow at the Urban Institute, Washington, DC.
National Resident Matching Program. Advance data tables: 2009 main residency match. (Accessed June 4, 2009, at http://www.nrmp.org/data/advancedatatables2009.pdf.)
Report to the Congress. Medicare payment policy. Section 2B. Washington DC: Medicare Payment Advisory Commission, March, 2009:77-128. (Accessed June 4, 2009, at http://www.medpac.gov/documents/Mar09_EntireReport.pdf.)
Nineteenth report: enhancing flexibility in graduate medical education. Rockville, MD: Council on Graduate Medical Education, September 2007. (Accessed June 4, 2009, at http://www.cogme.gov/19thReport/default.htm.)
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