Background Brief

Issue

The United States currently faces a shortage of primary care professionals that threatens to develop into a major crisis if not addressed. 

Primary care comprises four main features: [1]

• A first contact for any new health issue or need
• Long-term, person-focused care
• Comprehensive care for most health needs
• Coordination of care when it must be received elsewhere (i.e. with a specialist)

General practitioners, general internal medicine practitioners, family physicians, and sometimes general pediatricians are considered primary care physicians. [2]  Other health care providers, such as physician assistants (PAs), nurse practitioners (NPs), nurses, and health coaches or care coordinators, may also provide primary care.  Care delivered with an orientation toward primary care has been found to be associated with more effective, equitable, and efficient health services; residents of countries more oriented to primary care report better health at lower costs. [3]

60 million Americans, or nearly one in five, lack adequate access to primary care due to a shortage of primary care physicians in their communities. [4]  Very few new physicians today are choosing to enter primary care: whereas fifty years ago, half of U.S. doctors practiced primary care, just over 30% do today, and just 8% of the nation’s medical school graduates enter family medicine compared to 14% as recently as 2000. [5]  People who are uninsured, low-income, members of racial and ethnic minority groups, or living in rural or inner-city areas are disproportionately likely to lack a usual source of care (USC)—a key indicator of access to a primary care provider. [6],[7]

Many experts believe that this skewed distribution contributes to overspecialization of care and fragmentation and inefficiency in the health system; for example, more than half of specialist visits are for routine follow-up, a misuse of expensive care. [8]  Furthermore, a higher ratio of primary care physicians to population is associated with lower mortality rates while a higher ratio of specialists to population has been correlated with higher mortality rates, [9] perhaps because patients with a usual source of primary care tend to use more preventive health care and have health problems treated at a less advanced stage.

Background

The shortage of primary care physicians is fostered by the current payment system.  The existing fee-for-service compensation system pays physicians based on the volume of care they deliver, providing financial incentives to perform more procedures rather than providing counseling, diagnosis, or dispensing prescriptions.  Because primary care doctors spend relatively less time doing procedures,[10] this reimbursement system results in a wide income disparity between family physicians, whose annual income by one estimate averages $173,000, and those practicing specialties such as radiology ($391,000) and cardiology ($419,000), Graduating medical students faced with repaying loans of averaging over $100,000 may be more inclined to enter a higher-paying specialty. 

Due to their lower salaries, primary care doctors often take on more patients than specialists to make ends meet. Studies indicate that graduating medical students perceive the lifestyle associated with primary care physicians as unfavorable and requiring more hours and less predictability than specialties, factors contributing to low job satisfaction--another major driver of the primary care shortage. [11]  Primary care physicians may enter the field with the goal of forming long-term relationships and coordinating care for patients and instead find themselves confronted with the realities of back-to-back appointments, long hours, and frustration and stress on the part of patient and doctor.  Particularly as more women enter the field of medicine and focus more on work-life balance, many doctors desire greater flexibility and control over their lifestyles; some specialty practice affords more potential for part-time work and fewer on-call hours. 

Policy to Address

In general, proposals to address the primary care shortage focus on increasing the efficiency of a physician’s time and adjusting compensation. 

• Teams – Primary care physicians currently perform many duties in addition to clinical care, such as securing social supports, administering care that could be provided by other clinicians, or coordinating discharges and follow-up care.  Some current proposals to address the primary care shortage call for a team-based model of care, where physicians would act as “team leaders” and see far fewer patients per day, spending the rest of their time consulting with team members, making physician-level phone calls and emails, and ordering medication changes.  Team members would be nurses, other medical professionals  or medical assistants retrained to be “health coaches,”.  Team member responsibilities would include contacting patients and responding to their questions and concerns and in some instances, routine management of chronic diseases.  Phone and email consultation would decrease the demand for visits, keeping costs down and restoring more balance to providers’ workloads.
  
• Adjusting physician payment – The current physician payment rates place lower value on office visits and other evaluation and management aspects of primary care, compared to technology and procedure services.  Current  physician payment reform policies under consideration would  pay primary care doctors’ for the broad level of responsibilities they conduct rather than simply the number of procedures performed.  Though many advocate for value-based compensation over volume-based payment and/or the integration of pay-for-performance programs into a fee-for-service system, others worry that the lack of concrete outcome goals in primary care makes this impractical. One proposal to fix payment while taking performance into account is for a system of a risk-adjusted “base payment,” supplemented by a risk-adjusted “bonus” upon the achievement of goals in cost, quality, and patient satisfaction. [12]  However, it has been found that primary care physicians often respond to wage increases by decreasing the number of patients they see.  Thus, while increasing compensation is an important facet of addressing the primary care shortage, doing so will not single-handedly solve the problem.
  
• Resources for technology, learning, and continued improvement – The American Recovery and Reinvestment Act of 2009 (the federal economic stimulus package) provided $19 billion for the purchase of health information technology (HIT), which is meant to encourage medical practices to adopt more integrated and efficient IT systems to improve coordination of care and ease of communication between offices.  Because many primary care physicians work in small or solo practices and lack a system for keeping up with technology and best practices, some propose establishing a cooperative extension service to train practices in HIT and other technology that would be modeled on the U.S. Department of Agriculture’s Cooperative Extension for farms.  These organizations would provide the infrastructure for local learning communities and practice, as well as a support network for primary care practices. [13]
   
• Increasing the network of federally funded community health centers – Community health centers (CHCs) provide health care homes, or centers for a steady health care provider, coordination of care, and a large variety of health and welfare services.  CHCs have been associated with a host of positive health outcomes and focus on primary care to underserved populations, and often work with multidisciplinary teams that may include physicians, PAs, NPs, nurses, dentists, dental hygienists, behavioral health providers, case managers, and health educators.  By supporting primary care physicians and coordinating patient care efficiently, CHCs provide a model for primary care in general.

Potential Hurdles

The changes to solve the primary care shortage are neither simple nor would have immediate results.  Due to the long time periods required to train new physicians, nurse practitioners, and physician assistants, it is estimated that current legislation with incentives to increase the primary care pipeline would not fix the problem for at least the next eight to twelve years.  Health reform that provides universal or near-universal insurance could exacerbate the existing shortage as more patients would have access to care and seek out primary care professionals, which could lead to long wait times.  Still, these obstacles are relatively short-term compared to the potential long-term consequences if action is not taken quickly to address this shortage.