Advocacy and policy news for internists

Worsening Primary Care Shortage Predicted

HealthDay News -- America's looming shortage of generalist physicians is destined to reach crisis proportions by 2025 if nothing is done, experts are warning.

In a string of reports and commentaries, leaders in primary care and health policy have begun fleshing out the problem and offering up potential fixes.

"There's no single step that will solve the problem, but I think it's going to require multiple approaches," said Dr. Jack Colwill, professor emeritus of family and community medicine at the University of Missouri School of Medicine in Columbia.

Many policy experts believe that fixing primary care would also go a long way toward mending a broken health system.

"At a time when the new president and Congress are looking for ways to improve quality and save money, what we're trying to get across is that primary care is certainly a big part of that solution," said Bob Doherty, the ACP's senior vice president of governmental affairs and public policy.

Indeed, the World Health Organization recently called for a renewed emphasis on primary care to ensure equitable access, better outcomes and healthier communities around the globe. "Countries need to demonstrate their ability to transform their health systems in line with changing challenges as well as to rising popular expectations," the report noted.

In the U.S., the Association of American Medical Colleges (AAMC) is projecting a shortage of 46,000 primary care physicians by 2025. Primary care will account for 37 percent of the overall physician shortage. The AAMC's estimate is consistent with projections by Colwill and his research team, who anticipate a shortage of 44,000 generalists by 2025.

Many parts of the country are already feeling the pinch of an inadequate primary care workforce. It would take an additional 8,000 primary care physicians to fill demand for services in areas currently designated by the federal government as underserved, the AAMC observed.

The New England Journal of Medicine's Nov. 13 issue spotlighted primary care with a series of articles and a roundtable discussion on possible solutions.

Dr. Thomas H. Lee, network president for Partners HealthCare System in Boston, explained that boosting pay is not a panacea because many organizations have found that primary care doctors respond by seeing fewer patients.

"These physicians, it turns out, place a higher priority on trying to do a good job and having a sane life than on making a higher income," he wrote. "The message they're sending is that more money will not be enough to revitalize primary care."

A lot of residents reject primary care because they're afraid of the enormity of the task, observed Dr. Katherine Treadway, an assistant professor of medicine at Harvard Medical School.

Dr. Thomas Bodenheimer, professor at the Center for Excellence in Primary at the University of California, San Francisco, proposes relieving primary care physicians of many patient care burdens by implementing a team-based approach and restructuring the reimbursement system accordingly.

As "team leaders," physicians would handle no more than 10 patient visits a day. The rest of their day would be spent handling telephone and electronic encounters, ordering medication changes, and consulting with team members, including health coaches and panel managers.

Having others order preventive screenings and teach patients about making lifestyle changes would go a long way toward relieving the burden on the typical 15-minute patient encounter, he said.

A team approach has become universal for primary care in the United Kingdom, noted Dr. Martin Roland, director of the National Primary Care Research and Development Centre at the University of Manchester. However, a recent study reveals a concern that the increasing use of nurses in providing protocol-driven care for chronic disease may result in physicians becoming "deskilled."

Dr. Allan H. Goroll, professor of medicine at Harvard Medical School and chair of the Massachusetts Coalition for Primary Care Reform, and his colleagues propose a new primary care payment model that would replace volume-based reimbursement with comprehensive payment for comprehensive care.

Applying evidence-based, coordinated care would reduce wasteful spending, freeing up money to fund the new payment model, which would result in a primary care pay hike of as much as 40 percent, Goroll estimated.

Having better patient-level information on quality and outcomes and using information technology to facilitate that care would be part of the solution, envisioned Dr. Barbara Starfield, professor of health policy and management at Johns Hopkins University's Bloomberg School of Public Health in Baltimore.

"The message we're trying to send to policymakers and to our own members is that studies show that primary care really is the best value in the U.S. healthcare system; that if you pay primary care physicians fairly for their services, you will get better access, better outcomes and overall lower cost of care," ACP's Doherty said.

December 2 2008
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