American College of Physicians

Advocacy and policy news for internists

Primary-Care Shortage Spawns Innovation

Efforts run the gamut from targeted fixes to longer-term solutions

HealthDay News -- The looming shortage of generalist physicians in the United States is spurring a wave of public- and private-sector experimentation.

The recent report by researchers from the University of Missouri and the U.S. Department of Health and Human Services projecting that the nation will experience a shortage of as many as 44,000 generalists to care for adults by 2025, has put an exclamation point on a trend that's being bending downward for decades.

"There are forces mobilizing to address this issue because . . . the solution is to produce more primary care physicians and to make primary care more attractive to doctors in terms of status and reimbursement," said Dr. Richard Reece, an editor and author of Innovation-Driven Health Care: 34 Key Concepts for Transformation.

The problem has indeed become a critical one.

With only 35 percent of U.S. physicians practicing primary care, compared to 50 percent of doctors in most European nations and Canada, the U.S. "has never had a strong primary care foundation," business and policy leaders write in a Heath Affairs article on employers' role in strengthening primary care.

Some 56 million Americans already lack adequate access to primary-care services because of physician shortages in their communities, reports the National Association of Community Health Centers (NACHC).

In Massachusetts, where legislation to reduce the ranks of the uninsured has fueled heightened demand for primary-care services, 42 percent of internal medicine offices are not accepting new patients, and among those who are taking new patients, the average wait time for an appointment is 50 days, the Massachusetts Medical Society reports.

A study was published in the Sept. issue of the Journal of the American Medical Association that showed how critical the situation is becoming. The JAMA survey results of 1,200 fourth-year medical students showed that only 2 percent plan to go into primary care internal medicine. In a similar survey in 1990, the figure was 9 percent.

Recognizing the threat to patient care, stakeholders are attacking the problem on multiple fronts. Congress recently reauthorized legislation providing scholarships and loan repayment for medical students who go into primary care in underserved areas.

In late 2006, several large employers, including IBM, partnered with the American College of Physicians, the Academy of Family Physicians and other primary-care provider groups to form the Patient-Centered Primary Care Collaborative. The mission is to advance the concept of the "medical home," whereby generalists receive additional payments for managing and coordinating all of a patients care.

The collaborative was instrumental in advancing federal legislation authorizing a medical home demonstration with Medicare patients in eight states.

"In order to stabilize the situation, you need a mechanism of payment reform, which is included in the medical home (and) you need to give the docs a sense that providing comprehensive care is something that society values," said collaborative chairman Dr. Paul Grundy, IBMs Director of Healthcare, Technology and Strategic Initiatives.

Some states and health systems are already testing the concept. Early results from a pilot at Geisinger Health System in Danville, Pa., show sharp reductions in hospital admissions (down 14-to-20 percent) and readmission rates (off 12-to-48 percent).

But will it save money? Writing in the New England Journal of Medicine, Dr. Elliott S. Fisher, a professor and director of the Center for Health Policy Research at Dartmouth Institute for Health Policy and Clinical Practice in Lebanon, N.H., notes that hospitals and specialists need to be on board, too.

"To the extent that the income of other providers continues to depend on service volume, it is unlikely that either specialists or hospitals will respond to fewer visits and stays from medical-home patients by allowing their incomes to fall," he wrote.

Preserving Patient Access to Primary Care Act Introduced in House

Act comprehensively addresses crisis in access to primary care

The Preserving Patient Access to Primary Care Act, H.R. 7192, was introduced in the House of Representatives by Rep. Allyson Schwartz (D-PA) on Sept. 27.

ACP worked closely with Rep. Schwartz and other primary care organizations -- including AAP, AAFP and AOA -- to craft the new legislation. "We are confident the bill addresses the reasons for the shortfall in access to primary care services in a comprehensive fashion," pointed out ACP President Jeffrey P. Harris, MD, FACP. "The legislation would put Congress on record as finding that there is a growing crisis in access to primary care and that primary care medicine is critical to improving outcomes and reducing costs."

"Primary care in the United States is in jeopardy. Despite the fact that, for most, primary care is the lynch-pin to care coordination and preventive health care, fewer and fewer medical students are entering primary care professions. As someone committed to ensuring that every American has access to quality, affordable health care, I understand deeply how vital it is that we increase the number of physicians practicing primary care medicine," noted Rep. Schwartz. "This bill takes common sense, effective steps, including expanding medical education grants, scholarships, debt forgiveness and loan repayment initiatives, to address many of the main challenges facing primary care doctors or those interested in entering the field."

The bill outlines a series of different measures designed to help support the field of primary care. The legislation:

requires a study to recommend the designation of primary care as a shortage profession, as long as certain criteria are met;

provides recruitment and retention incentives, through grants, scholarships, and loan forgiveness, to encourage medical students to choose careers in primary care;

establishes measures to support and expand the patient centered medical home (PCMH) model of care to ensure that primary care practices are able to achieve the infrastructure and have the capability to provide patient-centered, physician-guided coordinated care; and,

proposes comprehensive reforms of payment systems under Medicare, to support, sustain, and enhance the practice of primary care.

A just-completed study was published in the Sept. issue of JAMA that showed how critical the situation is becoming. The JAMA survey results of 1,200 fourth-year medical students showed that only 2 percent plan to go into primary care internal medicine. In a similar survey in 1990, the figure was 9 percent.

With Congress adjourned, the legislation likely will not be taken up until 2009. Rep. Schwartz plans to re-introduce the bill in the new 111th Congress and Sen. Maria Cantwell (D-WA) plans to introduce a companion Senate bill at that time.

During the next few months, ACP will be working with Rep. Schwartz and Senator Cantwell and other supportive members of Congress to urge as many members of Congress as possible to become original co-sponsors when the bill is introduced again in early 2009. ACP members are urged to contact their legislators about becoming original cosponsors of the Schwartz and Cantwell bills when they are introduced in the new Congress.

October 22, 2008