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The Coming Crisis in Primary Care Medicine

Is primary care a waste of talent and of a great education to boot?

Those concerned about this question feel strongly that curricula and culture at top-tier medical schools are doing precious little to encourage medical students to pursue primary care.

Given the convergence on the medical system of aging baby boomers and potential mandatory health insurance nationally through universal healthcare—both of which will drive need—the impact of too few primary care physicians could be dire.

There is an attempt through the Affordable Care Act to address the problem. In the next five years, $250 million in federal funding will provide training to more than 16,000 primary care providers. The Medicare payment gap between specialists and primary care providers would also be reduced through a 10 percent bonus for the same period. Additionally, the act calls for expanding the number, capacity and services of community health centers. The act also supports substantial funding of scholarships and loan repayment for doctors, nurses and other health professionals who will then practice in rural and urban areas designated as underserved through the National Health Service Corps.

The question remains: is this enough to address the most critical needs?

In a Journal of the American Medical Association piece, “Policy for an Aging Society,” C. K. Cassel, M.D., states that in the three-year period from 2007 to 2009, fewer than 100 U.S. medical school graduates opted for postdoctoral training in geriatrics. A study conducted by the Institute of Medicine, a federal agency, reported in 2008 that there is an acute shortage of geriatricians now and that it will continue. There does not seem to be a plan in place to overcome this shortage.

A recent Wall Street Journal article reported that WellPoint, Inc., which insures some 34 million Americans, will offer primary care doctors an increase of about 10 percent, with the possibility of sharply higher payments if they reduce their patients’ overall cost of care. The article pointed out that Aetna will begin paying more than 50,000 doctors in its network an extra fee of up to $3 per patient if those doctors meet certain standards for accesss and coordination of care.

Given these incentives and those offered by the Affordable Care Act, will medical schools take into account the need for increased education and training in primary care and geriatric medicine to meet the increased demand? And will physicians be sufficiently comfortable in the chronic-care encounter, when a patient needs to be located in a patient-centered medical home or is facing physical decline, to undertake the analytic and interpersonal processes necessary to help that patient?

Part of the problem in addressing the primary care shortage is to reverse a lack of interest among medical students in matching or doing residencies at hospitals and medical centers in primary care fields, a trend that continues to show a decline. In a New England Journal of Medicine article, “The Case for Primary Care—A Medical Student’s Perspective,” Ishani Ganguli cites figures showing that primary care applications declined from 55.8 percent in 1998 to 40 percent in 2009.

I leave the reader with some questions. Can income inequality in medicine be reduced? Or should healthcare policymakers avoid attempting to find more primary care physicians via the medical school route and simply increase the supply of providers through advanced practice nursing—that is, nurse practitioners?

(Dr. Birenbaum is the author of Remaking Chronic Care in the Age of Health Care Reform: Changes for Lower Cost and Higher Quality Treatment [2011]; this post is an abstract from chapter 8.)

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