I just returned from ACP Leadership Day where 375 internal medicine physicians and future physicians from all over the country descended on Capitol Hill to advocate for primary care. Before I left, one of my colleagues asked me what we would have to talk about since healthcare reform already passed and includes some boosts for primary care. Well, we had plenty to talk about! While the main goal of healthcare reform was to provide coverage and insurance reform, the ultimate question is will newly insured Americans be able to access care? Even if they have insurance coverage, they may not be able to see a doctor if there are not enough primary care doctors to see these patients.
Therefore, the focus of our efforts this year was to ensure that we have a primary care workforce to meet the demands of the newly insured. Because of the long dwell time to train primary care physicians, we need to start now to ensure we have doctors for the future. One staffer told us that he heard that medical students wanted to go into lucrative specialties to pay back their debt, and I asked if they had ever heard of the “ROAD” (aka Radiology, Ophthalmology, Anesthesiology, Dermatology) which refers to the desired lifestyle and highly reimbursed specialties. He responded we needed to get primary care back on the ROAD or maybe make it “P-ROAD.” I don’t think P-ROAD makes a great acronym, but PATH may work better: Primary care = Access To Healthcare. While healthcare reform law (aka PPACA) includes many boosts to primary care, there are a few key omissions that can easily undermine healthcare reform. Moreover, the question is now what provisions will be funded and at what level. To get Primary Care back on the ROAD, we need to create a new PATH that includes fixing every step of the pipeline for physician workforce so future and current doctors can see themselves providing this valuable service.
- Medical student: Debt relief so students can go into primary care Medical students cannot pursue careers in primary care if they continue to carry an average debt burden of roughly 160,000 dollars upon graduation. The initial healthcare reform bill included loan repayment programs for those who enter primary care, but this was stricken due to the cost of these provisions. While the National Health Service Corps is the most widely recognized loan repayment program, it is very competitive and will not fill the primary care shortage alone. Therefore, expansion of this program or creation of new loan repayment programs are needed. Medical students are especially adept at making the case for loan repayment – and the health legislative aides that we met with were especially sympathetic to them since they may be able to relate to them (they are also closer in age).
- Residency: Expand primary care spots & create new training models With new medicals schools designed to train primary care physicians, it is unclear if there will be enough residency spots for these newly minted physicians to match into. As I’ve stated before, the supply of US graduating medical students will overtake the number of residency positions in a few years if there is no increase in residency spots. Moreover, if residency slots aren’t ‘slated’ for primary care, one can imagine that new graduates will gravitate to the specialties. There are provisions to reallocate 65% of unused residency positions to primary care, but that still won’t be enough due to the shortfall of primary care physicians. The ACP recommends 90% of these spots go towards primary care. In addition to creating slots, residency programs must be given the latitude to design new models to train primary care physicians. Since funding for residency training is given to hospitals, currently residency programs face significant challenges in getting residents experiences in ambulatory settings. This may change with healthcare reform legislation that supports the creation of new ‘Teaching Health Centers’ in the community to train primary care physicians, provided that these programs get the funding they need.
- Practicing Physicians: Reward & redesign primary care work Lastly, entering and staying in primary care will not be possible as long as the income disparity continues to persist. Moreover, with a pending 21% cut in Medicare physician fees kicking in on June 1st if nothing happens will not help things. This is why we need to ultimately reform the payment system (for how we ended up here, see this earlier post). The House has just introduced legislation HR 4213 which would stop the cuts and provide 3.5 years of stable Medicare payments and reward primary care doctors. Certainly, this will help things in the short term. However, several of the trainees I spent time with in DC firmly stated that it was not just about the money, but also the hard work associated with primary care. This point was eloquently illustrated by Dr. Richard Baron in a recent New England Journal of Medicine article in which the primary care physicians in his practice responded to a telephone call or a lab test an average of 43.2 times a day! All of this care goes uncompensated in our current system. As one physician writes, it is time to reward coordination and communication of care. One possible way to do this is to adopt the new patient-centered medical home, which is a way to redesign practice to promote a team approach (with physicians and other allied health professioanls) supported by technology to deliver primary care to a group of patients. Another solution was featured in a recent issue of Health Affairs devoted to primary care, which contains an article which poses the provocative question: what would martians think about primary care? The answer is a more radical redesign to overhaul the entire physician workday to see fewer patients and compensate the uncompensated care such as email and phone calls.
Unfortunately, as one of the other staffers said, “there is a lot of healthcare fatigue on the Hill” so this may take time. Moreover, the big barrier is cost especially given the high price tags of these bills in a fiscally challenged environment. While these reforms will cost money in the short term, its important that we highlight that fixing these things later on will cost exponentially more — if it can be fixed at all. This is why its important that physicians and medical trainees need to make the case now about the importance of these issues to ensure physicians for the future.
–Vineet Arora, MD