American Medicine – The Death of Primary Care

  Primary care is dying.  If and when it does, will anyone notice?


In a paper entitled: "The Impending Collapse of Primary Care Medicine and Its Implications for the State of the Nation’s Health Care: A Report from the American College of Physicians."  the following observations are made:

Too Few Physicians Are Going into Primary Care

The demand for primary care is increasing, while at the same time there has been a dramatic decline in the number of graduating medical students entering primary care

  • Over the past several years, numerous studies have found that shortages are occurring in internal medicine. vii viii ix x xi xii Factors affecting the supply of primary care physicians, and general internists in particular include excessive administrative hassles, high patient loads, and declining revenue coupled with the increased cost for providing care. As a result, many primary care physicians are
    choosing to retire early. These factors, along with increased medical school tuition rates, high levels of indebtedness, and excessive  workloads, have dissuaded many medical students from pursuing  careers in general internal medicine and family practice.
  • A recently-published study of the career plans of internal medicine residents documents the steep decline in the willingness of physicians to enter training for primary care. In 2003, only 19 percent of first year internal medicine residents planned to pursue careers in general medicine. Among third-year internal medicine residents, only 27 percent planned to practice general internal medicine
    compared to 54 percent in 1998.
  • More than 80 percent of graduating medical students carry educational debt. The median indebtedness of medical school students graduating this year is expected to be $120,000 for students in public medical schools and $160,000 for students attending private medical schools. About 5 percent of all medical students will graduate with debt of $200,000 or more.


The numbers are bleak.  One report I heard (and don\’t have the actual citation at this time) states that under 5% of 4th year medical students are now looking at a career in primary care.  Study after study seems to confirm that not only are American medical students not interested in primary care; many such programs can\’t even fill with foreign medical graduates.

Compound this with the high attrition rates within primary care (with a very large percent of physicians in their 50\’s contemplating early retirement), made even worse by the increasing elderly population, and it is clear that there is a crisis.

This begs the question:  so what?  What is the big deal?  We can just use subspecialists and physician extenders to fill the slots.  Patients can become more empowered to provide their own care using e-visits and web-guided care.  This sounds sacrilegious coming from a primary care physician, but it is what is being said on the outside by some.  Although the feelings may not be so overt by the politicians in Washington, it seems that inaction in the face of a crisis is tantamount to denial of the reality of that crisis.

What is being done?   Medicare is giving a 1.5% bonus to physicians for quality measures.  This will amount to a few hundred extra dollars for the average physician (with an enormous amount of work to set up a system that will properly submit the right codes in the proper format).  That is not help; it is an insult.

From the same paper by the ACP, the following suggestions are made:

First, we are calling on policymakers to implement and evaluate a new way of financing and delivering primary care called the advanced medical home. The advanced medical home is a physician practice that provides comprehensive, preventive and coordinated care centered on their patients’ needs, using health information technology and other process innovations to assure high quality, accessible and efficient
care. Practices would be certified as advanced medical homes, and certified practices would be eligible for new models of reimbursement to provide financing commensurate with the value they offer. These practices would also be accountable for results based on quality, efficiency and patient satisfaction measures. The advanced medical home would be particularly beneficial to patients with multiple chronic diseases—a population of patients that is growing rapidly and that consumes a disproportionate share of health care resources.

Second, ACP calls on policymakers to make fundamental reforms in the way that Medicare determines the value of physician services under the Medicare fee schedule. The current process for establishing relative values has resulted in payment rates that under-value office visits and other evaluation and management services provided principally by primary care physicians, and over-value many technological and procedural services. Primary care is perhaps the most vital part of  patient care. Access to primary care services provides higher quality care at lower costs. Medicare should begin paying physicians more for the time spent with patients evaluating and managing their care; for investing in health information technology to improve quality and for helping patients with chronic illnesses manage and control their diseases to avoid later complications. The program should begin paying primary care physicians for email and telephone consultations that can reduce the need for face-to-face visits and increase patiernts’ ability to get medical advice in a timely manner. Medicare reimbursement policies should also recognize the value of the time that physicians spend outside the face-to-face visit in coordinating the care of patients with multiple chronic diseases, including the work involved in coordinating care with other health care professionals and family caregivers.

Third, Congress and CMS should provide sustained and sufficient financial incentives for physicians to participate in programs to continuously improve, measure and report on the quality and efficiency of care provided to patients. Financial incentives under a Medicare pay-for-performance program (P4P) must be nonpunitive (physicians who are unable to participate in the program should not be subject to
negative updates), prioritized so that physicians are rewarded for achieving improvements for the top 20 conditions identified in the Institute of Medicine’s “Crossing the Quality Chasm” report, recognize the critical role of primary care physicians in achieving such improvements, and be sufficient to offset physicians’ investment in health information technology and other office redesign innovations required to measure and report quality. Pay-for-performance should be implemented along with reforms to change the way that physician services are valued and reimbursed, rather than grafted onto an underlying payment methodology that pays doctors for doing more, instead of doing better.

Fourth, Congress must replace the sustainable growth rate (SGR) formula with an alternative that will assure sufficient and predictable updates for all physicians and be aligned with the goals of achieving quality and efficiency improvements and assuring a sufficient supply of primary care physicians. Because of low reimbursement levels, primary care practices are operating under such tight margins that they are unable to absorb cuts resulting from the SGR. The SGR has been ineffective in reducing the volume of inappropriate services and cuts payments to all physicians without regard to the quality or efficiency of care they provide.

Do I agree with this?  Yes, but I wonder if it is too late and wonder if congress sees any sense of urgency on this issue.  The lobbyists for the specialty physicians, insurance companies, and device manufacturers are very strong.  Their job is to take care of the incomes of their constituency – not to look at the big picture of how their costs are killing primary care.  Besides, even if enacted, few of these will change my bottom line in the next few years.

It seems that there is little political groundswell for saving primary care.  What will American Medicine look like once the crisis becomes acute?  Will a lack of primary care physicians drive salaries up?  Will the current dysfunctional payment system be fixed in time to avert the crisis?  I have my doubts.  While it is good to hear some people saying the right things, I have to go back to my office and work hard to even be able to see if the dreams are ever realized.