The Collapse of Primary Care?

The American College of Physicians (ACP) annual meeting offered many reports of significant medical progress, especially in diabetes and rheumatoid arthritis. But this glow of clinical accomplishment was doused as the leadership of the ACP seemed to dump a bucket of cold water over my head-the vision of a collapse of primary care in the U.S. Just when I and millions of other baby boomers start to develop the chronic diseases so common in advanced age, the number of primary care physicians who can coordinate the marvelous but complex care being described in the ACP's clinical lectures may simply not be there.

“There has been a steady decline of medical students and residents pursuing careers in primary care specialties, including general internal medicine” said Dr. Donna Sweet, Chair of the ACP Board of Regents. “At the same time, many of those already in practice are nearing retirement and others are under such stress that they are looking for an exit strategy.”

I knew that the drop in the number of young physicians choosing primary care as their specialty was a trend that has been building for years. At their 2005 annual meetings, both the ACP and the American Academy of Family Physicians sounded alarms about the continuing dearth of applicants to primary care residencies and even the closure of many of these training programs.

But now the rhetoric is escalating to “a looming collapse of the nation's primary care.” Invoking the apocalyptic vision of a “collapse” reportedly caused some soul-searching by members of the ACP Board, but they decided to start ringing the alarm bells in hopes of moving Congress, the Centers for Medicare & Medicaid Services (CMS), the medical profession, and the general public to action.

As befitting an association of internists, the ACP unveiled a wide-ranging, multi-faceted strategy to try to head off this complex problem. Policy papers were issued on the primary-care workforce needed to care for retiring boomers, major changes in internal medicine residency and training, and rebalancing the Medicare payment system to boost reimbursement for evaluation and management services. For more details on the ACP recommendations, you can download the following papers at www.acponline.org:

• Redesigning Training for Internal Medicine
• Creating a New National Workforce for Internal Medicine
• Reform of the Dysfunctional Healthcare Payment and Delivery System

Some of the recommendations appear to me to be a long and hard “sell”: including changing hospitals' view of residents as inpatient manpower to give trainees more exposure to ambulatory care and convincing CMS and other medical specialists to cut reimbursements for procedures to free up resources to reward cognitive services more generously.

Changing the financial incentives, however, may be the most potent and quickest strategy for change. The median medical student debt has risen to $100,000 for those who went to public medical schools and $135,000 for those who went to private medical schools and 5% of students carry debts of more than $200,000. The ACP recommended new loan deferment, repayment, and forgiveness programs linked to careers in primary care. And it called once again for new models for paying physicians for coordinating care of patients with chronic diseases and even separate payments for email consultations.

The good news is that the numbers of applicants for medical school has remained high, according to data from the Association of American Medical Colleges. Winning the hearts and minds of these intelligent young people to primary care will require a redressing the financial futures that they face. The ACP and AAFP have a track record of successfully increasing state and federal expenditures to fund more residency programs when the last primary care manpower crisis arose. This time, I think, they're going to need even more help from the grassroots.

So when my Congressmen come calling to solicit my vote in this Fall's elections, I'm going to ask what they're doing to prevent the collapse of primary care just when I'm going to start needing it more. Hey, now this is personal!

See why Steve Murata thinks today's primary care physicians are up to the task.

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