Primary Care Condition Critical

In January 2006, the American College of Physicians (ACP) warned that primary care, rightly referred to as the backbone of the nation's health care system, was on the verge of collapse. The ACP noted then that few young physicians were going into primary care and that many of those already in practice were leaving.

Factors cited as affecting the supply of primary care physicians included administrative hassles, high patient loads, and declining revenues coupled with the increased cost of providing care.

In the nearly 3 years since its warning, the ACP has proposed the following to shore up primary care: create pathways to eliminate student debt for physicians choosing primary care careers; increase payments to primary care physicians who are linked to accountability for improved outcomes; and design new models of primary care, such as the patient-centered medical home.

The United States has yet to implement comprehensive strategies to recognize, support, and enhance primary care to the degree necessary to reverse a worsening primary care shortage, according to the ACP. Meanwhile, the demand for primary care services is expected to increase to care for an aging population with more chronic conditions. A shortfall of 35,000 to 40,000 primary care physicians is projected by 2025.

In a survey of fourth-year medical students published in the September 10 issue of the Journal of the American Medical Association (JAMA), only 2% said they intended to pursue careers in general internal medicine. A major factor is the salary gap. Family medicine had the lowest average annual salary of $186,000 compared with orthopedic surgery, the highest, at $436,000. Students were also dissuaded from internal medicine by their experiences during their training of caring for the elderly and chronically ill.

What's more, 49% of 12,000 primary care physicians surveyed by the Physicians' Foundation said they would consider leaving the practice of medicine. These doctors say they are overwhelmed, not from seeing too many patients, but by too much paperwork generated by health plans and government agencies.

The classic definition of primary care includes first-contact care, continuity of care, comprehensive care, and coordinated care. In a commentary on "21st-Century Primary Care," in the April 2 issue of JAMA, Richard Baron, MD, and Christine Cassel, MD, suggest that while expanded roles for nurses and physician assistants could provide first-contact care, health plans should consider recognizing the other functions performed by primary care physicians as reimbursable services. For patients with multiple chronic illnesses, for example, better coordination can reduce unnecessary services and gaps in services, resulting in savings elsewhere in the health care system. Baron and Cassel note that hospitals do not hesitate to purchase a new imaging machine with revenue-generating prospects, but they are less likely to invest in electronic medical records, integration of specialties, or other care coordination models that might reduce their own revenues.

A payment mechanism is also needed to encourage and reward efforts of primary care physicians to promote disease prevention if we are ever to contain health care costs; that is, if our health care system can be redirected to emphasize prevention and wellness.

Health plans and government programs need to examine their own roles in developing overly complex administrative procedures and regulations that are contributing to the exodus of physicians from primary care. Policymakers should also take note. Before we embark on a complete overhaul of the financing mechanism of our health care system to improve access, we need to rebuild and support the primary care infrastructure.