The Primary Care Physician and Health Care Reform

Whatever form it takes, health care reform will increase the number of Americans covered by health insurance. But there is concern that the legislation will not bend the cost curve—that is, will not reduce the growth of health care costs so that it more closely resembles the growth of the US gross domestic product (GDP). Currently, health care consumes about 16% of the GDP; advocates of bending the cost curve hope that in 2020 it will still consume roughly the same proportion.

Increased health care coverage raises issues in addition to cost containment. Increased coverage will mean increased demand for primary care physicians. Virtually everyone would like to have a primary care physician—a trusted physician who provides comprehensive, continuous care. Many studies, including many with international comparisons, have established the benefits of primary care.¹ However, it is increasingly difficult to convince graduates of US medical schools to choose primary care as their professional career path. Why is there such a disconnect between the demand for and supply of primary care physicians? Two reasons appear to predominate: scope of practice and salary.

The scope of practice for primary care physicians is contracting. There are 900 million visits to physicians annually in the United States,² and about half of these are to the 200 000 physicians who identified themselves as office-based primary care clinicians.³ These physicians manage most of the care for diabetes, hypertension, and obesity; address acute problems such as viral or bacterial infections; and provide general examinations. On the other hand, a large proportion of the visits for conditions that could be managed by primary care physicians such as rheumatoid arthritis, epilepsy, depression, angina pectoris, and other chronic conditions are diagnosed and managed over time by specialists.² The role of primary care physicians in the hospital has also narrowed, driven by the emergence of hospitalists and the trend to move a substantial portion of medical care to outpatient facilities.

The salary differential between a primary care physician and a specialist is substantial. The median salary in large, multispecialty group practice for a US internist is about $205 000 a year; for a family medicine physician, $198 000; and for a pediatrician, $203 000. The median dermatologist salary is $351 000.⁴ Given this pay differential and the narrowed scope of practice, why should bright, hardworking, debt-ridden, or even altruistic medical students choose internal medicine, family medicine, pediatrics, or primary care for residency?

In 2010, only 2722 (54.5%) of the 4999 residency spots in internal medicine were filled by graduates of US-based allopathic medical schools; respective numbers for family medicine residency were 1169 (44.8%) of 2608, and for pediatrics, 1711 (70.5%) of 2428.⁵ In comparison, at least 90% of positions in neurological surgery, orthopedic surgery, and dermatology were filled by US medical school graduates.⁵ Young clinicians are simply not willing to forfeit lifetime earnings of over $3 million even though the medicine they would practice as primary care physicians is critical to improving the health of patients and to making the current health system more functional.⁶ To many of these students, the primary care physician might seem a lot like the water boy on a football team making sure that the really important members of the medical team do their work.

Many reports have lamented the current situation. For example, the Society of General Internal Medicine (SGIM) published a report enthusiastically defining the roles of a primary care physician and arguing why these roles are so important to the health care system.⁷ The American Academy of Family Physicians (AAFP) Statement Report reconfirms the worsening shortage of primary care physicians.⁸ Many efforts are underway to enhance the environment in which primary care physicians practice, including building medical homes, developing accountable health care organizations, and installing information technology systems. All of these initiatives could substantially improve the lives of primary care physicians, making it more intellectually stimulating, as well as feasible and efficient to provide integrated, continuous care.⁹ But despite efforts to highlight the potential clinical and professional contributions of primary care physicians, interest in this path remains extraordinarily low among graduates of US medical schools.

One approach to this situation is to do nothing. As a result, the number of primary care physicians in practice will continue to decline. Patients who want a primary care physician will probably need to pay some kind of retainer and enroll in a concierge-type practice. Those who cannot afford this luxury will have to endure a medical care system that is even more fragmented than it is today.

An alternative approach is to convince 50% of students entering US medical schools, starting in June 2010, to choose primary care (pediatrics, family medicine, or general internal medicine) as their professional career path. The suggestions of multiple task forces for making delivery of primary care easier can be implemented. For this approach to be successful, a way must be found to reduce the pay differential between primary care physicians and specialists.

In addition to fulfilling the roles so eloquently outlined by the SGIM⁷ and AAFP⁸ taskforces, primary care physicians must lead the effort to bend the cost curve and eliminate variations in health care expenditures based solely on where one lives rather than on medical need. If successful, a Dartmouth Atlas produced in 2020 would confirm that variation in expenditures on health care is related to need, not to geography.¹⁰

To achieve these goals, primary care physicians need a different set of clinical responsibilities and skills. They must become leaders in efforts to avoid preventable hospitalizations for patients with chronic diseases, eliminate inappropriate or equivocal surgery and radiologic procedures, and help individuals die with the least pain and without expenditures of vast amounts of money. The workflow of the medical system must be redesigned so that primary care clinicians can perform procedures and carry out tasks for which they have been trained. In addition, for patients with single or multiple chronic illnesses, primary care physicians must provide a greater proportion of the continuing care.²

The contract primary care physicians must make with the public is simple: If society working with insurance companies, Medicare, and Medicaid would close the salary gap between primary care physicians and specialists, primary care physicians would lead the medical profession in eliminating unnecessary variations in care and bending the cost curve, in addition to being the trusted allies of patients by providing high-quality care. Will expanding the scope of practice and increasing salaries motivate enough medical students to forsake careers in higher paying specialties? Or will the fascination of working at the cutting edge of medical technology still capture the minds and hearts of most medical students? The answer is unknown; however, it is certain that if the salary gap cannot be closed and the role of the primary care physician redefined in a powerful way, there is little hope of producing a health care system that provides high-quality affordable care to the US population.