Special Report: Primary Care Doctors—Unsung Heroes?
By Jackson & Coker Research Associates
The primary care physician is the gatekeeper of the health care experience, typically serving as a patient’s first and most constant contact with the health care industry. Considering the linchpin nature of the field, one would think its practitioners would occupy something of a venerated status within the American health care industry and be compensated accordingly. Such isn’t always the case, however; and, in America, primary care is a field in crisis. From demographic trends to cheaper competition, educational second-class status to governmental intervention: primary care’s continued health is going to be subject to any number of factors and actors outside the field itself. In the following report, we take a look at primary care: its present state and its possible future.
The image issues begin early for primary care. While the breadth of training necessary for practice means that a primary care physician might be able to handle ninety percent of an individual patient’s medical needs in-office,[1] the perception still exists even among some medical educators that primary care is a dead end.[2] It’s not uncommon to hear about medical students being told not to “waste” a medical education by going into primary care; and research grants and consulting opportunities are more commonly biased for other specialties, so primary care physicians have a much tougher road to professor positions and other perks of a career in medicine.[3] As Dr. Lori Heim, the president of the American Academy of Family Physicians, claims, from the classroom to the residency to the billing department, “Primary care hasn’t been properly valued, not relative to the value it provides for patients and society.”[4]
A look at the numbers confirms the dire straits for primary care in medical education: The Government Accountability Office noted in 1995 that there were fewer than 23,800 residents in primary care programs nationwide.[5] That number dropped to 22,100 by 2006. Since 1997, the number of medical students entering primary care has dropped by more than half.[6] In 2007, less than 45 percent of primary care residencies in the U.S. were filled, and growth in the specialty since 1995 has stalled at 1.2 percent annually, far below what is necessary to fill the national need.[7] The past year saw about a nine percent increase in U.S. medical school graduates choosing family medicine,[8] but in comparison to the numbers from 25 years ago, the relative decline of the specialty is striking.[9] According to Heim, herself a family care physician with twenty years in practice, many students begin their medical training with an interest in primary care but lose that interest over time: “If you talk to first year medical students, you’ll see lots of hands when you ask about interest in primary care. Then compare that against what they go on and do. That’s where we lose them: we lose most of them in terms of their original choice of residency.”[10]
While the image and workforce of the specialty are eroded from one end, practicing primary care providers come under economic and professional pressure from the other end. Even though primary care access is strongly correlated with better management of chronic illness, higher patient satisfaction, better health outcomes, lower hospitalization rates, and lower health expenditures,[11] the specialty is undervalued when it comes to the health care payment system. It’s well known that the conventional pricing model disadvantages primary care physicians. Specialists are able to increase the volume of services they provide and increase revenue, but primary care physicians’ principal services are office visits.
Payers use resource-based reimbursement methods, which strongly favor procedure-based services over office visits. Medicare, for instance, may pay about $100 for an office visit in which a patient is evaluated and given preventative advisement, but $450 for a single diagnostic colonoscopy.[12] As a result, primary care physicians are the lowest-paid among physicians, earning $173,000 per year, while their peers in other specialties earn multiples of that: orthopedic surgeons bring home around $481,000,[13] and the average neurosurgeon and cardiovascular surgeon make around $440,000 and $560,000 per year. [14]
These pressures are having an effect on the primary care physician workforce. Burnout is widely reported, and job satisfaction among primary care physicians is plummeting. Primary care doctors regularly report dramatic increases in nonclinical paperwork, which—in two thirds of cases—is causing them to spend less time with patients. “It does take away from the general enjoyment of a day,” says Dr. Chris Lupold, a Pennsylvania family physician in a five-doctor practice. Lupold has been practicing for seven years and notes that “as a general rule, I spend about as much time doing paperwork as I do face to face with patients doing clinical care.”[15]
Some reports estimate nearly half of primary care physicians are considering abandoning practice altogether or at least reducing their patient loads over the next three years. Early retirement is an attractive option for those that can afford it, but reductions in reimbursement put that option out of reach for many practicing physicians.[16] One survey of primary care providers found that one out of every eleven internists originally certified between 1990 and 1995 was no longer working in general internal medicine or a subspecialty thereof. While satisfied with their career choices, internists weren’t satisfied with their careers. That is to say: they love practicing medicine, just not all the other things modern practice entails.[17] Lupold sees a reason for the disconnect: “Most doctors will finish their residencies very well trained clinically” but be unprepared for the business administrative side of practice. “You want to worry about patients,” he says, “not accounts receivable.”[18] Heim concurs: “Documentation, the problems of preauthorization… all of these are unrealistic within the current practice model. We have to work toward administrative simplification.”
Among those not retiring or otherwise leaving medicine, locum tenens has proved an attractive option.[19] A considerable number of physicians are taking up this itinerant physician lifestyle as it is a mode of practice that results in reduced or eliminated administrative load and fewer paperwork headaches, all while getting back to what they love most: the actual practice of medicine.[20]
Of course—whether you love seeing patients or currently find yourself overwhelmed by them—the question is: how will you feel with 47 million more of them in the system? This is the issue at hand thanks to the recently passed health insurance overhaul. Such a massive influx of patients runs the risk of overwhelming a primary care system already stretched thin. The recently passed law bears much in common with the law passed in Massachusetts several years ago. Patients in Massachusetts saw average wait times to see a primary care physician spike significantly, while at the same time primary care providers became less likely to take on new patients. Are we destined for a repeat on a national scale? Dr. Heim is optimistic regarding the bill’s impact, claiming that “Health care reform is having generally a positive impact. We think the [increase in primary care residencies] is a result of the highlighting of the specialty in the health care reform discussion. That’s a beginning. It is an excellent start.”[21]
Dr. Lupold is also optimistic, though perhaps a bit more cautiously: “It’s too soon to tell,” he says. “I’m optimistic and excited, and I feel like I need to wait and see how it’s going to progress.”[22]
A key feature of the reform bill is loan forgiveness for primary care providers working in underserved areas. Additionally, the bill provides a new funding stream for teaching health centers—residency programs set in community health centers or other non-hospital centers. The bill also contains additional funding for Title VII Health Professions Programs, which fund family medicine departments in medical schools and residency programs.[23] So there is much within the bill to encourage prospective physicians to choose and stick with primary care. But at the end of the day, it will still be a hard specialty to sell if the price isn’t right. So what does the new bill do about primary care reimbursement?
The federal reform legislation doesn’t simply mandate greater access to primary care; it also mandates a ten percent bonus payment for primary care services for five years, beginning in 2011, as well as components promoting medical practice models that would emphasize the role of primary care such as the patient-centered medical home model. The bill also contains increased funding for the National Health Service Corps and community health centers. There is also a two-year pilot program beginning in 2013 that will ensure equity between Medicaid and Medicare reimbursement rates for primary care services.[24] The legislation isn’t nearly perfect—for example, many of the reimbursement gains for primary care physicians are not permanent—but it does represent an acknowledgment on the part of the federal government—the largest third party payer—of the vital importance of primary care to the nation’s overall health.
Beyond the health reform bill itself, Heim sees other indications from the government that it is serious about the primacy of primary care going forward. “Look at what the administration has signaled outside the legislation,” says Heim. “Look at the CMS 2010 rules… we’re seeing movement from both regulatory and legislative arms in positive directions.”[25]
And perhaps that’s a good starting point on the road to recovery for an under-respected but indispensable field. There is, really, little that can be done to make operating a primary care practice easier. Primary care physicians will continue to see the most patients, and even more than usual in the coming years, as more enter the system. There are some measures—electronic health records, the medical home model, maintenance of suitable compensation levels for primary care—that can improve the vitality of the specialty, but it really does come back to a certain level of respect for the first point of contact in the health care world. In the face of shifting revenues and increased workloads, primary care physicians find themselves at a crossroads: they are essential in some manner to the functioning of the health system, but it seems apparent that their profession must undergo some sort of change to move forward.
Drs. Lupold and Heim see the potential for a healthier specialty in the future. Reform efforts, Lupold says, mean we’ll likely see “an increase in student interest in going into primary care. It’ll hopefully bring some of the joy back into it.”[26]
Meanwhile, Heim sees this as a moment of opportunity: “We have an opportunity to really integrate more quality and strengthen primary care. It’s an opportunity for us to refine and help lead the way.”[27]
[1] Carlson, Gail. “What Is a Gate Keeper?” MissouriFamilies.org Health. http://missourifamilies.org/features/healtharticles/health44.htm
[2] Chen, Pauline. “Primary Care’s Image Problem,” The New York Times, November 12, 2009. http://www.nytimes.com/2009/11/12/health/12chen.html
[3] Friedman, Emily. “Surf, Turf, and the Future of Primary Care,” H&HN Magazine, June 3, 2008. http://hhnmag.com/hhnmag_app/jsp/articledisplay.jsp?dcrpath=HHNMAG/Article/data/06JUN2008/080603HHN_Online_Friedman&domain=HHNMAG
[4] Telephone interview, Lori Heim, President, American Academy of Family Physicians, August 26, 2010.
[5] ibid
[6] Lloyd, Janice. “Doctor Shortage Looms as Primary Care Loses Its Pull,” USA Today, August 18, 2009. Available at http://www.usatoday.com/news/health/2009-08-17-doctor-gp-shortage_N.htm
[7] Friedman, H&HN Magazine, op cit.
[8] Heim, Telephone interview, August 26, 2010.
[9] Beaulieu, Debra. “Increased Primary-Care Interest Not Enough to Affect Physician-Shortage Trend,” Fierce Healthcare, March 19, 2010. http://www.fiercehealthcare.com/story/increased-primary-care-interest-not-enough-affect-physician-shortage-trend/2010-03-19
[10] Heim, Telephone interview, August 26, 2010.
[11] United States Government Accountability Office, Testimony Before the Committee on Health, Education, Labor, and Pensions, U.S. Senate, February 12, 2008. http://www.gao.gov/new.items/d08472t.pdf
[12] ibid
[13] Wechsler, Pat. “Doctors’ Hours Fall for a Decade, Adding to a U.S. Shortage,” Bloomberg Businessweek, February 23, 2010. http://www.businessweek.com/news/2010-02-23/doctors-hours-fall-for-a-decade-adding-to-a-u-s-shortage.html
[14] ibid
[15] Telephone interview, Dr. Chris Lupold, August 27, 2010.
[16] Stouffer, Rick. “Medical Experts Foresee Critical Shortage in Primary Care Soon,” Pittsburgh Tribune-Review, May 2, 2010. http://www.pittsburghlive.com/x/pittsburghtrib/business/s_679113.html
[17] American College of Physicians, “ACP and ABIM Survey Finds General Internists Leave Practice Sooner, Less Satisfied with Career than Subspecialists.” http://www.acponline.org/pressroom/int_survey.htm
[18] Lupold, Telephone interview, August 27, 2010.
[19] Samuels, Jennifer. “Locum Tenens Can Solve Shortage of Primary Care Physicians,” LocumLife, March 15, 2010. http://locumlife.modernmedicine.com/locumlife/Modern+Medicine+Now/Locum-tenens-can-solve-shortage-of-primary-care-phy/ArticleStandard/Article/detail/662972
[20] Butterfield, Stacey. “Practice Hassles Have More Docs Going Locum,” ACPInternist.org. http://www.acpinternist.org/archives/2009/05/locum.htm
[21] Heim, Telephone interview, August 26, 2010.
[22] Lupold, Telephone interview, August 27, 2010.
[23] White, Brandi. “How Health Care Reform Will Affect Family Physicians,” Family Practice Management, April 13, 2010. http://www.aafp.org/online/en/home/publications/journals/fpm/preprint/reform.html
[24] American Academy of Family Physicians, “How Will Health Care Reform Legislation Impact Payment to Physicians?” http://www.aafp.org/online/en/home/policy/federal/hcrleg2010/payment.html
[25] Heim, Telephone interview, August 26, 2010.
[26] Lupold, Telephone interview, August 27, 2010.
[27] Heim, Telephone interview, August 26, 2010.