October 2011

Addressing the Primary Care Crisis

John Geyman, MD is Professor Emeritus of Family Medicine at the University of Washington School of Medicine in Seattle, where he served as Chairman of the Department of Family Medicine from 1976 to 1990. As a family physician with over 25 years of experience in academic medicine, he has also practiced in rural communities for 13 years. He was the founding editor of The Journal of Family Practice (1973 to 1990) and the editor of The Journal of the American Board of Family Practice from 1990 to 2003. Dr. Geyman served as President of Physicians for a National Health Program from 2005 to 2007 and is a member of the Institute of Medicine. Dr. Geyman is a prolific writer. His most recent book is Breaking Point - How the Primary Care Crisis Endangers the Lives of Americans.

What is the primary care crisis, and how did it come about?
The crisis is that we no longer have enough primary care physicians to meet the primary care needs of the American people. Despite all the efforts to increase their numbers since the late 1960s through development of training programs in family medicine, general internal medicine and general pediatrics, their numbers have steadily fallen. Today they are not being replaced as U.S. medical graduates seek out the higher incomes and more attractive lifestyles of non-primary care specialties.

These markers show the extent of the problem:

• In 1930, 70 percent of U.S. physicians were in general practice, or primary care. By 1960, only 18 percent were general practitioners; this year, only 8 percent of  U.S. medical graduates entered family medicine residencies.
• Collectively, the three primary care specialties account for about 30 percent of the nation’s physician workforce. Internal medicine and pediatrics are losing most of their graduates to subspecialties; this year only 2 percent of medical school graduates entering internal medicine want to be general internists.
• As a result of these shortages, only 42 percent of 354 million annual outpatient visits for acute care are to primary care physicians; the majority of visits are to ERs (28 percent), specialists (20 percent) and hospital outpatient clinics (7 percent), often with considerable difficulty in arranging for follow-up care.
• Specialization has even affected graduates of nurse practitioner and physician assistant programs, where again a majority select specialty practice over primary care.
• Although the shortage of primary care clinicians involves urban and suburban areas, it is especially serious in rural areas—an increasing number of rural counties are without any primary care physicians.
• We can expect a projected shortage of generalist physicians for adults of 35,000 to 44,000 by 2025.

Many factors have coalesced over the years since World War II in creating this crisis in primary care. Advancing technology, specialization and subspecialization have all played a part, as has the growth of the medical-industrial complex and the shift from a service ethic to a business “ethic” in health care. Health care has become a large and profitable industry on the supply side. Reimbursement policies favor procedures and specialized services over the evaluative and personal side of primary care, thereby creating a large gap between incomes in primary care and the other specialties. And as markets in health care have became the dominant force, a laissez faire approach to physician workforce planning has failed to deal effectively with maldistribution of physicians by specialty.

How is this crisis affecting the health care that Americans receive?
In many parts of the country, patients already have great difficulty in finding a primary care physician for themselves or their family. This is especially true for those on Medicare or Medicaid, and for the 50 million Americans without health insurance. The access problem will only get worse as more baby boomers reach age 65, and as underfunded safety net programs are further cut.

Primary care, of course, involves four essential elements: first-contact care; longitudinal continuity of care over time; comprehensiveness, with capacity to manage a majority of health problems; and coordination of care with other parts of the health care system. Without primary care, patients face increased costs, less coordination and more fragmentation of care. As a result, they make greater use of emergency rooms, often leading to hospitalizations that could have been prevented by adequate primary care. For both individuals and the population, quality of care is compromised. Patients with multiple chronic conditions find themselves bouncing back and forth among specialists, typically with inadequate coordination and integration of care.

What effect will the Affordable Care Act have on primary care?
The Affordable Care Act (ACA) is intended to improve our primary care infrastructure in these ways: a 10 percent primary care bonus (but only for two years); expansion of funding for community health centers and the National Health Service Corps, with a goal to place 16,000 primary care physicians in underserved areas over the next 5 years; and funding of 15,000 new graduate medical education positions (with no plan or mechanism to assure their being in primary care fields). But these efforts are a drop in the bucket compared to the needs. The market-based system will continue on, largely unimpeded, even as accountable care organizations (ACOs) are established, with a wide income disparity between primary care and specialties still making other specialties more attractive than primary care. In fact, the ACA will exacerbate the primary care crisis by providing new coverage for 32 million previously uninsured Americans, especially through expansion of Medicaid.

What changes would you make in medical education to encourage students to go into primary care?
We have already learned over the last 40 years that changes in medical education alone cannot resolve the primary care problem. Changes in the entire health care system are needed before we can expect to have enough primary care clinicians to meet state and national needs. As is argued in Breaking Point, this will require fundamental system changes, including how health care services are financed, how physicians are paid (with more salaried practice and much less use of fee-for-service), and reevaluation of reimbursement policies (with increased value given to primary care services and decreased value to many procedural services). In order to improve health care quality and reduce health disparities, we should establish a system of universal access to health care, preferably through a single-payer system of national health insurance. Medical need is a much better foundation for our health care than ability to pay. We also need to work toward a service ethic in health care, and recognize that health care is not just a commodity for sale on an open market.

With those kinds of enabling changes, accompanying changes in medical education can be expected to succeed in addressing primary care needs. Medical schools and teaching hospitals need to place higher priority on training generalists, both in their mission statements and actual programs, at predoctoral, graduate and continuing medical education levels. Medical school admissions policies should seek out applicants with the goals and attributes to enter primary care, and student loan programs can be targeted to those committed to primary care careers. Some medical schools might consider establishing Departments of Primary Care, integrating teaching programs in family medicine, general internal medicine and general pediatrics. Interdisciplinary team training should be encouraged involving other professionals, including nurse practitioners, physician assistants, clinical psychologists, pharmacists, and others. Whether in urban, suburban or rural areas, new models of delivering primary care need to be designed and piloted, together with expansion of primary care outcomes research.

Physician workforce planning groups need to set a firm long-term target for the generalist:specialist balance (preferably 50:50). Since the membership of these groups are specialty dominated with various conflicts of interest, they should have a larger representation from primary care. And of course, new federal grant programs are needed for primary care training and research.

How can we get more primary care physicians to practice in rural America?
If we can move in the above directions over the next 10 to 20 years, we will have more medical students entering primary care with the values, skills, and commitment to serve in areas of need. Selection criteria including background in rural areas can help to identify those most likely to enter and stay in rural practice. Rural training tracks in community-based residency programs have already demonstrated their capacity to train and place their graduates in rural areas, with long-term retention in rural communities. Loan forgiveness programs for graduates entering primary care in rural areas can further increase the numbers of rural physicians. As in other settings, team group practice will be required to avoid burnout.

What are the barriers to implementing these changes?
Given the ongoing recession, election politics, political gridlock, emphasis on deficit reduction, and the power of corporate stakeholders in preserving the status quo in our market-based system, all of these changes may seem utopian at this particular time. But that does not reduce their importance. Instead it just increases the stakes as the primary care crisis gets worse and our health care system further unravels for much of our population.

The collapse of primary care, still under-recognized and below the radar screen of policy makers, exposes the soft underbelly of U.S. health care. It has already produced a crisis in the health care that most Americans receive. Soaring costs of health care, increasingly unaffordable, have led a growing number of Americans to delay or forego necessary care, thereby leading to worse outcomes and more preventable deaths.

This cannot go on forever. Health care costs are not sustainable. As the well-known economist Herbert Stein says: “If something cannot go on forever, it will stop.”

Although we may tend to think that big changes cannot happen, they can, as we have found by the bursting of the housing bubble and collapse of the financial system.

Meanwhile, we need to continue our dedicated efforts to expand and improve primary care, while recognizing our successes even against all the constraints of our present system. Grand Junction, Colorado gives us one good example of success that we can learn from. Starting in the 1970s, a group of family physicians and specialists founded the physician-run Rocky Mountain Health Plans and the Mesa County Physicians Independent Practice Association. With local leadership of family physicians and specialists in both groups, a partnership was established with hospitals in the region and St. Mary’s Hospital, a tertiary care hospital in Grand Junction, that has assured access to a population of 50,000 over the last 35 years. As a result, since then, markedly improved outcomes of care for the population being served have been documented and sustained compared to national averages.

This is the time to rethink how we finance and deliver health care that best meets the needs of all Americans for access to affordable care of good quality wherever they may live. And it is a time to experiment with new models of care. As the Grand Junction experience has shown, dedicated people and institutions in a rural area, working together on a sustained basis, can help us find new answers to old problems.

We have a challenging road ahead to reform our health care system so that it assures access, choice, affordability, quality, security, equity, and social justice in health care for all Americans. That should be an American ideal, as it is in many advanced countries around the world. We may think we’re exceptional, but unfortunately we’re behind many countries in access and quality of care even as we spend far more on health care than any other country in the world. We need more than tweaks to our unsustainable market-based system. It’s time to go for more fundamental reforms!

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