Judging from healthcare advertisements on the Internet, television, and radio, specialists rule the roost as healthcare providers in the U.S. healthcare system. From orthopedic surgeons to cancer centers to ophthalmologists, it's hard to avoid the onslaught of advertising for specialist care. In the U.S., primary care is not featured nearly as prominently in advertising or the media.
But, increasing primary care access is seen as essential to improving population health. Effective primary care can help reduce emergency room visits and hospitalizations. However, in most U.S. states, primary care spending represents 5%-7% of total healthcare expenditures, which is less than half of the 14% average in Western European countries.
The federal government estimates that approximately 84 million Americans presently lack adequate access to primary care.
The national per capita supply of primary care physicians declined between 2005 and 2015 by an average of five physicians per 100,000 persons. And, by 2030, the shortage of primary care physicians is expected to grow to close to 50,000. Given the concentrated supply of primary care physicians in urban and suburban centers this will have a disproportionate impact on people living in rural areas, who are generally older, poorer, sicker, and less well-insured.
According to the Lown Institute, the shortage of primary care doctors can be attributed to low numbers of residency slots, the salary gap between primary care doctors and specialists, and high rates of student debt which drive many into higher-paying specialties.
And, it's not as if the issues cease once one becomes a primary physician.
The administrative burdens imposed by requirements related to electronic medical record keeping and quality metrics have been cited as contributing to widespread primary care physician burnout. Evidently, primary care doctors have two hours of required documentation for every hour of patient care.
Furthermore, while novel payment models that promote "value over volume" sound promising, if not optimally planned for and executed they can be an added burden for primary care clinicians.
As an illustration, in May of this year the Centers for Medicare and Medicaid Services (CMS) unveiled an initiative called the Primary Care First payment models, which CMS hopes to implement starting in January 2020. Primary care physicians can voluntarily sign up for the program. CMS asserts that these new payment models will reduce administrative burdens for primary care physicians, and enable them to earn "performance-based payments" if they deliver care to Medicare patients that meets certain pre-determined targets that decrease downstream healthcare costs.
However, what may deter some physicians from signing up is that the new payment models could actually increase their administrative burdens and practice costs. The CMS value-based payment models require a more expensive staffing mix for primary care practices, in part because of requirements regarding compilation and reporting of a wide array of data on patients. In itself, imposing such data requirements is sensible, but for primary care practices finding money for this investment may be a problem.
All this raises the question how to reconfigure the healthcare system to revitalize primary care. The obvious answer is to increase primary care reimbursement to reduce the disparity between primary and specialty care income.
But, there may be other less conventional ways to achieve the objective. The Lown Institute proposes that the government cover the cost of medical school for students who devote ten years or more to primary care and that CMS residency subsidies are offered to those entering the field of primary care.
Further, the Lown Institute wants to promote more use of direct primary care models: Here, primary care practices bypass insurers by directly charging patients a monthly membership fee in lieu of accepting insurance payments. The membership fee covers all or most primary care services including clinical and laboratory services, consultative services, care coordination, and comprehensive care management.
The counter argument to the decline in primary care may be that primary care has been partly supplanted by the emergence of numerous urgent care facilities. But, urgent and emergency room care for that matter do not replace primary care. In fact, inefficiencies abound when the emphasis is on acute rather than maintenance or chronic care.
