OP-ED

Reviving the Pipeline: A Call to Action For All

Annie Lowrey’s July 28 article “Doctor shortage likely to worsen with health law” in the New York Times noted the growing shortage of primary care doctors particularly in economically disadvantaged communities, both in rural and inner-city America. This problem will likely get worse before it gets better as more Americans gain coverage and seek a regular source of care. As the article suggests, training more doctors and incentivizing them to pursue careers in primary care will be a key part of the solution. And it will require a multipronged campaign, using both some of the traditional strategies for workforce renewal and a few unique tactics not typically deployed in efforts to fix health care.

The primary care workforce pipeline had dried up before the Affordable Care Act was passed. Currently, one out of every five Americans lacks access to primary care. As a result, up to 75% of the care delivered in emergency departments these days is primary care . This overcrowds and overburdens EDs, raises costs, and limits EDs’ ability to do what they were designed to do: provide acute, emergency care that makes the difference between life and death. So the primary care shortage threatens our access not only to primary care but also to emergency care.

How did we get here? Many are quick to point to primary care doctors’ low salaries compared to those of their sub-specialist colleagues. Indeed, choosing a career in primary care rather than a sub-specialty means walking away from 3.5 million dollars of additional lifetime earnings.That’s tough to do when you’re looking at $150-200,000 of debt, which is the average debt of an American medical student at graduation.But the crisis in our primary care pipeline goes far beyond the money.

Medical schools aren’t recruiting enough of the right people in the first place. Numerous studies show that people from rural and lower SES communities are more likely not only to pursue primary care careers but also to return to those disadvantaged communities to practice. Unfortunately, medical schools’ acceptance of applicants from these communities has declined substantially in recent years. Instead, medical school admissions criteria favor more affluent applicants who are ultimately more likely to pursue sub-specialty careers.

Further, these same medical schools have been actively discouraging primary care careers for decades. This is due partly to cultural biases that place super-specialized medicine on a pedestal over generalism, which is due in part to how NIH research dollars flow, predominantly supporting cutting edge biomedical/technological research usually advanced by sub-specialists. The result is that primary-care-oriented trainees face four long years of admonishments against primary care careers – a hidden curriculum in which generalists are portrayed as nothing more than referral centers and lectures from so-called primary care mentors warn trainees against primary care careers at all costs. It’s no wonder fewer than 20% of Americanmedical school graduates are choosing to go into primary care today. We’ve all but legally barred them from doing so.

If that weren’t enough, in their rotations, trainees see the most dysfunctional, antiquated and frustrating approaches to primary care delivery that exist in our health care system. The combination of a sicker, more-complex-than-average patient population, inadequate funding and support for improvement efforts, and predominantly part-time faculty who are frequently not available for teaching or improvement activities has created a toxic milieu. I can’t tell you how many primary care students and residents have noted that it feels like their clinics were specifically designed to destroy their interest in primary care.

Trainees need exposure to the existing models of care delivery that are transforming primary care to work better for patients, providers and payers. Patient-centered medical home (PCMH) practices, which use highly-coordinated, enhanced access, team-based care, are showing exciting results : higher quality of care, decreased ED visits and hospitalizations, happier patients, and lower overall spending. And it seems that exposure to this new model of care is one of the best ways to help trainees see a future for themselves in primary care. The problem is, only a tiny group of trainees are exposed to these types of clinics due to poor penetration of this model in the academic environment . This is something that needs to be remedied.

Revitalizing the primary care pipeline is going to require a multipronged campaign, with the greatest thrust being a change in the way we pay physicians in order to create greater equity between sub-specialist and generalist salaries. If we really value primary care as the foundation of our health care system, purchasers must invest in it and give clinicians the financial support they need to do their job well. We must also expand the definition of a ‘primary care provider’ to include Nurse Practitioners and Physician Assistants, two critical members of the primary care team who can immediately expand access to high value primary care services in communities across America.

As the patient-centered medical home model spreads across the country, academic leaders must ensure it also takes root in our medical school practices, where trainees are both learning what it means to deliver high-value care and making career decisions. We’re increasingly realizing that trainees not only have much to gain from these experiences, but they have much to give. And the sooner we get medical students involved in inter-professional training opportunities with nursing students, social work students, etc, the better. ‘Learners learning together’ is a critical first step to get trainees used to practicing as a team – which is one of the key ingredients of high value primary care delivery.

American medical schools must be held accountable for producing the primary care providers this country needs. This means not only reinvigorating primary care programming and developing new approaches to recruitment and retention of those individuals most predisposed to primary care careers, but also teaching the actual patient-centered, team-based skills that providers need in order to deliver high-value care today. The public cannot afford to wait for medical schools to do the right thing. We must leverage our collective power as purchasers and consumers to demand that these institutions break from their “business as usual,” specialty-focused approach to training. Maybe it’s time for a national campaign to publicly call on all American medical schools to step up to the plate and start revitalizing the primary care pipeline.

Finally, we – from academic faculty to laypeople – must all recognize the role we play in perpetuating the bias in America that being a primary care provider just isn’t good enough. Whether it’s through our questions tofamily members in medical school about what “specialty” they’re going to pursue, or our negative responses to their explicit intentions to practice primary care, we make clear that we wish they’d do anything *but** *go into primary care. I implore all of us to face up to our responsibility to remedy and reverse these biases. So, next time a student tells you he or she is planning to pursue a primary care career, do yourself, your country and the future generations of Americans – who are currently on target to not have access to their own primary care provider – a favor and thank that student for doing the right thing.

We’ll never achieve real health care reform without a foundation of robust primary care in this country. However, fixing the pipeline is no small undertaking. It will require a multifaceted approach to remedy the financial, academic, cultural and political challenges that have plagued the primary care pipeline for years. It will also require us thinking more expansively and inclusively about the definition of a primary care provider. But to increase the primary care physician supply, our course is clear: we must come together now, as a nation, and both collectively demand more from our medical schools while also providing that system with the support it needs to change. Without that, it will be next to impossible to help our academic medical machine break free from it’s specialty-centric approach to workforce creation.

Andrew Morris-Singer, M.D., co-founded the precursor to Primary Care Progress to advocate for improved primary care programming at Harvard Medical School. He now serves as President of Primary Care Progress and speaks regularly on the topic of clinical innovation in primary care,primary care advocacy and trainees’ critical role in that process.

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Lori Christensen MD MBA FACSLucy StoneCraig "Quack" Vickstrom, M.D.Bill SpringerJames Ripa Recent comment authors
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Lori Christensen MD MBA FACS
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Lori Christensen MD MBA FACS

There is no wonder that the primary care “pipeline” has dried up it has become almost impossible to stay in practice. I am one of those specialists that charge for procedures and would normally not rely on an office practice for income. However, I crossed over to the dark side twelve years ago and opened an Integrative Medicine Practice. Although I am not a primary care provider I have come to understand the untenable position my colleagues struggle with in providing primary care to patients. My practice based in functional medicine is centered on a significant amount of time with… Read more »

Lucy Stone
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Craig "Quack" Vickstrom, M.D.
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Craig "Quack" Vickstrom, M.D.

You know, the more I look at the trends, the more I think if I want to stay in primary care, my best option would be to emigrate.

Bill Springer
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Bill Springer

I’m afraid that I agree with those who point to higher costs as the most likely outcome of increasing what we pay PCP’s. It will take a number of years for the higher pay to translate into better working conditions and an influx of new freshly minted PCP’s. And if specialists respond by pushing their rates up, this latter benefit may not be realized.

Peter1
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Peter1

“I just want to pay primary care physicians enough to allow them to practice at the top of their license.”

Margalit, first I agree with PCPs as best defence and for good compensation, but why aren’t they “practicing at the top of their license” now? From posts this is not PCPs not doing their duty, but too little of them – for which higher pay is the “solution”. If patients are using PCPs as primary entrance then how are the specialists getting so much of patient care?

Margalit Gur-Arie
Guest

I think Peter that the two problems are intertwined. Because we pay them so little PCPs are forced to churn through patients quickly to make ends meet and in 10 minutes intervals it is almost impossible to do much more than refer people to specialists. This creates a distorted image of primary care (which really should be called general practice because primary implies that something secondary exists) and the appearance that other less qualified people can do this primary triage and refer everybody out as needed. I doubt this is an occupation that can appeal to a bright and bushy… Read more »

Peter1
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Peter1

“I know some have said that even if you triple the PCP pay, the docs will still keep the same schedule and style and just triple their income. I don’t think so.”

That would be human nature and without some enforcement of time spent with patient I’m afraid most would add to bank account without better care.

James Ripa
Guest

I agree with everything in the article. If you are a physician practicing in a physician shortage area please make sure you are using modifier AQ on your claim submission. This will at least get you a higher visit reimbursement from Medicare.

mary
Guest

Thank you. This is a well thought out and well written article. I believe you really want to be a PC doctor and I send kudos. I wish many more people would go for happiness and contentment instead of money and fame.
Since the government is making us all buy insurance maybe they could help out too by making available grants to rural and middle/low income families if they sign to go to an area most in need. If they forfit, they repay the grant……makes sense?

Margalit Gur-Arie
Guest

It’s the money.
If we paid $200 for an average primary care office visit (instead of $60), there would be enough money to delegate the paperwork to the “team”, and there would be enough money to listen to patients, educate patients, “engage” patients, and “coordinate” care, and refer less, and there would be enough money to repay student loans and, yes, to change the image of “anybody can do primary care”.
And there would be more than enough students wanting to practice this highly prized type of medicine instead of merely “cutting for stone”.

southern doc
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southern doc

Exactly.

Peter1
Guest
Peter1

“If we paid $200 for an average primary care office visit (instead of $60), there would be enough money”

Enough money from whom? You can bet there would be NO reduction to specialist reimbursement. Where would the cost curve go then? “It’s the prices stupid”.

Margalit Gur-Arie
Guest

Enough money from nothing more than a rounding error in the total cost of care. There will be reduction in utilization of specialists and the associated, supposedly, excessive tests & procedures. The cost curve should slow its upwards growth over time. Hoping for more than that without purposefully skimping on quality is not realistic anyway. Yes, it is the prices, but not all of the prices. And since we seem hellbent on experimenting, why not try something like this in some enlightened State somewhere…. The only caveat I can see here is that the primary care docs MUST remain independent… Read more »

DeterminedMD
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DeterminedMD

“And since we seem hellbent on experimenting, why not try something like this in some enlightened State somewhere…. The only caveat I can see here is that the primary care docs MUST remain independent and beholden to no one but their patients.”

Isn’t that a tad incongruent with the terms of PPACA? IPAB for instance.

Gotta hate those trivial truths, eh?

Peter1
Guest
Peter1

“There will be reduction in utilization of specialists and the associated, supposedly, excessive tests & procedures.”

Really, a reduction in income for specialists? Are you going to legislate PCPs as the gatekeepers to specialists?

Margalit Gur-Arie
Guest

No, I don’t want to legislate anything. I just want to pay primary care physicians enough to allow them to practice at the top of their license. I think that’s something they want and something they think will improve the quality of care and I am much more inclined to listen to docs when it comes to health care than any other learned experts.

If we are really interested in quality patient-centered care, and if we really believe that such care is also more affordable, than we should at least try it out…..

BobbyG
Guest

We’re paying $500 per hour for Outside Counsel for our HIE.

Good physicians should make at least as much as attorneys. But, we don’t want to pay for it.

andymc
Guest
andymc

” If that weren’t enough, in their rotations, trainees see the most dysfunctional, antiquated and frustrating approaches to primary care delivery that exist in our health care system. The combination of a sicker, more-complex-than-average patient population, inadequate funding and support for improvement efforts, and predominantly part-time faculty who are frequently not available for teaching or improvement activities has created a toxic milieu. I can’t tell you how many primary care students and residents have noted that it feels like their clinics were specifically designed to destroy their interest in primary care” I work with medical students every day from one… Read more »

DeterminedMD
Guest
DeterminedMD

Politicians are about micromanagement and cookie cutter applications to societal issues. PPACA had no interest to do otherwise. Yeah, let the uninvested MDs and non physicians like NPs blaze this trail. Good luck America, nah, scratch that, PPACA supporters, I look forward to your figurative iceberg collision by 2014!

southern doc
Guest
southern doc

Larger organizations can provide more paperwork support (and “pay for performance” data massaging) because they negociate fees that are 2-3x as much as what smaller groups are paid (with facility fees thrown in).

I don’t think that gravy train is going to last.

Randall Oates, M.D.
Guest
Randall Oates, M.D.

The larger organizations have been able to afford to both take on some of the paperwork and subsidize primary care physicians (typically >$100k/annual) because the PCPs are feeders into their profit centers. With health reform, and the migration away from fee-for-services, it will become increasingly untenable to subsidize these feeder physicians into what will become cost centers. The need for more data at the point of care will only grow. For example, the back office is not going to be able to code to the specificity of ICD10 after the encounter. ICD10 and the data needed to measure/improve care have… Read more »

maggiemahar
Guest

On the paperwork– As more and more PCPs became part of larger organizations, they will have more help with all of the paperwork. One of the things many of today’s docotrs like about being on salary at such an organization is tgat the back office takes care of filing for payments. They practice medicine. At Mayo, doctrorsdon’t even know how much insurers pay for their services, or whether a patient has insurance. Not their problem. Finally, under reform, if doctors want to be paid extra for good outcomes. Medicare also will be asking for more information. And as Medicare increases… Read more »

Vikram C
Guest
Vikram C

Peter1, a very relevant comment and one of my railing point on inadequacy of statistics. Say, that insurance is just 15% odd of overall healthcare expense. That is expense on side of payors. It doesn’t include big billing group expenses on side of provider. Then is the question of value add coming from payors and the wonks note that it’s only now insurance is trying to focus on making people’s live’s healthier. I would like to ask these wonks to live uninsured for some time and haggle prices with doctors. Then argue about bills with provider billing group. Try getting… Read more »

Randall Oates, M.D.
Guest
Randall Oates, M.D.

The more immediate solution to the lack of capacity in primary care is not via the pipeline but by removing the waste within the primary care process. Multiple studies have revealed that primary care clinicians are performing 2-3 hours daily of documentation and administrative tasks. This can almost all be removed with proper use of information technology and the care teams. Doing so would increase primary care capacity by 30% almost immediately. Sadly, the current approaches being commonly implemented at the point of care are not increasing primary care capacity, and commonly seem to either be attempting to turn doctors… Read more »

Peter1
Guest
Peter1

“Multiple studies have revealed that primary care clinicians are performing 2-3 hours daily of documentation and administrative tasks.”

Could it be private insurance hassles having to serve multiple providers and fight for reimbursement?