Having enough primary care physicians (PCPs) does far more to increase life expectancy than boosting the ranks of specialists, but today’s misaligned incentives chase young doctors away from where they are most needed. And data published today in JAMA Internal Medicine
show that the crisis in primary care is growing, especially in rural areas.1
Authors led by Sanjay Basu, MD, of Stanford Department of Medicine used a decade’s worth of county-level data to show that the concentration of primary care physicians is rapidly declining just as the focus on population health is increasing. From 2005 to 2015, the rate of PCPs fell from 46.6 to 41.4 per 100,000 population, with the greatest loss in rural areas. The authors note that the overall number of PCPs is increasing, but the ranks are not keeping up with population, and young physicians do not always set up practices where they are needed.
Yet the call for primary care to be medicine’s hub is warranted, as the authors showed that life expectancy rose 51.5 days for every additional 10 PCPs per 100,000 population. By contrast, an additional 10 specialists added 19.2 days to life expectancy.
As discussed by both the authors and in an accompanying editorial,2
there are reasons for why primary care has become unattractive, and why rural America is having a particularly hard time attracting the family doctor, who was once a pillar of the community. Among the findings:
Greater physician supply was associated with lower population mortality, which Basu et al said “may have important consequences for population health.” An additional 10 PCPs was associate with reduced cardiovascular, cancer, and respiratory mortality by 0.9% to 1.4%.
- Basu et al write that Medicare’s Accountable Care Organization (ACO) programs “fail to explicitly direct more resources to primary care supply, instead relying on the usual Medicare fee schedule.”
- In their editorial, Sondra Zabar, MD; Andrew Wallach, MD; and Adina Kalet, MD, MPH; wrote successful PCP training programs have not been able to stem the decline of PCPs in rural areas. They write, “This decline has been attributed to factors such as desired income, level of debt, type of patients cared for, and perceived work hours and workload of a primary care physician.”
Incentives such as loan forgiveness, a jump start on residency, and practice constructs on par with those in specialty care—where PCPs get more support and physician assistants handle documentation and patient education—could improve patient outcomes and create a more satisfying work-life balance for physicians, the editorial states.
The crisis in primary care has been recognized for some time; a 2015 article
in The American Journal of Managed Care®
proposed rewarding teaching hospitals if 30% of graduates remained in primary are 3 years after residency. The article, led by Zirui Song, MD, PhD, argued that hospitals themselves benefited from having more primary care physicians.
Relying less on the American Medical Association Relative Value Scale Update Committee for rate-setting and more on other professional associations, including the American College of Physicians and the American Academy of Family Medicine, could close the gap between what primary care physicians and those in specialty care are paid, and thus start the process of realigning incentives, Zabar et al note. CMS sets the tone with Medicare for commercial insurers, and there is hope that the payment model Comprehensive Primary Care, now under way within the Center for Medicare and Medicaid Innovation, will bring insights that bring broader reform.
Both Basu et al and the editorial writers agree: fixing the PCP shortage will require new incentives.
“Higher pay and lifestyle preferences lead most students to choose non-primary care fields, even when their hearts say primary care,” the editorial states. “We must reverse this trend with substantive changes in physician payment policy; no amount of superb primary care training or innovative practice reform will prevent further declines in primary care physician density, which will lead to worsening health in the United States.”
- Basu S, Berkowitz SA, Phillips RL, et al. Association of primary care physician supply with population mortality in the United States, 2005-2015 [published online February 18, 2019]. JAMA Intern Med. doi:10.1001/jamainternmed/2018.7624.
- Zabar S, Wallach A, Kalet A. The future of primary care in the United States depends on payment reform [published online February 18, 2019]. JAMA Intern Med. doi:10.1001/jamainternmed/