QUALITY: Reformers Ponder the Shortage of Primary Care Physicians

As the Obama administration prepares a health reform strategy, they must grapple with the shortage of primary care physicians, reports the New York Times. If health reform passes, some question whether we'd have enough doctors in all parts of the country to cover all the newly-insured.

Before you start panicking, remember the shortage of physicians isn't exactly breaking news. To successfully bring down health costs, increase access, and ensure quality, comprehensive health reform is going to have to address the doctor shortage as part of a systematic approach to changing how we deliver care, and what we pay for. The goal is more value-based purchasing, with a health care system that rewards the overall quality of patient care and management, not just paying specialists to do more stuff.

There are a number of proposed solutions to the primary care workforce problem, including increasing enrollment in medical schools, more and better use of nurse practitioners and physician assistants, and the expansion of the National Health Service Corps, to place more doctors and nurses in poor or rural areas.

Under the current system, the financial incentives for doctors are heavily skewed against the practice of primary care. Recent graduates come out of medical school with an average of $139,517 dollars in debt. Because specialists are reimbursed far better than primary care doctors, many doctors thus feel compelled to specialize. To offset this phenomenon, Congress is considering revising the payment structure of Medicare reimbursement. The Medicare Payment Advisory Commission (MedPAC) has suggested paying up to 10 percent more for primary care, while paying less to specialists (the specialists, overall, are not crazy about this solution). Senate Finance Committee Chairman, Max Baucus, has prioritized such payment changes in his proposed reforms. "Primary care physicians are grossly underpaid compared with many specialists," Senator Baucus, told the Times.

Since enacting health care reform, Massachusetts has also run across the problem of doctor shortages. The State has a begun a series of initiatives aimed at promoting cost containment, transparency and efficiency in the delivery of quality health care. Recent legislation directed the State's Medicaid program to restructure its payment system to support primary care practices that use a medical home model. A public-private partnership has used loan-repayment as a tool to recruit providers to community health clinics. Massachusetts has also been a leader in reporting quality measures. Earlier this month, Massachusetts Health Quality Partners released its 5th annual report on clinical quality of care at primary care physicians’ offices.  Massachusetts physicians performed above the national average on 28 of 30 measures and above the 90th percentile on 14 out of 30 measures.

The primary care shortages are symptomatic of greater shortcomings within our health care system. Ultimately, the solution lies in realigning incentives to ensure that patients get the right care the first time. By reducing overuse and unwarranted variation in the delivery of care, we can help ease the short-term shortages in our workforce while laying the foundation for a provider community that more closely meets the needs of our population.