Commentary: Improving the Supply and Distribution of Primary Care Physicians
Dorsey, E. Ray MD, MBA; Nicholson, Sean PhD; Frist, William H. MD
Dr. Dorsey is associate professor of neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland.
Dr. Nicholson is associate professor, Department of Policy Analysis and Management, Cornell University, Ithaca, New York.
Dr. Frist is former majority leader, U.S. Senate, and, at the time of writing, was University Distinguished Professor (2009–2010), Vanderbilt University, Nashville, Tennessee.
Editor's Note: This is a commentary on Petterson S, Burke M, Phillips R, Teevan B. Accounting for graduate medical education production of primary care physicians and general surgeons: Timing of measurement matters. Acad Med. 2011;86:605–608.
Correspondence should be addressed to Dr. Dorsey, 600 N. Wolfe St., Meyer 6-181D, Baltimore, MD 21287; telephone: (410) 614-5991; fax: (410) 502-6737; e-mail: firstname.lastname@example.org.
The current medical education system and reimbursement policies in the United States have contributed to a maldistribution of physicians by specialty and geography. The causes of this maldistribution include financial barriers that prevent the individuals who would be the most likely to serve in primary care and underserved areas from entering the profession, large taxpayer subsidies to teaching hospitals that provide incentives to act in ways that are not in the best interest of society, and reimbursement policies that discourage physicians from providing primary care. The authors propose that the maldistribution of physicians can be addressed successfully by reducing the financial barriers to becoming a primary care physician, aligning subsidies with societal interests, and providing financial incentives that target primary care. They suggest that the Patient Protection and Affordable Care Act of 2010 takes steps in the right direction but that more financially prudent measures should be taken as politicians revisit health care reform with heightened financial scrutiny.
The supply of physicians in the United States has two principal shortcomings: a skewed distribution of specialists with a shortage of primary care physicians and a maldistribution of physicians by geography with a shortage of physicians in many rural areas.1 Numerous policy measures have been proposed to address these shortcomings,2,3 but few changes have occurred at the federal level. With an estimated 30 million newly insured people set to enter the health care market over the next six years, the demand for primary care services will skyrocket. The current physician shortage and maldistribution will be aggravated, and quality of care will be threatened.
In this issue of Academic Medicine, Petterson and colleagues4 critically examine the Resident Physician Shortage Reduction Act proposed in the U.S. Senate and House in 2009. As written, the act would increase the number of Medicare-funded graduate medical education (GME) slots in teaching hospitals by 15%. To qualify for the additional funding, a teaching hospital must have already self-financed additional resident positions above the cap on GME positions enacted in the Balanced Budget Act of 1997 and have at least 25% of its residents in primary care and general surgery programs at entry into the residency program. As Petterson and colleagues rightly point out, the latter requirement would exert a larger and more desirable change on the distribution of specialists if the threshold were applied later (e.g., after two or more years of training) by rewarding institutions that train more physicians in specialties in short supply. Their analysis indicates that the requirement's language would exclude only 14% of teaching hospitals that train only 2% of residents. In essence, the act would reward teaching hospitals that had financed their own expansion of residency positions without increasing the proportion of primary care physicians and general surgeons trained in the United States. The act would—at taxpayer expense—reward behavior that provides a private benefit to hospitals but does not address the public's health needs.
By seeking to expand the aggregate supply of primary care and other physician residency slots, this policy measure and others like it miss the mark. The problem is not a shortage of primary care residency positions but, rather, a shortage of interest in—and of U.S. applicants for—existing primary care positions. In the 2010 National Resident Matching Program, for example, only 54% of current family practice residency positions were filled by graduating U.S. medical students, the lowest percentage for any specialty.5 If there is insufficient interest among the largest group of incoming residents, increasing the number of positions available will not address the fundamental imbalance. Efforts should instead be focused on finding ways to increase future and current physicians' desire to practice primary care. This may be accomplished throughout the continuum of training by changing the composition of medical students and improving compensation for practicing primary care physicians.
Medical school graduates from rural areas and underrepresented minority groups are the most likely to serve in underserved communities and are more likely than peers to pursue careers in primary care,6,7 but individuals with such backgrounds often cannot afford to become doctors. In an Association of American Medical Colleges survey, the top two reasons otherwise qualified minority college graduates chose not to pursue a career in medicine were cost and duration of medical training.8 In 2008, the average parental income of a matriculating medical student was $169,000,9 and the average medical school debt on graduation in 2010 was $110,000.10 Not surprisingly, individuals from more modest means may be discouraged from entering the medical profession. Reductions in the upfront financial costs of a career in medicine, such as scholarships for medical school and more equitable pay in residency, may help attract the individuals who are most likely to address the principal physician supply shortcomings. Moreover, reductions in the duration of training would substantially reduce the financial burden of training11 and thus potentially increase the supply of future primary care physicians. One idea that has recently been advocated12 is reexamining the duration of medical school and considering a four-year combined undergraduate and medical school curriculum, followed by a mandatory two-year primary care “internship” paid for by the government with practice in an underserved area. One year of this required internship could count toward the three years of primary care residency. Other proposals that decrease the duration of training while maintaining educational excellence are worth considering as well.13
Equitable pay during residency could help reduce the financial strain on many residents and enable them to make career and specialty decisions that are less constrained by monetary considerations. Teaching hospitals have the ability and resources to pay residents more. In response to limits on residents' work hours, teaching hospitals have hired “replacement residents,” often physician assistants, whom they pay up to twice as much as they pay residents.14 In the presence of a cap on government-funded GME positions, many teaching hospitals have hired and paid additional residents without any subsidy,15 which suggests that residents generate considerable value to hospitals through the clinical care they provide. One estimate places the economic value of the labor that would be lost just to follow recent Institute of Medicine recommendations on work hours restrictions at $1.6 billion.16 Given that, on average, teaching hospitals receive GME subsidies in excess of $100,000 per resident per year,17,18 they could devote a larger proportion of those government subsidies to the compensation of residents. Linking current and future GME payments to higher resident salaries would enable more residents to choose a specialty based on nonmonetary factors and help teaching hospitals address concerns about accountability15 for how such funds are spent.
Additional changes in GME funding could reduce the primary care physician shortage. One option is for the federal government to provide a larger GME subsidy for primary care positions than for specialty positions, as it did on a small scale in 1994 and 199519 through the Direct Graduate Medical Education program. In response to funding caps on GME positions, teaching hospitals have self-financed residency positions outside primary care, which suggests that hospitals are using training positions to meet their own rather than society's goals.20 Two questions arise from this behavior: What magnitude subsidy is required to encourage hospitals to train specialists? Would a larger subsidy for primary care translate into a higher salary for primary care residents and, thus, increased interest among medical students? Residents in primary care may indeed generate less economic value to hospitals than residents in other fields (e.g., neurosurgery) because of the relatively short duration of their training and their limited engagement in activities that are large sources of hospital revenue (e.g., procedures, surgeries). Medicare could differentiate GME subsidies by specialty, year of training, and societal needs (e.g., geriatrics). Although a system of differential subsidies has the potential to save money and align taxpayer funds with societal interests, and has been proposed previously,21 it has yet to be implemented.
Another option, which has been implemented in parts, is to move subsidies for primary care residencies from teaching hospitals, where inpatient and specialty care are most valued, to settings (e.g., ambulatory care centers) where outpatient and primary care may be most appreciated. In these settings, the training of primary care physicians and their labor are more likely to be appreciated. The Balanced Budget Act of 199722 and the Patient Protection and Affordable Care Act of 201023 (PPACA) have taken steps in that direction.
Perhaps the biggest factor in increasing interest in primary care is increasing reimbursement. Raising prices is the market solution to shortages. Until very recently, that has not happened for primary care. Medicare has increasingly threatened large cuts in reimbursement rates that would only exacerbate the shortage of primary care providers. Higher pay would encourage new physicians to choose primary care as their long-term career and enable current physicians, who often cannot afford to provide primary care, to do so. Altering the behavior of current physicians is especially powerful because it can occur over the short term and obviate the need to wait for new cohorts of physicians to be trained at high cost to taxpayers.
PPACA took some modest steps in the directions outlined here, yet they are almost certainly insufficient to appreciably address the increased demand for primary care services. For example, PPACA authorizes but does not guarantee or appropriate funds for scholarships for medical school and loan repayment. Through the Teaching Health Center Graduate Medical Education Program, it authorizes but does not appropriate support to increase the training of primary care physicians in settings other than teaching hospitals, such as rural health clinics. More important, it offers incentive payment programs in Medicare of up to 10% for primary care practitioners and a similar incentive for general surgeons in health professional shortage areas.24 A recent report suggests that a much larger increase may be needed to change behavior and increase the supply of primary care physicians. Specifically, a primary care physician's annual practice income would need to increase by 63% (or $122,000) to generate the same lifetime earnings as that of a cardiologist.25
Despite some directionally appropriate but insufficient actions, most funding initiatives intended to change the composition of the medical workforce focus on the training institutions rather than on the individuals who actually provide primary care. Aligning incentives, especially monetary ones, for current and future physicians with the society's need for more primary care providers would bring about the desired change more quickly and dependably than will continuing to support the existing infrastructure that has contributed to the maldistribution of physicians and shortages in primary care specialties. As policy makers continue to revisit health care reform, likely with heightened financial scrutiny, they have the opportunity to change current incentives in a fiscally prudent manner.
The authors acknowledge Arthur Garson, Jr., MD, MPH, for his helpful critique and suggestions.
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