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Ensuring the Future of Primary Care

Manthous, Constantine A. MD

doi: 10.1097/ACM.0b013e3182358b19
Letters to the Editor

Associate clinical professor of medicine, Bridgeport Hospital and Yale University School of Medicine, Bridgeport, Connecticut;

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To the Editor:

Market forces have shaped a health care economy in which there are insufficient primary care physicians (PCPs).1 * Those same forces could be reshaped to solve this crisis. Although extenders (nurses, physician assistants) may assist in absorbing the overall greater demand for medical services, we simply need a greater supply of physicians if every citizen is to have a PCP. In addition to previously described measures of loan forgiveness for U.S. medical graduates2 and the construction of new medical schools, I propose two additional, market-based solutions that could significantly augment supply faster.

Pay for performance of primary care (P4PPC). It is highly unlikely that payment for primary care (PC) services can be increased sufficiently to draw enough physicians to choose PC as their exclusive practice.3 However, every subspecialty physician is also fully certified and competent to provide PC. Pay for performance has been used heretofore as an incentive for high-quality medical practices. Why not P4PPC? For example, if a pulmonologist documented that she was the primary caregiver for 500 patients a year, she would be eligible for an increment of reimbursement. The Department of Health and Human Services estimates a shortage of 21,000 PCPs by 2015.1 If the >100,000 subspecialty internists4 could be enticed to provide even 20% of their practice as PCs, the shortfall could be attenuated or eliminated. The government may not be able to offer financial support for P4PPC, but accountable care organizations could offer incentives (e.g. bonuses for PC), leveraging market mechanisms to provide financial security to physicians while they serve local PC needs. Although using subspecialists is not an ideal solution—they've chosen their primary vocations for a reason, and it might take time for them to refurbish their PC skills—they could help attenuate the looming crisis until more definitive solutions can be developed.

International medical graduates (IMGs). IMGs constitute more than 40% of physicians training in U.S. internal and family medicine residencies,5 a very large pool of candidates for filling the PCP shortfall. Many physician–trainees come to the United States with the dual purpose of training and citizenship; there are several gateways to citizenship for this large group. Those training on J1 visas may be granted a waiver of return home (required for two years) under the Conrad 20 program in exchange for practicing in an underserved geographic area for three years as a pathway to citizenship. For those training on H1b visas, one route to a green card (i.e., permanent citizenship) is to apply as an “alien of extraordinary ability,” which requires published research. Immigration authorities have viewed subspecialty expertise/scholarship and social service as grounds for granting green cards. Insofar as PC is now the “extraordinary ability” we truly need, simply tuning immigration policy to complement our country's needs would entice more talented IMGs to choose PC as their route to citizenship. Higher-quality graduates might be preselected if training programs nominated their best IMGs for “PCP green cards.”

Although the solutions I have proposed may not be ideal, our country faces a substantial structural barrier to “health care for all” that will require innovative interim solutions.

Constantine A. Manthous, MD

Associate clinical professor of medicine, Bridgeport Hospital and Yale University School of Medicine, Bridgeport, Connecticut;

*The complete list of references is available at
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