Why we have a primary care crisis – and how we solve it
The US has two big problems in primary care: 1) We don’t have enough primary care clinicians, and 2) Primary care clinicians are buried under a mountain of burdensome administrative regulations, with not enough time and resources.
In a two-part blog series in Health Affairs, Lown Senior Vice President Shannon Brownlee, internist Dr. Andy Lazris, and chairman of the Department of Family Medicine at Jamaica Hospital Medical Center Dr. Alan Roth, lay out the reasons behind these major issues and a blueprint to start fixing them (Read Part 1 and Part 2 on the Health Affairs website). The shortage of primary care clinicians can be attributed to many things – low number of residency slots, the salary gap between primary care doctors and specialists, high rates of student debt pushing trainees into higher-paying specialties.
However, the authors suspect another important reason fewer doctors are choosing primary care is that students see how primary care clinicians often have to work harder with fewer resources than specialists:
“Medical students also avoid primary care after watching primary care physicians struggle with short patient visits, large patient panels, increasing administrative burdens imposed by electronic medical record keeping and quality metrics, and significant night call responsibilities, all of which are disproportionate to the burden on specialists.”
New payment models that promote “value over volume” sound promising, but unfortunately have made things worse for many primary care clinicians, the authors write. Primary care clinicians are rewarded for jumping through administrative hoops and demonstrating they have achieved certain quality measures, while their pay decreases if they don’t fulfill the new measures. Many of these quality measures have not been validated, are not supported by evidence, do not benefit patients, and can even lead to overuse; in other words, they “serve mostly to distract from patient care.”
“Regardless of the inevitable resistance, the time to act is now”
Brownlee, Roth, and Lazris suggest several solutions for solving our primary care clinician shortage:
- Reduce the salary disparity between PCPs and specialists by replacing the specialist-run RUC with a truly representative advisory committee to determine physician fees
- Have the government cover the cost of medical school for students who devote ten years or more to primary care
- Provide more CMS residency subsidies to primary care fields
- Encourage direct primary care models
- Create “Primary Care Trusts” that provide state-based universal coverage for primary care
These policies may not be politically easy to implement. As the authors write, some of them will certainly anger training hospitals and specialty societies. But the authors are not backing down. “Regardless of the inevitable resistance, the time to act is now,” they write.