Government and Regulations

Endangered Species?


The 1961 classic “The Ecology of Medical Care,” published in the New England Journal of Medicine, mapped out the broad features of the American healthcare landscape.1 For every 1,000 adult, the study suggested, 750 reported an illness, 250 consulted a doctor, and nine were admitted to a hospital in any given month. The subsequent arrival of Medicare and Medicaid fundamentally changed the U.S. healthcare system. And yet an updated version of the study, released in 2001, yielded surprisingly similar numbers, with 800 residents experiencing symptoms, 217 visiting a physician’s office, and eight being hospitalized in an average month.2

“It helps kind of put in perspective where the bulk of care really occurs,” says Ann O’Malley, MD, a senior researcher at the Washington, D.C.-based Center for Studying Health System Change. “It’s in outpatient provider offices, mostly primary-care provider offices.”

Dr. O’Malley and a host of other observers, however, are warning that the keystone members of this healthcare ecosystem are in serious trouble. As organizations such as SHM have likewise made clear, the accelerating shortage of general internists, family practitioners, and other PCPs has created sizable cracks in the supports of the entire healthcare infrastructure.

How big are the cracks? The number of medical school students pursuing a primary-care career has dropped by more than half since 1997, according to the American Academy of Family Physicians. And with the number of medical students entering the field unable to keep up with attrition, the remaining doctors are facing increasingly difficult working conditions. “Overloaded primary-care practices, whose doctors are aptly compared to hamsters on a treadmill, struggle to provide prompt access and high-quality care,” asserted a 2009 op-ed in the New England Journal of Medicine.3 The result: a vicious circle of decline leading to an anticipated shortfall of roughly 21,000 PCPs by 2015, according to the Association of American Medical Colleges.

Many primary-care providers had already stopped taking new patients when June’s Medicare reimbursement rate fiasco allowed the sustainable growth rate (SGR) formula’s mandated 21.2 percent rate cut to temporarily go into effect. Legislators eventually plugged the hole, but not before a new round of jitters seized the nation’s physicians, and reports proliferated throughout the summer about Medicare beneficiaries being unable to find a doctor willing to see them. The recession hasn’t helped, with more privately insured patients waiting longer to see their doctors to avoid copays, and with hospital emergency departments becoming de facto primary-care centers for those patients who have waited too long or have no other alternatives.

According to recent surveys, PCPs earn about half the salary of dermatologists and an even smaller fraction of an average cardiologist’s pay.

Uneven Challenges

Not only is there an acute shortage of primary-care physicians, Dr. O’Malley says, but there is also a distinctly uneven distribution throughout the country. For hospitalists, she says, the implications could be profound. “Hospitalists are increasingly going to be evaluated around issues such as avoiding hospital readmissions and [reducing] length of stay,” she says, “and if they want to improve both of those things, one of the keys is improving chronic care management in the outpatient setting, and improving follow-up post discharge.”

Both metrics will require the involvement of outpatient care providers, underscoring the importance of good communication and mutual respect. Despite the longstanding support of hospitalists for their primary-care counterparts, however, leaders are still being forced to address the perception that HM is somehow bad for what ails PCPs.

In a recent online article posted on the Becker’s Hospital Review website, SHM President Jeff Wiese, MD, SFHM, responded to one such criticism: that hospitalists make primary care less attractive for physicians. Hospitalists are not to blame for the decrease in interest, he asserted, but are actually complementary to the PCP role. And with millions more Americans about to be newly insured, that complementary relationship will be even more important. “It’s a tremendous waste of resources to use a primary-care provider for [a hospital visit]. We need to move into proactive mode, not reactive mode,” Dr. Wiese said. “More PCPs are going to need even more time in the clinic to handle the increased number of patients, and you lose the luxury to run back and forth between the clinic and the hospital. For those that can develop a trusting relationship with a hospitalist, you can work together to see more patients and provide more care.”

So what’s the real root of the problem? Money. According to recent surveys, PCPs earn about half the salary of dermatologists and an even smaller fraction of an average cardiologist’s pay. With medical school debt routinely reaching $200,000, Dr. O’Malley and other analysts say, many doctors simply can’t afford to go into primary care.

“It all comes down to payment, basically,” she says. “At present, our payment system for physician services and for medical procedures is quite skewed. It overcompensates for certain types of diagnostics and procedures, and it undercompensates for the more cognitive type of care that primary-care providers provide.”

The Road Ahead

Fortunately, some relief is trickling in. One measure strongly supported by SHM and included in the Affordable Care Act is a 10% Medicare reimbursement bonus for primary care delivered by qualified doctors, slated to begin next year. In June, U.S. Department of Health and Human Services Secretary Kathleen Sebelius announced a separate, $250 million initiative to boost the primary-care workforce. The money would help train PCPs by creating more residency slots, and offer new support for physician assistants, nurses, and nurse practitioners. Among the measures included in last year’s stimulus package, an expansion of the National Health Service Corps will provide more debt-relief opportunities for PCPs. And in mid-September, HHS tapped stimulus funds to award another $50.3 million for primary care training programs and loan repayment.

The Obama administration has claimed its combined actions “will support the training and development of more than 16,000 new primary-care providers over the next five years,” according to a June 16 HHS press release.

Observers say those measures alone are unlikely to be enough to stem the tide, however. “It’s definitely a step in the right direction,” Dr. O’Malley says of the Medicare bonus. “I don’t think it’s going to solve the primary-care workforce issue, because a 10% bonus, given how low primary-care physician salaries are compared to their specialist counterparts, is not going to be that much of an increase. Among the physicians that I’ve talked to and other healthcare providers, few feel that that’s sufficient enough to really encourage a lot of people to pursue primary care.”

Several other efforts now underway might help:

  • Texas Tech University Health Sciences Center unveiled a new Family Medicine Accelerated Track program, which will allow primary-care medical students to complete a degree in three years. Certain students will receive a one-year scholarship, meaning that overall debt for some could be half that of the standard four-year program.
  • Reid Hospital and Health Care Services in Richmond, Ind., successfully reversed a downward trend in primary-care referrals by forming its own nonprofit subsidiary corporation, Reid Physician Associates. The nonprofit will include about 50 employed outpatient providers by year’s end to complement the 233-bed hospital’s inpatient staff.
  • Danville, Pa.-based Geisinger Health System has begun paying the salaries of extra nurses for both in-network and independent primary-care practices. The nurses manage patients’ chronic conditions, ensure that they are following prescribed treatments, and communicate with hospitalists and other providers about transitions of care. Although still in its early stages, the experiment suggests the nurses are helping to spot problems, prevent unnecessary hospitalizations, and save money.

The Geisinger experiment is among the first steps toward a patient-centered medical home model of care. An eventual Medicare-led expansion of such medical homes and accountable-care organizations, now in the early experimental stages, could provide even more direct support to PCPs. To be successful, though, Dr. O’Malley says the models will need to focus on paying providers fairly for the value they bring to the system. “Obviously, payment reform is what we need if we’re ever going to develop a sustainable primary-care workforce in this country,” she says. TH

Bryn Nelson is a freelance medical writer based in Seattle.


  1. White KL, Williams TF, Greenberg BG. The ecology of medical care. N Engl J Med. 1961;265:885-992.
  2. Green LA, Fryer GE Jr., Yawn BP, Lanier D, Dovey SM. The ecology of medical care revisited. N Engl J Med. 2001;344(26):2021-2025.
  3. Bodenheimer T, Grumbach K, Berenson RA. A lifeline for primary care. N Engl J Med. 2009;360(26):2693-2696.

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