Health Reform: Addressing Primary Care Shortages

Today I received the latest two editions of the New England Journal of Medicine. These editions contained three articles on the primary care shortage and how to resolve it.

One, Jim McDermott, MD,”Harnessing Our Opportunity to Make Primary Care Sustainable," pages 395-397, February 3.

Doctor McDermott, a psychiatrist and the lone Democrat among House of Representative's 17 doctor-politicians, says the health reform law affords a chance to correct primary care shortages. Success, he maintains, depends on fixing the SGR. At the very least, Congress should separate and shield prevention services from SGR cuts. Congress should restructure the composition of the AMA's Relative Value Update Committee (RUC). Specialists now dominate the committee. Congress should relieve medical students who choose primary care from medical school debt, which often exceeds $200,000. Training should be provided outside academic medical centers n primary care settings, and Congress should heavily promote CMI (Centers for Medicare and Medicaid Innovation) to create primary care networks and accountable care organizations.


Two, Leighton Hu, PhD, et al from the Department of Health Policy, George Washington University, “The States’ New Challenge – Securing Primary Care for Expanded Medicaid Populations,“ pages 493-495, February 10.

The authors say states with the largest expected Medicaid expansions have the fewest primary care doctors. Eight states – Oklahoma, Georgia, Texas, Louisiana, Arkansas, Nevada, North Carolina, and Texas – have the greatest shortages. The ACA marginally eases these shortages by investing more in Federal Qualified Health Centers, the National Health Service Corps, and by increasing Medicaid fees up to 100% of Medicare fees in 2013-2014. But in the end, the authors conclude, “Addressing the goals of health reform will take a combined federal, state and local strategy involving resource deployment and actions designed to expand the available short-term and long-term supply of well-trained primary care professionals who are ready and willing to serve the newly insured.”

Three, Stephen Smith, MD, Associate Dean of Medical Education, Brown University Medical School, “A Recipe for Medical Schools to Produce Primary Care Physicians, “ pages 496-497, February 10.

Smith recommends these steps: 1) Medical schools must recognize what discourages medical students from entering primary care – too much to do, too much to learn, and too little time to do both, disparaging remarks about primary care practitioners from residents and faculty members ; 3) too few adequate teaching sites for primary care; 4) the need for medical school leaders to better articulate the primary care mission; 5) making the dean of new medical schools a primary care physician; 6) accepting students on the basis of altruism, the desire to serve the poor, and assume social responsibility rather than solely on MCAT scores; 7) a patient-centered a curriculum based on coordinating their needs, 8) the ability to function in inter-professional teams; 9) emphasis on adherence to medications, smoking cessation, and other preventative practices, and 10) capitated payments and the narrowing of income disparities between primary care physicians and specialists.

Richard L. Reece, MD, blogs a Medinnovation and has a website under constuction. www.doctorreece.com. He is the author of three recent books, Obama, Doctors, and Health Reform (Iuniverse, 2009), Innovation Driven Health Care (Jones and Bartlett, 2007), and an E-book, Pros and Cons of Accountable Care Organizations (Practice Support Resources, 2011). He works with but does not speak for The Physicians Foundation, a 501C3 organization representing physicians in state medical societies. Opinions expressed in his blogs are his alone. He can be reached at rreece1500@aol.com