The Case of the Disappearing PCP

Patients who reside in Massachusetts, the first state in the United States to legislate universal coverage for all residents, often wait months to get an appointment with a primary care physician (PCP). Massachusetts, along with almost every other state is suffering from a “severe” shortage of family physicians and internists. According to a report issued by the American Academy of Family Physicians http://www.aafp.org/ and the National Association of Community Health Centers http://www.nachc.org/ almost 20 percent of Americans, 56 million people who are insured, have inadequate or no access to primary care physicians because there is a shortage of providers.

Recent data from Medical Schools show that only two percent of graduating students are electing to pursue careers in family practice and internal medicine, a decline of 52 percent over the past seven years. The cause of this seismic shift in career choice is money. Reimbursement rates for primary care have declined; student loan rates have skyrocketed and the complexity of caring for an aging population and chronically ill patients has become more challenging, especially when there is no pot of gold at the end of the rainbow.

The healthcare reimbursement system rewards doctors for procedures, not for diagnoses. A specialist who performs a procedure in a 30-minute visit is paid three times more than a primary care specialist who spends that same 30 minutes discussing and working through a patient’s issues. As a result primary care physicians must squeeze in three patients in 30 minutes just to stay even with specialists.

At a time when primary care is most needed just to service the first wave of the 76 million baby boomers in the United States, who become eligible for Medicare, there are fewer providers. Patients older than 85 who have chronic conditions requiring close supervision will rise by 50% in this decade alone. And there are always new young families looking for family physicians, who are in short supply.

Meanwhile Title VII funding, one of the only outside sources of funding to stimulate medical education, residency education, faculty and academic development in primary care was slashed by 54% in 2006 from $88.8 million for FY 2005 to $41 million for FY 2006. There is a resolution that would restore Title VII funding in the FY2008 budget, however, the impact of the 2006 budget cuts will be felt for some time.

There is no question that the primary care physician/gatekeeper plays a critical role in 21st century healthcare where patient issues are complex and most patients require consults with specialists and numerous tests that must be monitored and managed. Solving the shortage of PCPs is critical. There are alternatives to the PCP handling everything such as the use of nurse practitioners in the physician office to offload some of the standard cases, and the proliferation of walk in clinics both in hospitals and in retail establishments that see less serious patients and are open evenings and weekends. However, the expertise and interaction between primary care physicians and the patient population cannot be replaced and must be preserved. That will only happen if the healthcare system finds better ways to incent doctors to remain in primary care. The healthcare infrastructure including hospitals, insurers and medical schools must collaborate to make primary care a more attractive career path by working on better financial packages for aspiring physicians and more attractive compensation models for working physicians.