Spread the Wealth to Primary Care?

The American College of Physicians, which represents about 126,000 internists, has called on the incoming Obama Administration to ask Congress for a 10 percent increase in Medicare payments to primary-care physicians for a period of 18 months. In a letter to Tom Daschle, President-Elect Obama’s choice for Secretary of Health and Human Services, ACP President Jeffrey P. Harris, MD, said that this immediate increase in generalist physician compensation was necessary to reverse a growing primary-care shortage.

“Without funding to stabilize primary care practices, many will go under and have to close,” Harris wrote. “Primary care physicians who own small practices are struggling to survive because of inadequate access to credit, losses in their own investments, slower collections and more ‘bad debt’ and uncompensated care as their patients are unable to pay their bills and the numbers of uninsured increase.”

Harris said that recent studies “project a growing shortage of 45,000 or more primary-care doctors.” This insufficiency will increase, he predicted, as an accelerating number of primary-care physicians leave practice without enough young doctors to replace them. According to one recent study, he noted, only 2 percent of current medical students plan to go into primary care.

The internists’ association has been prophesying the imminent collapse of primary care for at least two years. How bad is the situation today?

One indication is that, as a result of the Massachusetts universal coverage program, many state residents are having difficulty in finding primary care doctors or getting appointments with them. Shortages are also being reported in areas of the country where there are high rates of unemployment, uninsured people, and Medicaid recipients.

But, partly because of the problems that hospitals and physician groups have encountered in recruiting primary-care physicians, generalist incomes have risen substantially in recent years. According to the 2008 Physician Compensation and Production Survey of the Medical Group Management Association, the median income of primary-care doctors—including family physicians, general internists, and pediatricians—rose 6.3 percent to $182,322 in 2007 from $171,519 in 2006. Between 2003 and 2007, generalist compensation jumped 16.2 percent. By comparison, the median income of specialists rose just 3.2 percent in 2007 and 12.1 percent for the four-year period. On the other hand, specialists earned a median $332,400 in 2007—one reason why most medical students plan to become specialists.

There is plenty of concern about the future of primary care outside the ACP. A recent report from the American Association of Medical Colleges, for example, warned that physician shortages are likely to become much worse by 2025. The AAMC predicted that the gap between supply and demand would widen faster in primary care than in the specialties, and that the nation risks becoming dependent on foreign medical graduates for primary care.

The ACP doesn’t believe that a temporary 10 percent raise for generalists will solve the long-term problem. Along with other societies representing primary-care doctors, it maintains that part of the answer lies in the development of “patient-centered medical homes” that restore the central role of primary care doctors in care management and coordination. But the hefty fees that primary-care physicians would receive in return for providing medical homes would have to come out of somebody else’s pocket—and specialists are going to fight fiercely to prevent that pocket from being theirs.