Amid Shortage Concerns, Could the ACA Bolster Primary Care Ranks?

Many health experts have predicted a primary care shortage as millions of consumers gain health coverage under the Affordable Care Act. But others say that the value of primary care providers and their services will increase under the law, attracting more doctors into the field.

Primary care doctors make up more than one-third of the physician workforce in the U.S. HHS’ Health Resources and Services Administration has designated more than 6,000 regions of the U.S. as primary care health professional shortage areas — meaning there are 3,500 or more residents for every one PCP. In addition, HRSA projects an overall shortage of about 20,400 primary care physicians by 2020.

Expanding the scope of practice for nurse practitioners and physician assistants could help to alleviate the shortage, but the American Academy of Family Physicians has said that such providers are not entering the workforce quickly enough to offset the gap.

At the same time, some medical schools and residency programs have reported an increased interest in primary care among students. However, some experts are dubious that primary care is really becoming the first choice for more new doctors. “Road to Reform” this week takes a look at the arguments.

Increasing the ‘Relative Value’ of Primary Care

Anoop Raman, a resident in the NYPH-Columbia Family Medicine Residency Program and a blogger at Primary Care Progress, writes in a KevinMD blog post that the “relative value” of primary care physicians will be higher under the ACA, particularly as accountable care organizations — designed to reward health care providers for keeping their patients healthy — increase in popularity.

“One of the less talked about elements of the [ACA] is how it will likely lead to massive changes in the ways insurance companies and hospitals make money,” Raman writes. Patients who receive preventive medicine and remain healthy as a result will “form the main revenue base for ACOs,” he notes.

In addition, the ACA has led to steadily rising pay for PCPs and an increasing number of scholarships and loan forgiveness programs available to medical students who choose to study primary care, Raman writes. Such changes could be drawing more new doctors into the field.

“Payment systems are changing to the benefit of primary care; our breadth of practice is broadening; and there are burgeoning opportunities for primary care doctors to become leaders in medicine,” Raman writes.

Are More New Doctors Choosing Primary Care?

Many residency programs across the U.S. are reporting a record-high number of primary care residency applicants. It’s not clear, though, whether that is the result of a heightened interest in the field or an oversaturation of applicants to specialist programs.

Rebecca Berman, director of Brigham and Women’s Hospital’s primary care residency program, said, “When I graduated from medical school, many of the top medical students felt pressure to go into dermatology and radiology. Now those people are going into primary care.”

Raman agrees, writing in his blog post that medical students are recognizing that “while health care is in a state of great flux, the changes that are happening are elevating the status of primary care doctors in order to keep patients healthy and prevent illness.”

Kelly McGarry, director of Brown University’s general internal medicine residency, told Primary Care Pulse that “there is a sea change going on nationally, an increasing national respect for primary care disciplines.” McGarry noted that while the number of general internal medicine residency applicants doubled, applications to the university’s categorical internal medicine residency program only climbed about 15% to 20%. If medical students were applying to primary care programs as a fall back, McGarry said, “I think we would have seen the same increase in categorical applications as we saw in primary care.”

At the same time, some experts suggest that the increase might be because some students interested in a more specialized field are applying for primary care residencies as a “back-up plan.”

Meanwhile, in a survey conducted by SERMO — an online social network for medical professionals — one gastroenterologist said that it’s “hard to determine the extent of the increase in primary care applicants when many are applying to internal medicine residencies,” noting that many such residents may plan to go into cardiology, gastroenterology or other specialties.

In the same survey, a rural family medicine physician said the apparent surge in primary care residency applicants is an “illusion” caused by more U.S.-trained doctors and fewer foreign medical graduates applying.

Payment Reforms: Key To Addressing Shortage

One critical change that could draw more physicians to practice primary care is major payment reform. Uwe Reinhardt, a Princeton University economist, described the U.S. as a place “where a nation pays a primary care physician poorly relative to other specialists and then wrings its hands over a shortage of primary care physicians.”

A Health Affairs study concluded that “improving access to primary care will require major macro-level system reform — in particular, increases in primary care reimbursement” to reduce the income gap between primary care and specialty providers and “to invest in primary care practice improvement.”

Access issues could be eased in the interim if primary care providers added evening and weekend hours, implemented open-access scheduling, increased time between return-visits and used telehealth and phone consultations, as well as delegated routine tasks to non-physician staff, according to the study.

Despite the need for payment reform and other challenges, many think the primary care field is on an upswing. McGarry at Brown University said the ACA at least has renewed interest in the field and that “primary care is going to have another heyday.”

Around the Nation

Here’s what else is making the news on the road to reform.

Inconsistencies in ACA applications: In the Wall Street Journal‘s “Market Watch,” Russ Britt highlights a recent HHS Office of Inspector General report that found nearly three million inconsistencies in ACA applications.

ACA encourages entrepreneurs: WebpageFX President William Craig outlines in Forbes how the health reform law could be a boon to entrepreneurs by offering greater access to non-employer health coverage.

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