The inadequate supply of primary care physicians is a complex issue that has been a national concern for many years.Â The solution to this problem must consider multiple factors.
One fundamental issue relates to the pipeline that produces family medicine and other primary care physicians, such as general internists, pediatricians, and obstetrician-gynecologists.Â In recent years, medical students are choosing to enter specialty, rather than primary care residencies.Â A factor in this decision is likely the huge loan burdens many medical students accumulate while in medical school.Â On average, their medical education debt exceeds $150,000 per graduate.Â Incomes for medical specialists are often several times higher than incomes for primary care physicians.Â If incomes for primary care physicians were increased, more medical students might choose a primary care career path.
Another disincentive to primary care practice has been the responsibility for large numbers of patients per physician, leading to briefer, unsatisfying encounters between physician and patient. Â In contrast, the experience of the Group Health Cooperative in Washington state demonstrates that implementation of an effective medical home practice model can create a much enhanced practice setting that benefits both patients and primary care providers.Â One of the design elements at GHC was a deliberate reduction in patient panel size achieved by hiring more physicians.
California has the infrastructure and organization to advance the medical home model.Â Therefore, within the Department of Health Care Services, we believe that the medical home model has great potential to improve medical quality for the Medi-Cal program by enhancing the integration and coordination of health services provided to the program’s beneficiaries.
Importantly, as has been demonstrated in various sites around the country, the medical home model can allow primary care physicians to practice in a setting that is more professionally rewarding and satisfying.Â DHCS will be working closely with stakeholders to encourage dissemination of effective applications of the medical home model.
A recent California HealthCare Foundation report, “Physician Participation in Medi-Cal, 2008,” by Bindman, Chu, and Grumbach, noted that Medi-Cal reimbursement rates for primary care services are at approximately 50% of Medicare.Â Stakeholders have cited such rates as a barrier to physician participation in the Medi-Cal program.Â While there is currently a $19 billion deficit in the state budget, an increase in physician reimbursement rates would be an important issue to be addressed by state government.
We must do everything possible from a policy perspective to improve the efficiency of our administrative processes so that providers can be paid on a timely basis, while ensuring the fiscal integrity of the billing process.Â As a new fiscal intermediary assumes operations, we will be implementing numerous system enhancements to improve our efficiency.Â In the managed care portion of the program, we will continue to work with plans, medical groups, and other stakeholders to focus on policy and programmatic changes that allow for a practice environment for the Medi-Cal program that can consistently attract and retain primary care providers.
Given the short timeframe, many stakeholders anticipate shortages in the primary care physician workforce.Â Certainly, policymakers in government and the health care sectors should be ensuring that nurse practitioners, physician assistants and other health professionals are fully utilized as part of California’s primary care network.
There may be innovative approaches to care delivery, such as the use of group appointments and expansion in telehealth, that could increase productivity of the primary care delivery system. Additionally, the further development of electronic health records across the state, with available federal funding, may also help to increase the efficiency of care delivery.
Finally, the importance of healthy lifestyles and communities cannot be overemphasized in reducing the need for and cost of medical care, both primary and specialty care.