Primary Care Might Get its Due With Health Reform

It’s hard to delineate the possible progress being made in fixing the primary care problem in California and the nation, without first looking at how bad that problem is, according to Kevin Grumbach of the UCSF Department of Family and Community Medicine, who addressed an audience of health professionals at UC Davis Medical Center in Sacramento this week.

“Health systems and regions built with primary care have better outcomes, better quality of care, lower costs and more equitable care,” Grumbach said.

“The trouble is, we’re finding that the whole foundation of primary care is crumbling.”

The number of new physicians entering primary care specialties has been plummeting.

• The number of current primary care doctors has also fallen, as the burnout rate has increased.
• Family practice numbers are down significantly, “but it’s even more dire in general internal medicine,” Grumbach said. The rate of new physicians entering internal medicine practices, he said, “was about 50 percent 10 years ago, and now it’s down to 1 in 5. In fact, the latest data suggests it may be down to 1 in 10 now.”
• The number of physician assistants going into primary care has also dropped, he said. “The only ones hanging in there, it looks like, are family nurse practitioners.”
• The gap in physician compensation has grown, between primary care physicians and specialists.
• Demands are increasing on primary care physicians — with more preventive procedures added onto the regular diagnosis and treatment physicians also need to do.

“The result of all of this,” Grumbach said, “is a destabilizing effect on medicine.”

Fewer primary care physicians, greater demand for physicians, less pay, more time demands on existing primary care doctors, that all adds up to a health care crisis in the nation, and in California, he said.

“Out of all of this is coming a new compact,” Grumbach said. “The primary care reform compact. Our message to payers, hospitals, the public is, you need to invest more resources into primary care — and if you do that, we will not just deliver adequate care, but we will think in a more patient-centered manner, lower costs and increase quality.”

The answer, he said, is the patient-centered medical home, team care empowered by upgraded health information technology. All of that, he said, has been among the tenets of national health care reform.

Ideally, all of the scheduled maintenance people need — from mammograms to flu shots — could become part of a patient’s overall health care, freeing up the physician to handle diagnosis and treatment.

“The whole point is, couldn’t that be delegated off the plates of the primary care doctor?” Grumbach asked. “Wouldn’t it be nice if that just all got done automatically?”

The good news is, he said, that many influential groups see the need for fixing primary care, from large employers to politicians to patients.

“When you ask people, what do you want from health care, it turns out that they want integrated, whole-person care,” Grumbach said. “They actually yearn for someone to put it all together.”

So there are several elements of national health reform that could make a difference, he said.

• The Affordable Care Act proposes a 10% increase in primary care physician fees in Medicare. And since many health plans base their fee structure on what Medicare pays, that could make an across-the-board difference, he said. (Though it is unclear what effect the impending 24% cut in Medicare physician payments will have on that.)
• There are medical home projects underway in the Centers for Medicare and Medicaid Services, in the Department of Defense and the Department of Veterans Affairs, among many other projects, Grumbach said.
• There is support for health information technology upgrades, particularly with ARRA funding.
• And there are efforts to recruit more physicians to enter primary care specialties, through state extension and community care programs.

“You need more than a medical home,” Grumbach said. “You need a medical neighborhood. You need the system to work well, to build the system with primary care as the base, but you need everything else to work well, too. You need all of this to fit together.”

And that’s on its way, he said. The question, of course, is whether or not it’s enough.

“But the pendulum,” Grumbach said, “does seem to be swinging in primary care’s direction.”