By 2015, according to the American Association of Medical Colleges, the U.S. health care system will be short approximately 30,000 primary care doctors. Yet, everything we read says that primary care physicians are the linchpins of the new (really rediscovered) coordinated care models being talked about by health care policy cognoscenti. What gives?
Since the mid-1990s the number of medical students pursuing a career in primary care has been on a steady, sinking decline, a trend likely fueled by the realization that the traditional Marcus Welby-style primary care practice doesn’t pay the bills. Throw in hefty malpractice insurance fees and the average overhead often hits 60 percent. There’s also the question of boredom and prestige. In medical school, future physicians are exposed to a breadth of compelling cases; in primary care, they’re asked to refer the majority of those away. And if you are interested in interesting procedures, medicine has clearly evolved to favor specialists.
And about the pay disparity— it is stark. Most residents looking at a career in primary care can expect to earn about $29.58 an hour. This, compared to $74.45 per hour as a specialist (by retirement, specialists will have earned about $3.5 million more). The main reason is that the options for reimbursement in traditional primary care practice are limited. Much of what PCPs do is cognitive work–checkups, simple diagnoses, referrals–and that just doesn’t pay as well. As for the reimbursable procedures that PCPs are able to perform, they’re few, but of a wide variety; getting such a breadth of claims paid is often a job in itself.
So here’s something surprising: In 2010 and 2011 the number of primary care residency matches increased by ten percent per year. For 2012, those gains were at least maintained, when the National Resident Matching Program last week reported a one percent rise in such matches.
Two factors may be accounting for this welcome change of tide. First, there’s accountable care. Within this premise of having one group–an accountable health care provider network–hold all the risk and be paid on quality measures and outcomes, primary care physicians can be even more effective quarterbacks, coordinating care for a team of specialists. Even more targeted are patient-centered medical homes, currently being tested within a number of ACOs. Here, PCPs are available for consultation, and for mapping out care, which is then put into action by a staff of physician extenders.
The second development is the Direct Care (also referred to as Concierge) model, such as One Medical and MD VIP, which have become a viable economic model for PCPs who want to maintain a traditional primary care practice. While the exact structure of direct care practices can vary widely—whether insurance is accepted, or scope and kinds services a patient can expect, for example–they all rest on the idea that patients pay annual or retainer fees to their primary care physicians.
If these trends continue, the primary care doctors of the future will have to be experts at communication, system change and quality improvement. They will need to focus less on traditional hospital tasks like putting in a central line (already largely atrophied skills given the widespread use of hospitalists), and more on skills like promoting teamwork, being able to build consensus and persuasively articulating ideas. Many will become experts in healthcare IT. What’s interesting is that already we’re seeing more young doctors and residents who possess these skills. It is these physicians who will lead the charge of translating medicine into the digital age.
Peter Alperin is an internal medicine physician and the head of the advisory board at Doximity.
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