Here’s a central difficulty of the Affordable Care Act: If everyone has access to health insurance, then everyone has access to all the medical care they need. Curing sickness and preventing death costs a lot, and society can go broke providing costly medical care to everyone. Society saves money and lives when everyone sees a primary care doctor who works to keep people well.
But we don’t and won’t have enough primary care providers in the United States. We’re already facing a shortage. The Affordable Care Act is only going to make it worse.
There are many people thinking about how to build the future health care workforce we need to keep Americans healthy, myself included. How do we train more primary care providers? How do we encourage them to work in the communities where their services are needed most?
The National Health Service Corps is one answer, and the president is banking on it through a proposed $3.5 billion expansion through 2020, increasing the number of primary care providers involved in the program from 9000 to 15,000.
The next critical step becomes this: Once we have recruited and trained these health care professionals committed to providing primary care in underserved communities, how do we get them to stay in the profession and places where they are needed most?
I went into medical school knowing I was going to do primary care. I knew I would care for the underserved. I had a scholarship from the federal government saying it was so — I had successfully applied for and received a National Health Service Corps scholarship. For each year of medical school the American people paid for, I would complete a payback year of doctoring in an underserved community, providing the cost-saving care people needed to stay well. A doctor to the community, saving money for society.
Today I am a family physician working in a community health center on Chicago’s South Side. In the federally qualified health center where I work, we have some old-timers — people who have been there for ten years or more, who have found their niche and stay with community medicine.
We have many more new graduates — NHSC scholars doing their payback, or NHSC loan-repayors who get significant dollars to pay back school loans. These NHSC-sponsored physicians come and go. Burnout.
A few years back, my medical director informed me that he assumed I would be leaving as soon as I was done with the NHSC payback. He planned to lose his physicians to burnout. He planned for me to leave. I was a cog in a broken machine to be worn out and replaced as soon as my NHSC contract expired. This was disheartening. In March, I submitted the final paperwork signing off from the NHSC program, and my medical director expressed surprise at my decision to stay.
Why should staying in a community health center be the surprising decision?
There is a two-fold trick to increasing the number of primary care providers in underserved communities. First there is bringing them into the community health centers through financial incentive and professional development programs such as the National Health Service Corps. Second there is ensuring a sustainable practice environment, so that primary care providers work in a positive practice environment and choose to stay in the communities that need them most.
We need policies in place to incentivize the creation of healthy practice environments. There are new incentive programs in place for community health centers to become patient-centered medical homes, with extra points awarded for implementing practices that optimize patient care.
We need new incentive programs for community health centers to become provider-centered medical practices, with extra points awarded for implementing systems that ensure input from all who are directly involved in patient care to optimize patient care delivery in their center.
The first step could be as simple as pay community health centers a $10,000 bonus for each physician who signs on to stay after the end of their NHSC contract. This external incentive could drive practices to think about what they need to do to retain their physicians, instead of automatically planning to lose them and replace them with a new set. Funding could be made available to study the management practices of the most effective community health centers, who retain their practitioners and provide outstanding care, then scale those practices nationally.
As a nation, we can’t continue to invest in building a primary care provider workforce only to lose us to burnout. We need to find and implement successful strategies for provider engagement and empowerment, making health care providers equal partners with community health center administration in the provision of quality, affordable, accessible health care for all Americans.
Kohar Jones is a family physician who blogs at Prevention Not Prescription.
