The Milbank Memorial Fund is an endowed operating foundation that publishes The Milbank Quarterly, commissions projects, and convenes state health policy decision makers on issues they identify as important to population health.
We focus on a number of topic areas identified by state health policy leaders as important to population health.
The Center for Evidence-based Policy at Oregon Health & Science University is a national leader in evidence-based decision making and policy design.
Keep up with news and updates from the Milbank Memorial Fund. Get the latest from thought leaders, including Christopher F. Koller, president of the Fund.
We publish The Milbank Quarterly, as well as reports and issues briefs on topics important to population health.
June 2016 (Volume 94)
Catherine D. DeAngelis
One of the most serious problems facing the health care professions and the public’s health in the United States is the shortage of primary care, or general care, doctors. Indeed, ignoring or failing to solve this issue has the potential to undermine the entire American health care system.
Some argue that there is little need to worry about this issue given the rising numbers of nurse practitioners (NPs) and physician assistants (PAs). As a general pediatrician with more than 40 years’ experience and practice, having been involved in several early NP programs, and having written the first textbook for NPs,1 I respectfully disagree. In order to better understand how dire this situation is, one needs to understand the role primary care doctors play in our health care system every day of the week.
The Role of Primary Care Doctors
Primary care consists of more than health maintenance or the treatment of minor illnesses, which today are often taken care of by NPs and PAs. When practicing medicine as they have been carefully trained to do and allowed the time to actually perform, primary care doctors function much like the conductor of an orchestra. They organize, supervise, and monitor every aspect of patient-centered medical care. While they do assume responsibility for health maintenance, disease prevention, and treatment of minor illnesses, sometimes with the assistance of NPs and PAs, they also diagnose and treat major illnesses, either by themselves or with the assistance of subspecialists, and coordinate essentially all care.
The primary care they provide involves ready access, continuity, and coordination in a partnership with the patient. It follows “the medical home” concept,2 conceived by Calvin Sia, a general pediatrician from Honolulu, and adopted by the American Academy of Pediatrics in 1992 and by the American Academy of Family Physicians, the American College of Physicians, and the American Osteopathic Association in 2007.
Everyone needs primary care at some point, and for much of the 20th century, general practitioners provided this care. As more advances were made in medical knowledge, medical schools and hospitals developed primary care residency programs for family medicine, general internal medicine, general pediatrics, and osteopathic medicine—the current primary care specialties.
In a well-functioning system, the subspecialists who provide patients with more complex care coordinate their care with that of the patient’s primary care physician. With advancing knowledge and technologies, the requirement for care by subspecialists has become increasingly necessary. However, it is rare for any subspecialist to provide and coordinate all the medical care necessary for any one patient. The need for care by several subspecialists becomes necessary, especially with an aging population, and someone must coordinate it all. As an orchestra would produce dissonant music without a conductor, a patient’s care is dissonant without a primary care doctor “conductor.” One of the most common complaints from patients is the difficulty they have in traversing the medical complex that makes up their care.
With the lack of coordinated care, expenditures rise because of misuse of emergency rooms, duplication of services, unnecessary visits to subspecialists by patients shopping for medical answers, and the ordering of unnecessary, often expensive tests and procedures.
In 2014, health care spending in the United States increased 5.3% to $3 trillion and the gross domestic product devoted to health care spending was 17.5%, an increase from 17.3% in 2013.3 Primary care accounts for only about 6% of health care expenditures, or about 1% of the GDP.
Why the Problem Exists
Given the importance of primary care doctors, why is there an insufficient number to meet the needs of the public? Here are some short answers. The average annual salary for a primary care doctor in the United States is about $180,000, in some cases one-half to one-third that of subspecialty doctors. Considering that many medical students graduate with debts from student loans of about $150,000, it is no wonder that fewer graduates choose primary care specialties.
How did this discrepancy in salaries happen? Enter insurance reimbursement. It is easier to have an objective measurement of “worth” or cost if something can be counted or visualized. Hence, a surgical intervention or the use of an instrument, especially an expensive one, is reimbursed at higher rates than cognitive expertise. Primary care doctors seldom, if ever, use instruments that are reimbursed; a stethoscope requires the gentle touching of the patient without discomfort (providing it is warm), but that is not rewarded.
For example, I remember practicing as a general pediatrician where I would make a diagnosis in a child that required surgical intervention. I would spend time explaining the problem to the parent and child and trying to answer questions and allay fears and concerns throughout the hospitalization and in follow-up care. My time spent for this intervention was more than three times that spent by the surgeon or the anesthesiologist, but my reimbursement was not a tenth of theirs. Fortunately, that was not important to me, but it is to many medical students.
In light of these salary differences, some material rewards are less accessible to primary care doctors and their families. Moreover, time spent with patients is substantial and in many cases more than that of many subspecialists because primary care doctors are essentially always on call for at least some of their patients. Further, primary care doctors spend a great deal of time completing forms for insurance reimbursement or office records, especially when using electronic health records.
Except for patients’ feelings about their own doctors, the respect and admiration the average person has for almost any subspecialist is greater when compared with that for a primary care doctor. Accurate or not, that is the reality felt, and avoided, by many medical students.
If the health needs of the population were to be shown on a triangle, the base and upward would be for primary care, the middle for secondary (subspecialty) care, and the apex for tertiary care. However, if that same triangle were to display the salaries of those providing the care, it would be turned upside down. While subspecialists deserve higher salaries, a two- to three-fold difference is simply neither fair nor sustainable, as the consequences for primary care needs have shown. If the reimbursement issue were resolved, the problems of lifestyle and prestige would likely be mitigated.
According to the American Medical Association’s master file, 246,000 physicians practice primary care, and according to the Agency for Healthcare Research and Quality, there are 56,000 NPs and 30,000 PAs involved in primary care. While NPs and PAs cannot assume the same role as primary care doctors because of differences in education and training, they can and do play a very important role working as team members with primary care doctors, thereby saving the doctors time to spend with patients requiring their expertise.
Clearly the most important issues that must be resolved before more doctors will choose primary care practice are financial reimbursement and better use of practice time. In the interim, doctors like me, who enjoy a fulfilling and joyful career, must continue by example and word to encourage medical students to select the wonderfully rewarding life of a primary care doctor.
Author(s): Catherine D. DeAngelis
Read on Wiley Online Library
Volume 94, Issue 2 (pages 246–250)
Published in 2016
Catherine D. DeAngelis is Johns Hopkins University Distinguished Service Professor Emerita and professor emerita at the Johns Hopkins University Schools of Medicine (Pediatrics) and Public Health (Health Policy and Management), and editor-in-chief emerita of JAMA, where she served as the first woman editor-in-chief from 2000 to 2011. She received her MD from the University of Pittsburgh’s School of Medicine, her MPH from the Harvard Graduate School of Public Health, and her pediatric specialty training at the Johns Hopkins Hospital. She has authored or edited 12 books on pediatrics, medical education, and patient care and professionalism and has published over 250 peer-reviewed articles, chapters, and editorials. Her recent publications have focused on professionalism and integrity in medicine, conflict of interest in medicine, women in medicine, and medical education. DeAngelis is a member of the Institute of Medicine and a fellow of the American Association for the Advancement of Science and the Royal College of Physicians (United Kingdom). She currently serves on the advisory board of the US Government Accountability Office, is a member of the board of Physicians for Human Rights, and serves on the board of trustees of the University of Pittsburgh.
Hospital Community Benefit Spending: Leaning In on the Social Determinants of Health
Behind the Bipartisan Kumbaya on Opioids and Drug Abuse