Passage of the Patient Protection and Affordable Care Act (ACA) in 2010 created a number of challenges for primary care, not the least of which was providing enough primary care physicians to care for the millions more patients that would be insured due to provisions in the ACA. All bets on the future of the ACA, however, were suspended when it faced legal challenges that ended up in the Supreme Court in 2012 and when it faced the possibility of full repeal depending on the outcome of the national election.
When the Supreme Court upheld most of the provisions of the ACA and then the national election left the Washington power structure virtually intact, the pressure was on to entice more students into entering primary care to meet the future expected demand for primary care physicians.
The message on the importance of primary care seemed to be getting through as more medical schools added departments of family medicine. In fact, the addition of a family medicine department at Mount Sinai School of Medicine in New York City left just 10 allopathic medical schools in the United States without a family medicine department.
Students seemed to gradually be getting the message, as well, and the family medicine match rate once again ticked upward, albeit only slightly. In 2012, the fill rate for family medicine residency programs improved only by 0.1 percent compared with 2011, which saw a record-high fill rate of 94.4 percent.
It's not enough, said (then) AAFP President Glen Stream, M.D., M.B.I., of Spokane, Wash. "Family medicine is the foundation of improved health care in this country," said Stream. "We must continue to promote programs that generate and sustain student interest in the specialty."
In response to continuing efforts by nurse practitioners (NPs) and others to be granted independent practice authority, the AAFP issued a report in 2012 that focuses on primary care in the 21st century.
The AAFP points out in the report that "the best, most efficient (health care) is provided by teams of health professionals in the patient-centered medical home (PCMH) led by physicians, not independent practice by a single nonphysician health professional."
Although NPs are a vital part of the health care team, "they cannot fulfill the need for a fully trained physician," says the report. Efforts by NPs to set up independent practices will undermine the ability of primary care physicians and PCMHs to deliver team-based care.
"The PCMH model improves the quality of care because it capitalizes on the unique expertise of each member of the patient's health care team," said (then) AAFP Board Chair Roland Goertz, M.D., M.B.A., of Waco, Texas, in a press release. "It ensures patients are under the care of a physician and expands access to health care services.
"Wholesale substitution of nonphysician health care providers for physicians is not the solution, especially at a time when primary care practices are being called upon to take on more complex care. Patients need access to every member of their health care team -- starting with a primary care physician, nurse practitioners, physician assistants, and all the other professionals who provide health care."
In fact, one study published in 2012 predicted the future shortage of primary care physicians would be 52,000 by 2025. Study researchers estimated that America's current primary care workforce would need to expand by 3 percent between 2010 and 2025 to keep up with the country's health care demands.
"A crisis in access to first-contact, comprehensive and coordinated medical care is occurring in the United States," said another study by authors from the AAFP's Division of Medical Education. The bottom line, they noted, is that the family medicine workforce is not growing at a rate sufficient to meet the country's needs.
However, one bright spot in 2012 was the increasing number of osteopathic students who chose family medicine. Graduates of colleges of osteopathic medicine filled 706 first-year positions in July 2012 compared with 633 in 2011 and 599 in 2010.
According to the study's authors, those numbers likely will continue to rise because of the growing enrollment numbers at current and newly accredited osteopathic medical schools in conjunction with an increase in the number of dually accredited family medicine residency programs. There were just 26 such programs in 2003 compared with more than 113 in 2012.
In addition, according to the Association of American Medical Colleges (AAMC), U.S. medical schools are seeing a steady increase in first-year enrollment. AAMC President and CEO Darrell Kirch, M.D., said that U.S. medical schools have been doing all they can to address a serious future physician shortage.
According to an AAMC survey, it is anticipated that first-year medical school enrollment will reach 21,376 in 2016-17, which is a 29.6 percent increase compared with first-year enrollment statistics from 2002-03. In addition, 43 percent of schools surveyed said they had targeted or planned to target increases in enrollment to specific population groups or to meet the needs of underserved communities.
But more has to be done, said the AAMC, pointing out that without increases in funding for residency positions, efforts to increase interest in primary care could be wasted. In a white paper released in September, the AAMC stressed that "the United States cannot afford to wait until the physician shortage takes full effect, because by then, it will be too late."
The organization recommended
- increasing the number of federally supported graduate medical education (GME) training positions by at least 4,000 new positions a year;
- basing funding for new residency positions on population growth, regional and state-specific needs, and changes in delivery systems, with half of the new positions being allocated to primary care and other generalist areas;
- using clinical reimbursement and other mechanisms to affect geographic distribution of physicians and influence specialty composition; and
- continuing to invest in delivery system research and evidence-based innovations in health care delivery.
Even as medical schools increasingly saw the wisdom of investing in primary care, new physicians were changing their ideas about how and where they want to practice. In its 2012 membership satisfaction survey, the AAFP saw its membership increasingly choose salaried positions instead of individual practice. In fact, employed physicians now account for 60 percent of the AAFP's membership.
That trend was confirmed as spanning all specialties and subspecialties by a survey overview from health care staffing and consulting firm Merritt Hawkins.
"The great majority of final-year residents surveyed, 94 percent, would prefer a straight salary or a salary with production bonus in their first year of practice," said the survey. "Only 2 percent would prefer an income guarantee, a type of compensation structure usually offered in independent rather than employed practice settings. This reinforces the fact that residents today are not particularly entrepreneurial and would rather earn a paycheck initially than assume the financial risk of practice ownership."
Merritt Hawkins cited the uncertainty in the health care world created by changes in all aspects of health care in the United States as one reason for the shift to salaried positions. But other factors played a role, as well, including the difficulty of purchasing an electronic health record system for small practices and the cost of repaying education debt.
However, according to the AAMC, education debt levels for medical students have been holding steady. In 2011, 86 percent of medical school graduates owed a median amount of $162,000 in education debt, which breaks down to monthly payments of $1,500 to $2,100. That median amount was only 3.1 percent higher than the median amount of education debt in 2009 ($156,500).
And another study from the AAMC in 2012 concluded that primary care is a financially viable career choice for medical school graduates with median levels of education debt. However, students graduating with higher debt levels may need to consider additional strategies to support repayment.
(Then) AAFP President Glen Stream, M.D., M.B.I. (left) meets with Senate Majority Leader Harry Reid, D-Nev., about the critical need to boost graduate medical education funding for primary care training and other issues.
Payment issues for GME also were a key focus for AAFP advocacy efforts in 2012. Debt-reduction negotiations targeted GME funding several times, and each time the AAFP flew into action to ensure GME funding was not cut.
During a series of Capitol Hill visits by AAFP leaders in March, GME funding was at the top of the list. (Then) AAFP Board Chair Roland Goertz, M.D., M.B.A., of Waco, Texas, and Academy EVP Douglas Henley, M.D., met with White House staff members to express their concerns about a provision in the 2013 fiscal year budget that called for a 10 percent reduction in direct GME payments. "We made the case for protecting primary care training programs in relation to any of those reductions because of the need for primary care physicians going forward," said Goertz.
GME legislation was again at the top of the list when Stream returned to Capitol Hill in April to rally support for H.R. 3667, a bill that would establish a pilot project to allow a portion of GME payments to go directly to community-based primary care residency programs. Those programs then would collaborate with local hospitals to provide necessary training in inpatient care.
By June, the Academy was asking members to contact their legislators to support a funding increase for Section 747 of Title VII of the Public Health Service Act, the only federal program that provides funds specifically to academic departments and programs to increase the number of primary care health professionals.
The AAFP also joined with the Council of Academic Family Medicine to call on Congress to spare GME funding in the deficit-reduction negotiations. However, if cuts cannot be alleviated, said the organizations, any reductions in Medicare GME "should be tailored in a manner that would allow for the advancement of primary care training."
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