'Solid Investments in Primary Care Workforce' Needed, AAFP Member Tells Congressional Committee

April 26, 2013 02:30 pm James Arvantes Washington –

Congress could alleviate the nation's growing shortage of primary care physicians by making a greater investment in primary care training programs and taking steps to ensure that more medical school and residency training takes place outside of hospitals and in the community.

AAFP member George Rust, M.D., M.P.H., left, discusses primary care issues with Sen. Bernie Sanders, I-Vt., chair of the Senate Health, Education, Labor and Pensions Subcommittee on Primary Health and Aging.

That was one of the key messages(www.help.senate.gov) delivered by family physician George Rust, M.D., M.P.H., and other witnesses who testified before the Senate Health, Education, Labor and Pensions Subcommittee on Primary Health and Aging here on April 24.

Rust, who serves as co-director of the National Center for Primary Care at the Morehouse School of Medicine in Atlanta, called on Congress to "dramatically increase" funding for Title VII and VIII health professions training programs. He said a substantial increase in funding for these programs would amount to "solid investments in the primary care workforce."

Rust also urged Congress to "reconnect academic centers with community-based practice," a process that should start "with sustainable direct funding for a large number of teaching community health centers." In addition, Rust called on Congress to unlink graduate medical education (GME) from hospital-based subspecialty care, which has produced "absurd proportions of subspecialists and hospitalists."

story highlights

  • During recent testimony before a Senate subcommittee on primary health and aging, family physician George Rust, M.D., M.P.H., urged Congress to take concrete steps to increase the number of primary care physicians.
  • Rust called on Congress to make greater investments in primary care training programs and to provide funding for community-based outpatient residency programs that train physicians to keep patients out of the hospital.
  • Sen. Bernie Sanders, I-Vt., chair of the subcommittee, decried the lack of primary care physicians, saying that the country needs 16,000 additional primary care physicians to meet today's demand for primary care services and another 25,000 primary care physicians by 2025 because of increasing demand.

"Instead, let's create direct, sustainable funding for community-based outpatient residency programs that train doctors to keep people out of the hospital," said Rust, one of five witnesses to address the subcommittee.

The subcommittee hearing took place as the health care reform law begins to extend insurance coverage to a projected 30 million more Americans during the next few years. In his opening remarks, Sen. Bernie Sanders, I-Vt., chair of the subcommittee, said one in five Americans now lives in an area without adequate access to primary care.

The nation needs 16,000 additional primary care physicians to meet today's demand for primary care services and another 25,000 new primary care physicians by 2025 because of increasing demand, said Sanders, citing various statistics.

"As a result of the primary care health care crisis in this country, we are losing tens of thousands of people every single year who die because they don't get to a doctor when they should," said Sanders. "We are seeing people ending up in hospitals -- when they could have been treated earlier -- because they did not (have) access to medical care when they needed it."

Sanders said expanding access to primary care physicians and services will save lives, ease suffering and save billions in health care costs.

Disproportionate Ratios

Sanders also cited the disproportionate ratio of primary care physicians to subspecialists in the United States, saying the ratio now stands at 30 percent primary care physicians and 70 percent subspecialists, the exact opposite of that seen in many other countries. Sanders also pointed out that the United States spends nearly twice as much per capita on health care as other nations, and he asked what role the disproportionate ratio of primary care physicians to subspecialists plays in driving up health care costs.

Rust said it is possible to tie the ratio of subspecialists to primary care physicians to both health outcomes and health care costs. "But also look at how we reimburse (sub)specialists," said Rust. "We reimburse people on piecework."

The system, as a general rule, does not pay physicians for spending time with patients and coaching them to better health, he noted. "When you pay people to do a significant number of procedures, when you train people to do hospital-based care … you tend to get the most expensive forms of care," said Rust, adding the U.S. medical system provides that type of care "exquisitely well, but we do it way too much."

Right Time and Place

Rust described primary care as giving people "the right care, in the right setting, at the right time," thus making it possible to avoid expensive hospitalizations and downstream costs in many instances. "Having more primary care allows you to practice in the most cost-effective way," Rust said.

Rust and other witnesses also addressed inherent disincentives that tend to discourage medical schools from training and producing primary care physicians. For example, medical schools are more likely to hire subspecialists than primary care physicians as faculty because subspecialists can generate more in revenue, according to Rust.

He said there should be a way of holding medical schools accountable for producing the physicians that the nation truly needs. The federal government should have a way of requiring production of physicians to match the country's need for certain specialties and subspecialties, said Rust.

For his part, Sanders noted that Medicare spends $10 billion a year on GME, but in many ways, medical schools are not accountable for how the money is spent in terms of the resulting workforce.

Sanders also addressed the wide income disparities between primary care physicians and subspecialists, saying that salary and reimbursement rates act as a strong incentive to encourage medical students with high debt loads to go into higher-paying subspecialties.

"At the end of the day, we have to ask ourselves why some of the people who work harder end up earning substantially less than others," said Sanders. "We need medical schools around the country to create a culture within their student body emphasizing the importance of primary care."


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