From the Board Chair

Success of Health Care Reform Depends on Physician Workforce Reform

By Ted Epperly, M.D.
Posted: 10/19/2009, 4:05 p.m.

Want a surefire recipe to make health reform fail? Just extend coverage to millions of Americans without expanding the supply of primary care physicians -- especially family physicians -- to deliver the care all those people will need.

AAFP Board Chair Ted Epperly, M.D.

Without enough doctors like us practicing in the right places, Americans won't be able to access the system, no matter how extensive their coverage. It's like giving everyone a bus pass, but then providing only two buses to meet their needs.

The AAFP has already been pressing Congress and the Obama administration to boost the production of primary care physicians, and some primary care provisions have been included in the health care reform bills now in play. But a new AAFP physician workforce report really drives home the need for more primary care doctors, and it provides a roadmap for getting there. This new report speaks for the entire family of family medicine organizations, not just the AAFP. The report's recommendations, if adopted, would significantly change medical schools and residency training, especially the training of family physicians.

I'd like to discuss some of the report's key ideas here.

By the year 2020, 50 percent of the U.S. physician workforce should practice in true primary care specialties -- family medicine, general pediatrics and general internal medicine. We're not alone in calling for this 50/50 split; other advocates are the Council on Graduate Medical Education, the Association of American Medical Colleges, the Robert Wood Johnson Foundation and the Pew Health Professions Commission.
The expanded primary care workforce should include at least 40,000 more family physicians by 2020 than we have now. Neither internal medicine nor pediatrics contributes much to primary care today, so unless there's a significant about-face, those specialties likely won't contribute much in 2020. Family medicine will power primary care in the future, just as it does today.
A new national commission should formulate a 10-year strategic plan to help the nation reach these workforce goals, and a public-private entity should allocate funding for GME positions in accordance with the goals. The strategic plan would align GME policy with the nation's needs. You'd think the United States would already have such a plan, but it doesn't. As a result, the current physician supply is terribly distorted, with 70 percent subspecialists and only 30 percent primary care doctors. Unfortunately, the situation is getting worse. In the past 10 years, about 90 percent of medical school graduates have gone into subspecialties, and only 10 percent have chosen to go into primary care. This trend must be reversed.
A variety of GME reforms should be tried. For example, a new funding stream could be established to develop "teaching health centers" -- a hybrid of the family medicine residency and the community health center, or CHC. Most CHC physicians are family physicians, so this hybrid could care for people in underserved areas and train more FPs at the same time. Another idea is to have some GME funding come directly to family medicine residency programs to support training in the ambulatory setting. Currently, the funds first go to hospitals, which keep some or all of the money.
Increased Title VII funding should be provided for both family medicine and geriatrics, and more geriatrics education should be incorporated into the training of all health professionals who provide adult primary care. The current Medicare population of 40 million will skyrocket to 80 million in 15 years. Enough said.
Medical school expansion must target primary care rural and underserved practice. Business as usual would just perpetuate the oversupply of subspecialists we're facing now. Instead, schools should dedicate a portion of new slots to students who plan to enter family medicine or other true primary care fields. Schools should adopt admissions and recruitment policies that attract those students. Scholarship programs, such as the National Health Service Corps, or NHSC, should be expanded on the front end of medical school, and loan repayment programs should be enhanced on the back end.
All entities that pay for health services should contribute to the cost of medical education. This means insurers should pitch in, not just Medicare and Medicaid.
Efforts should be made to attract primary care physicians to areas that need them and to keep them there. These include new payment models that boost payment for primary care services and for practices in rural and other underserved areas. The AAFP also is proposing a Senior National Health Service Corps, which would offer incentives to retain FPs after they've fulfilled their obligations and to deploy them to places of greatest need. I was an Army family physician for 21 years, and the Army had incentives and bonuses to keep us in. It worked. This approach could work for the NHSC as well.
The Academy should continue its work to develop and implement the patient-centered medical home. The medical home concept should be implemented in all family medicine residency programs so that FPs come out with the background they need to succeed in this model of care. The medical home is the most effective way to deliver primary care.

The AAFP will distribute this new workforce report to the White House, Congress, the Association of American Medical Colleges, the Accreditation Council for Graduate Medical Education -- in other words, to all the places that can drive change. Constituent chapters can help with this distribution, especially to state governments, family medicine departments and family medicine residency programs.

I'm very excited that the AAFP has released this workforce report at this critical moment in time, and I hope you're excited about it, as well. If all or even some of our ideas win support, there's a much better chance that enough family physicians will be available to meet America's future needs. These changes are long overdue and much needed. We need to act on them NOW!