Future of Health Care Tied to Government Support for Primary Care

The ratio of primary care physicians to subspecialists in any given geographic area has a direct bearing on the overall cost and quality of health care, making it incumbent on the federal government to adequately support programs that promote the recruitment and retention of primary care physicians. That sentiment was behind a presentation Joseph Gravel Jr., M.D., residency director of the Lawrence Family Medicine Residency Program in Massachusetts, recently gave during a Capitol Hill briefing on primary care physician workforce issues.

According to Gravel, the proportion of primary care physicians now stands at 32 percent, but various studies point to better outcomes if the proportion is in the 40 percent to 50 percent range. Meeting that goal would achieve optimal cost and quality outcomes, said Gravel, one of three main speakers to address the briefing sponsored by the Partnership for Primary Care Workforce, of which the AAFP is a member.

"The actual place where we would love to be is 50 percent generalists," said Gravel, who also is president-elect of the Massachusetts AFP and chief medical officer for the Greater Lawrence Family Health Center. When that percentage is reached, overall quality increases while costs decrease, said Gravel, citing various studies.

However, Gravel also presented data showing that if the proportion of primary care physicians exceeds 50 percent, both quality and costs decline. "So we have to have … the right percentage of (sub)specialists and the right percentage of generalists," he said.

By the same token, if the proportion of primary care physicians falls below 40 percent, quality decreases and costs increase, said Gravel, pointing out that the proportion of primary care physicians to subspecialists is expected to fall from the current level of 32 percent. This creates an increased likelihood of higher health care costs, lower quality and overt health care rationing.

During his presentation, Gravel called for greater federal support for programs with a proven track record of producing primary care physicians, including the National Health Service Corps, or NHSC, and health professions programs supported by Section 747 of Title VII funding in the Public Health Service Act, which provides the only federal grants for training family physicians.

Gravel and other speakers noted that the federal government has increased its investment in the NHSC during the past few years, tripling the number of NHSC physicians and other providers. This increase has allowed the program to serve 6.8 million more patients in 2011 than in 2008. In his presentation, Gravel said 82 percent of "NHSC clinicians continue to serve in high-need areas after they fulfill their service commitment."

"In Lawrence, I can attract some family physicians partially because of NHCS loan repayment programs that I can offer," Gravel said.

Meanwhile, the federal government's investment in Title VII funding for primary care has declined recently, dropping to less than $40 million annually, according to Gravel. "I have an indoor water park down the street from me that cost twice as much to build as the federal investment in Title VII," he noted.

Alissa Craft, D.O., M.B.A., associate professor and vice chair of pediatrics at the Western University of Health Sciences College of Osteopathic Medicine of the Pacific in Lebanon, Ore., also presented data on the effectiveness of primary care physicians in reducing costs and improving quality.

In making her case, Craft cited data that found a 15 percent increase in primary care physicians in a given metropolitan area could decrease emergency room visits by nearly 11 percent and cut surgeries by 7 percent. In addition, a 15 percent increase in primary care physicians could decrease inpatient hospital admissions by 5.5 percent and cut inpatient hospital visits by 5 percent.

Craft also cited data from health services researcher Barbara Starfield, M.D., that found a 1 percent increase in the primary care physician workforce per 10,000 people reduces mortality rates by 5.3 percent per year. Why then, does the United States continue to struggle to get more medical students into primary care? Craft asked.

Income disparities are a major reason for the inequities, she explained. For example, the median income for a primary care physician is $150,000 a year compared with more than $450,000 or $500,000 a year for some subspecialists, said Craft. That translates into a differential of about $4.5 million during the course of a career, an amount that becomes even more significant considering that a medical school education costs about $200,000, said Craft.