Introduction
Primary care is the backbone of our health care system. It is associated with better patient outcomes, fewer inequities in care and lower costs.1 Yet, it is estimated that by 2025, the United States will experience a shortage of more than 52,000 primary care physicians.2
Today, 73% of AAFP members are employed physicians, with more than half (53%) of members employed by a hospital or health system, and only 24% are full or partial owners of their practice.3 An estimated 90% of all physicians accepting new positions will practice as employees, not as owners or partners.4 For comparison, that figure was approximately 60% in 2001.
Since most family physicians are employed, the decisions of their employers can help strengthen the primary care and family medicine workforce. The overarching principles to optimize family physician employment below describe ideal employment practices that value and prioritize primary care and family medicine, foster professional satisfaction and retention, support the effectiveness of primary care and family medicine and advance equity in employment for family physicians.
Total Compensation
- An organization’s compensation package for family physicians should align with the value provided by primary care's four core functions (4Cs): first contact, continuity, comprehensiveness and coordination of care.5
- Compensation should be based on meaningful quality, value and patient experience rather than productivity.
- Financial incentives should align with what matters most to patients and their family physicians, as well as the movement toward well-designed value-based primary care payment models.
- The salary structures, levels, benefits and policies of the compensation package should also foster internal equity and reflect the family physician’s leadership of the care team.
Leadership and Culture
- An organization’s culture and leadership structure should demonstrate a commitment to a strong primary care foundation as essential to a high-performing health care system.
- Family physicians and other primary care physicians should be in visible and influential governance, management and leadership roles throughout the organization, and a pathway of diverse family physician and primary care leaders should be supported through ongoing leadership development.
- An organization should demonstrate its commitment to primary care by returning to primary care the value primary care generates for the organization.
Clinical and Operational Autonomy
- A physician’s duty is first and foremost to their patients, and they should have autonomy in their clinical decisions. This is especially important to family physicians who are uniquely positioned to provide care throughout a patient’s lifespan.
- Scope of practice decisions should be made on a clinical and not financial basis, and the organization should support family physicians in maintaining their desired scope of practice, including privileges and procedures.
- An organization should have policies and practices that give all primary care and family physicians meaningful influence and input into the decision-making process on all practice operations, including the composition of practice teams and technology implementations.
Care Delivery Supports
- An organization should provide structures and supports that align with the 4Cs of primary care. Its systems of care (i.e., electronic health records [EHR], physical design, interdisciplinary teams, etc.) should recognize primary care as a foundation for value-based care success and improved patient health outcomes.
- The systems within the organization should seek to minimize administrative burden on primary care practices.
- All primary care payments, incentives and other non-financial resources provided by value-based payer contracts should flow directly to the primary care practices responsible for earning them.
Contracting and Transparency
- An organization should support transparency and equity in physician compensation, regardless of gender, gender identity, sexual orientation, race and ethnicity, by removing non-disclosure clauses from physician employment contracts or other suitable methods of assuring non-discrimination in compensation.
- An organization should be open to primary care-specific modifications to the terms of employment, including exceptions for non-compete clauses or other practices that interfere with the continuous nature of the physician-patient relationship.
- An organization should be fully transparent about its employment practices and compensation models.
References
1. Patient-Centered Primary Care Collaborative. Investing in primary care. A state-level analysis. Robert Graham Center. Accessed June 15, 2023. https://www.graham-center.org/content/dam/rgc/documents/publications-reports/reports/Investing-Primary-Care-State-Level-PCMH-Report.pdf
2. American Academy of Family Physicians (AAFP). America needs more family doctors: 25x2030. Accessed June 15, 2023. https://www.aafp.org/membership/initiatives/25x2030.html
3. AAFP. Family medicine facts. Table 4: Selected practice characteristics of active AAFP members. Accessed June 15, 2023. https://www.aafp.org/about/dive-into-family-medicine/family-medicine-facts/table4.html
4. Merritt Hawkins. A growing number of physicians are employed. Accessed June 15, 2023. https://www.merritthawkins.com/news-and-insights/blog/healthcare-news-and-trends/increase-of-employed-physicians/
Jimenez G, Matchar D, Koh GCH, et al. Revisiting the four core functions (4Cs) of primary care: operational definitions and complexities. Prim Health Care Res Dev. 2021;22:e68.
(July 2023 BOD)