'Four Pillars' Blueprint Charts Course for Physician Workforce Reform

January 22, 2014 04:27 pm Sheri Porter
[Four white ornate columns]

A burgeoning demand for a primary care physician workforce that can meet the needs of the United States has led to much introspection on what can be done to increase the number of primary care physicians in the United States. Meeting that demand will require changes in education, physician practices and payment, say the authors of a newly released report.

"The Four Pillars for Primary Care Physician Workforce Reform: A Blueprint for Future Activity"(www.annfammed.org) appears in the January/February issue of Annals of Family Medicine. The report is the outcome of a task force created by the Council of Academic Family Medicine (CAFM) -- which comprises the Association of Departments of Family Medicine, the Association of Family Medicine Residency Directors, the Society of Teachers of Family Medicine and the North American Primary Care Research Group -- with support from the AAFP, the AAFP Foundation and the American Board of Family Medicine.

Story highlights
  • The Council of Academic Family Medicine just released a report outlining its "four pillars" concept on how to advance primary care physician workforce reform.
  • The pillars address the workforce pipeline, medical education, practice transformation and payment reform and are labeled as such.
  • There is a lot involved in transitioning our health care system to one based on primary care, says one AAFP expert.

"This paper presents a framework with consistent language to guide our efforts to increase production of well-trained primary care physicians for our populations," say the authors of the report. "The 'four pillars' is a powerful vehicle for promoting the expansion of the primary care workforce which can serve as an 'elevator speech' to effectively communicate the key steps to increase the number of primary care physicians in the United States."

According to AAFP President Reid Blackwelder, M.D., of Kingsport, Tenn., "This document describes the important roles that high school and college education, medical education, the physician community and the public and private payment sectors play in producing the physician workforce that the United States needs.

"A patient-centered, efficient health care system is not the responsibility of just one group of people or sector of the economy. Access to high-quality health care affects everyone, and all of us are part of the solution," he added.

Defining Pillars, Advancing Reform

The authors of the report point to four pillars that are necessary to change primary care to meet the current and future needs of the U.S. population. Those pillars are

  • pipeline,
  • process of medical education,
  • practice transformation and
  • payment reform.

Pillar No. 1, the pipeline, relies on identifying, recruiting and sustaining students who are most likely to pursue primary care as a career throughout the continuum of training.

The process should begin early in a student's education with coursework heavy in math and science. And it includes counselors who are skilled at first identifying -- and then encouraging -- young people who are most likely to become primary care physicians.

Later, proactive medical school admissions committees can identify and advocate for applicants who hail from rural backgrounds, have broader life experience, exhibit lower income expectations and show an interest in public service. These characteristics are "most predictive of medical students who will eventually pursue a career in primary care," say the report's authors.

Pillar No. 2, the process of medical education, depends on the development of curricula and educational opportunities at all levels of medical, residency and fellowship education that model positive primary care clinical experiences, according to the report.

Report authors also call for improvement in leadership skills for family medicine educators so that they can effectively stand up for primary care and help "enhance professional respect" for family medicine and other primary care specialties.

Pillar No. 3, practice transformation, involves ongoing work to help physicians transform their practices into patient-centered medical homes where health care teams led by primary care physicians work together to provide patients with high quality and efficient health care.

The fourth pillar, payment reform, calls for reducing the payment disparity between primary care physicians and subspecialists by appropriately valuing the comprehensive services provided by primary care physicians. This pillar also includes reform of how medical education is funded.

"The most important predictor of specialty choice is the ratio of mean primary care income to mean specialty income," say the authors. "Increases in payment to primary care practices through blended payments for fee-for-service, care coordination and quality outcomes will lead to practice transformation and to a significant increase in student primary care career choice," they conclude.

Expanding the Discussion

Perry Pugno, M.D., M.P.H., AAFP vice president for education, also serves as the Academy's liaison to CAFM. Pugno helped write the report and agreed to answer a few lingering questions about it for AAFP News Now.

Q. Why was this blueprint necessary?
A. This report is an attempt to succinctly address the need to revamp the U.S. health care system. There's a lot involved in transitioning our system from its current uncoordinated, maldistributed and expensive state into an efficient primary-care-based system. This document represents a "repackaging" of our current policies, initiatives and efforts.

Q: What was the main objective when you undertook this project?
A: One of the objectives was to create a message that was straightforward and memorable so that when we talk to legislators and their staff members they get the big picture without us having to hand them 100 pages of documentation.

Q: What barriers threaten to block the implementation of the concepts in this blueprint?
A: The first barrier I see is the tremendous need for change in how U.S. graduate medical education (GME) is financed. With the current instability in the nation's economy, it's difficult to get legislators' attention focused on how to fix GME funding.

The second barrier is accepting the reality that too many people exploit the current health care system. People who benefit financially from the present system will be reluctant to support changes. And so there's going to be a lot of pushback and a lot of resistance to the kinds of reform necessary to make the U.S. health system function more efficiently.

Q: What's the most important takeaway for family physicians?
A: Think of it this way: We are trying to change the direction of a supertanker going at high speed, and we're only one little tugboat poking at this huge problem. It's going to take time and effort and a creative legislative strategy to fix what's wrong with this health care system.

Q: Is there anything else you'd like to add?
A: You will notice that the four pillars integrate many of the Academy's key initiatives, including advocacy for the patient-centered medical home. I think it's important that family physicians recognize that the patient-centered medical home is the health care delivery model for the future.

We have to head in that direction if we want to remain relevant in this rapidly evolving health care environment.