American College of Physicians: Internal Medicine — Doctors for Adults ®

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Strengthen primary care to heal the U.S. health care system

From the November ACP Internist, copyright 2008 by the American College of Physicians

By Jeffrey P. Harris, FACP

It is widely believed that our current health care system is unsustainable. In my September column, I contend that a new model of health care delivery, the patient-centered medical home (PCHM), will benefit patients, and general and subspecialist internists. However, as I'm sure you can attest, this model of care cannot function properly without a robust primary care physician workforce.

In the time period surrounding the Presidential election, much of the national focus has been on the economic and financial challenges facing our country. While everyone is impacted by the state of the economy, so too are all Americans affected by the health care crisis. We must work together to keep elected officials, legislators and the public focused on solving the health care problems of the nation. The consequences of not doing so will be higher costs, greater inefficiency, lower quality, more uninsured persons, and growing patient and physician dissatisfaction.

As I travel around the country talking with my internal medicine colleagues, I agree with their concerns that, thus far, the national debate about health care has been limited to the issue of expanding health insurance coverage. While that is indeed an essential national priority, even if all Americans were given health insurance, access to care would continue to be a challenge in many parts of the country because the number of primary care physicians continues to dwindle.

Massachusetts is a microcosm of the primary care crisis. The state's 2006 health insurance mandate provided coverage for an additional 439,000 residents. However, the wait to see a primary care physician has grown to as long as 100 days and the number of practices accepting new patients is dropping. The state legislature has approved a set of financial incentives to attract primary care doctors but it will be several years before the new measures have a measurable effect on the shortage.

The latest report from the Council on Graduate Medical Education forecasts a shortage of 85,000 physicians by the year 2020. An article published in September in the Journal of the American Medical Association (JAMA) found that only 2% of nearly 1,200 fourth-year students surveyed planned to work in general internal medicine.

The combination of factors cited for this predicament has long been voiced by ACP: little exposure to the pleasures of ambulatory medicine during medical school, large student debt, the lure of higher-paying subspecialties, unfair reimbursement policies, time pressures and inadequate resources. Without a doubt, many of you know bright, skilled and dedicated medical students and young physicians who have no intention of pursuing an internal medicine career.

I take comfort in knowing that since ringing the alarm bell nearly three years ago about the crisis in primary care, the College has continued to outline solutions to reform how primary care is organized, financed and compensated. We continue to press for a national physician workforce policy and physician payment reforms, like the PCMH, which ultimately will help deliver medicine to our patients the way we want to deliver it and in a manner that will best serve them.

I am confident that the state of primary care can and will improve. ACP continues to work with policymakers to enact comprehensive legislation to preserve and increase patient access to primary care services. Key issues at which we are at the table include medical education grants, scholarships for medical students, and student loan forgiveness for physicians; redesign of Medicare, Medicaid, and SCHIP programs to support primary care; and assistance to practices in becoming PCMHs.

It's gratifying to know that we are not alone in our desire to reform the U.S. health care system, for there is strength in numbers. ACP is a founding member of the Patient Centered Primary Care Collaborative (PCPCC), a broad, multi-stakeholder coalition of business, health care and consumer groups who have joined together to develop and advance the PCMH. Among its 160 members are the U.S. Chamber of Commerce, AARP, AFL-CIO and a consortium of major U.S. corporations which collectively have 50 million employees. The PCPCC recognizes that the current payment system is inadequate to account for care management and is working to restructure primary care reimbursement.

The PCMH model of care and the other critical reforms pursued by ACP underscore the reason we practice medicine in the first place: to enhance the quality and effectiveness of health care for our patients.

Our challenge during this election year is to elevate health care reform to the same level as the other issues that our country is facing. Over the next few months I will be actively seeking speaking opportunities to share ACP's reform messages with multiple audiences. I urge you to take every opportunity to do the same in your own communities. Together, as the collective voice of ACP, we can make a positive difference in helping avert the further erosion of primary care in the U.S. health system.

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