Association of US Supply and Population Mortality Original Investigation Research

Invited Commentary The Future of Primary Care in the United States Depends on Payment Reform Sondra Zabar, MD; Andrew Wallach, MD; Adina Kalet, MD, MPH

In this issue of JAMA Internal , Basu and colleagues1 The practice environment is becoming increasingly inhos- report that greater density of primary care is asso- pitable for physicians who want to make a career in primary ciated with better population health in the United States. Their care. Practice model innovations—patient-centered medical findings are consistent with an extensive body of literature link- homes, use of interprofessional teams, physician extenders ing access to primary care such as scribes, care managers, and community health

Related article page 506 with better individual- and workers—attempt to improve the primary care environment. population-level health out- However, even with a differential payment to fund patient- comes. Unfortunately, their study also confirms that the pri- centered medical homes, the payment is not enough to cover mary care workforce is maldistributed, with many rural com- costs. In contrast, in a well-run practice, a team munities having no primary care physicians. To increase access consisting of a physician and a physician assistant can care for to primary care, especially in underserved areas, we must align 7 patients in 1 hour. The physician assistant completes all of incentives to attract individuals into primary care practice, in- the documentation and patient education, with the physi- novate primary care training, and greatly improve the pri- cian conducting the clinical assessment and, together with the mary care practice model. Physician payment reform is a key patient, formulating a plan. Reimbursement for this clinical ac- to making all of this happen. tivity covers all the costs and leaves enough time for the sub- Successful models for attracting primary care physicians specialist to have a satisfying professional and personal life. to underserved settings exist, and positive exposures to pri- Most primary care physicians work with minimal support and mary care during lead to an increase in physi- can see only 2 to 3 patients per hour, and they are likely to re- cians who are practicing primary care. For the past 30 years, ceive lower payment than the subspecialty physician for each the Health Resources and Service Administration has been of those patients. What if primary care physicians had re- the primary source of federal funding for primary care work- sources similar to those of subspecialty physicians? Primary force development, including training programs for medical care physicians need enough resources to build teams with all students, residents, and fellows; for faculty development; members practicing at the top of their licenses and time and and more recently for primary care practice transformation space for teaching and building rapport with staff, patients, and education. This funding was essential because during the families, thereby creating a satisfying work life for the physi- same period, academic health centers have prioritized build- cians and the best possible patient outcomes. ing networks of subspecialty providers for their quaternary Our reimbursement system needs to incentivize a realign- hospitals. Even with some positive changes, graduate medi- ment in the ratio between primary care and nonprimary care cal education programs continue to focus on training physi- that is associated with the best population health, such that cians for acute and specialty care. Ultimately, this govern- primary care physicians no longer shoulder a disproportion- ment support has fostered primary care training program ate share of administrative work such as medication refills and innovation, which has allowed many programs to attract prior authorizations. Time spent on important activities such highly competitive candidates to primary care and as arranging for a patient to be seen by a specialist for a poten- to satisfying careers.2 tially serious abnormal finding or communicating with pa- Despite successful training programs, there has been a tients and their families should be compensated. Underlying steady decline in interest in primary care among US medical the current incentive structures is a devaluing of cognitive work students. Those who choose primary care physician disci- and interpersonal interactions compared with performance of plines are not being attracted to practice in underserved rural procedures.5 or urban areas in large enough numbers. This decline has been The American Medical Association (AMA) Relative Value attributed to factors such as the desired income, level of debt, Scale Update Committee (RUC) reviews resource costs for phy- type of patients cared for, and perceived work hours and work- sician services as described by Current Procedural Terminol- load of a primary care physician.3 Factors that favor the choice ogy codes and recommends how many relative value units to practice primary care medicine in these communities in- should be associated with each of the more than 8000 bill- clude early clinical training experiences in underserved areas able procedures.6 The committee’s recommendations have and loan forgiveness for practicing in those areas.4 However, generally been implemented by the Centers for & these strategies alone are not common or powerful enough. Medicaid Services (CMS) in its annual updates to the physi- Current low reimbursement levels for primary care and high cian fee schedule, which determines physician services burden reporting of quality and performance measures that compensation for Medicare beneficiaries and heavily influ- monopolize many patient encounters make it difficult to sup- ences Medicaid and commercial insurance rates. The RUC’s port sustainable, satisfying, and impactful careers. recommendations have led to the growing compensation

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gap between cognitive and proceduralist physicians owing for better salaries in specialty care. For this reason, debt for- to inequities in how evaluation and management codes are giveness programs have been successful in recruiting medi- valued, even in alternative practice models such as patient- cal students to serve as primary care physicians in under- centered medical homes, accountable care organizations, served areas. Innovative medical school curricula that allow and bundled care.7 The Medicare Payment Advisory Com- primary care–oriented students to begin residency after 3 years mission and CMS’s growing recognition of the problem is of medical school may also help by decreasing debt and add- heartening, and as a result of relentless advocacy, there is ing a year of earnings. less reliance on the AMA RUC for relative value unit exper- Payment reform is key to attracting more US physicians into tise. New Current Procedural Terminology codes have also primary care training and practice. Higher pay and lifestyle been added to increase compensation for annual wellness preferences lead most students to choose non–primary care visits, transitions of care services, and caring for patients fields, even when their hearts say primary care.8 We must re- with multiple chronic diseases. Continuing advocacy by the verse this trend with substantive changes in physician pay- Cognitive Care Alliance and other entities such as the Ameri- ment policy; no amount of superb primary care training or in- can College of Physicians, Society of General Internal Medi- novative practice reform will prevent further declines in cine, and American Academy of Family Physicians can help primary care physician density, which will lead to worsening keep the issue of undervalued evaluation and management health for the United States. As Basu et al1 have shown, an in- codes and the need for innovative payment policy solutions crease of 10 primary care physicians per 100 000 population front and center for CMS and US Congress. The Medicare was associated with an increase in life expectancy that was Payment Advisory Commission has proposed changes in more than 2.5 times that associated with a similar increase in reimbursement, such as primary care bonuses and other non–primary care physicians.1 The inverse is also true and changes, to help narrow the compensation gap, which is starker: as the density of primary care physician decreases (11% essential to rebalance the physician workforce to align with decline across 10 years), there is a predictable increase in the the country’s health needs. number of deaths due to preventable causes and an average High levels of medical student debt have further eroded loss in life expectancy of 51.5 days. The cost of inaction will the primary care pipeline. Medical students graduating with be increased morbidity and higher premature mortality in the debt burdens greater than $100 000 may eschew primary care US population.

ARTICLE INFORMATION REFERENCES review and meta-analysis. Educ Health (Abingdon). Author Affiliations: Division of General Internal 1. Basu S, Berkowitz SA, Phillips RL, Bitton A, 2017;30(2):146-155. doi:10.4103/efh.EfH_226_16 Medicine and Clinical Innovation, Department of Landon BE, Phillips RS. Association of primary care 5. Medicare Payment Advisory Commission. Medicine, New York University School of Medicine, physician supply with population mortality in the Report to the Congress: Medicare payment policy. New York (Zabar, Wallach, Kalet); NYC Health + United States, 2005-2015 [published online 2018. http://www.medpac.gov/docs/default- Hospitals/Bellevue, New York (Wallach). February 18, 2019]. JAMA Intern Med. doi:10.1001/ source/reports/mar18_medpac_entirereport_sec. Corresponding Author: Sondra Zabar, MD, Division jamainternmed.2018.7624 pdf. Accessed December 7, 2018. of General Internal Medicine and Clinical 2. Lipkin M, Zabar SR, Kalet AL, et al. Two decades 6. RVS Update Committee. https://www.ama-assn. Innovation, Department of Medicine, New York of Title VII support of a primary care residency: org/about/rvs-update-committee-ruc/rvs-update- University School of Medicine, 550 First Ave, New process and outcomes. Acad Med. 2008;83(11): committee-ruc. Accessed November 19, 2018. York, NY 10016 (sondra. [email protected]). 1064-1070. doi:10.1097/ACM.0b013e31818928ab 7. Ginsburg PB, Patel KK. Physician payment Published Online: February 18, 2019. 3. Schwartz MD, Durning S, Linzer M, Hauer KE. reform—progress to date. N Engl J Med.2017;377 doi:10.1001/jamainternmed.2018.7623 Changes in medical students’ views of internal (3):285-292. doi:10.1056/NEJMhpr1606353 Conflict of Interest Disclosures: None reported. medicine careers from 1990 to 2007. Arch Intern 8. National Resident Matching Program. Main Med. 2011;171(8):744-749. doi:10.1001/ residency match results and data. Additional Contributions: Mark D. Schwartz, MD archinternmed.2011.139 (New York University School of Medicine), provided https://mk0nrmpcikgb8jxyd19h.kinstacdn.com/ insightful policy perspective. He was not 4. Raymond Guilbault RW, Vinson JA. Clinical wp-content/uploads/2018/04/Main-Match-Result- compensated for this contribution. in rural and underserved areas and-Data-2018.pdf. Published April 2018. Accessed and eventual practice outcomes: a systematic December 7, 2018.

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