Primary care physician growth trails population growth

Publish date: February 26, 2019

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For more primary care physicians, pursue payment reform

Resolving the maldistribution of primary care physicians noted by Basu et al. will require a serious commitment to payment reform, according to Sondra Zabar, MD; Andrew Wallach, MD; and Adina Kaler, MD, of New York University.

Along with observing a steady decline in primary care interest overall, Dr. Zabar and her coauthors highlighted the lack of attraction to practicing in rural or urban areas. Among the reasons they cited are desired income, perceived workload, and level of debt. As compared to a well-run subspecialty practice, “most primary care physicians work with minimal support and can see only 2 to 3 patients per hour, and they are likely to receive lower payment than the subspecialty physician for each of those patients,” they wrote.

What solutions are there?

“Our reimbursement system needs to incentivize a realignment in the ratio between primary care and nonprimary care that is associated with the best population health such that primary care physicians no longer shoulder a disproportionate share of administrative work such as medication refills and prior authorizations,” they wrote. The problem has already been somewhat recognized by the Medicare Payment Advisory Commission and the Centers for Medicare & Medicaid Services, but more initiatives like debt forgiveness and innovative medical school curricula are needed to make a serious dent.

“To increase access to primary care, especially in underserved areas, we must align incentives to attract individuals into primary care practice, innovate primary care training, and greatly improve the primary care practice model,” they wrote. “Physician payment reform is a key to making all of this happen.”

These comments are adapted from an accompanying editorial (JAMA Intern Med. 2019 Feb 18. doi: 10.1001/jamainternmed.2018.7623 ). No conflicts of interest were reported.

FROM JAMA INTERNAL MEDICINE

Although the total number of primary care physicians increased from 2005 to 2015, disproportionate losses across counties and general population increases have created an imbalance that may affect life expectancy, according to a study of U.S. population data and individual-level claims data linked to mortality.

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“Greater primary care physician supply was associated with lower population mortality, suggesting that observed decreases in primary care physician supply may have important consequences for population health,” wrote lead author Sanjay Basu, MD, PhD, of Stanford (Calif.) University and his coauthors. The study was published online in JAMA Internal Medicine.

Dr. Basu and his colleagues gathered data from 3,142 U.S. counties, 7,144 primary care service areas, and 306 hospital referral regions over a 10-year period to determine whether primary care physician supply was correlated with changes in life expectancy and cause-specific mortality. They found that, from 2005 to 2015, the total number of primary care physicians increased from 196,014 to 204,419. However, mean primary care physician supply decreased from 46.6 per 100,000 population (95% confidence interval, 0.0-114.6 per 100,000 population) to 41.4 per 100,000 (95% CI, 0.0-108.6).

In the researchers’ fully adjusted models, an increase of 10 primary care physicians per 100,000 population was associated with a 51.5-day increase in life expectancy (95% CI, 29.5-73.5 days; 0.2% increase). This effect was more favorable than the foreseen result of a similar increase of 10 specialist physicians per 100,000 population, which was associated with a 19.2-day increase in life expectancy (95% CI, 7.0-31.3).

Almost 300 (296) counties had no primary care physicians in 2015, while 128 counties had more than 100 per 100,000 population. On average, rural areas saw a larger decrease than urban areas (–7.0 per 100,000 population vs –2.6 per 100,000 population). Primary care physician supply did not disproportionately decrease by county poverty level or racial/ethnic demographics.

The coauthors shared their study’s limitations, including the use of private insurance data to conduct individual-level analyses and the possibility for unobserved confounding. However, they also noted that their results reinforced earlier findings on primary care physician density and overall life expectancy, calling for “future investigations [to] acquire data on the quality and comprehensiveness of primary care, types of primary care physician training and service delivery offerings, and effective access rather than just supply.”

The study was supported by the National Institutes of Health; data was accessed through the Stanford Center for Population Health Sciences Data Core, which is supported by the National Center for Advancing Translational Sciences and by Stanford University. One author reported being a senior adviser at the Center for Medicare & Medicaid Innovation; another reported being an adviser to Bicycle Health. No conflicts of interest were reported.

SOURCE: Basu S et al. JAMA Intern Med. 2019 Feb 18. doi: 10.1001/jamainternmed.2018.7624.

Primary care physician growth trails population growth

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