Primary care is in trouble, and there may be no way to save it. That was the conclusion of a 2004 report conducted by the American Academy of Family Physicians (AAFP), which projected that family medicine would not exist in the United States in 20 years unless major changes are made to delivery models and compensation.
Since then, the news has not improved. In 2007, 16% of first-year family practice (FP) residency slots went unfilled. More than 50% of the 2007 FP slots that were filled were taken by international medical graduates, underscoring the lack of interest U.S. medical graduates have in primary care.
Merritt Hawkins & Associates recently conducted a survey of 12,000 physicians—of which about 9,000 are in primary care—for the Physicians' Foundation, a doctor advocacy group.
Almost half of the doctors surveyed indicated that they are going to take steps that would reduce patient access to their practices by retiring, seeking nonclinical jobs, closing their practices to new patients, working part-time, or working locum tenens. Physician recruiters are acutely aware that primary care doctors—general internists in particular—are becoming increasingly hard to find.
The most visible solution to the primary care crisis being put forward is the medical home. The medical home is still a somewhat vaguely described model in which a primary care physician, working closely with the patient, leads a team of healthcare professionals who provide for or facilitate all the patient's needs. The idea is to expand patient access and communication with physicians.
The model is data-driven and relies on electronic medical records to help doctors make evidence-based decisions. It may feature expanded doctor hours, open scheduling, group visits, interactive Web sites, and secure e-mails, providing timely and frequent doctor-patient communication. The hope is that the medical home will, through a more preventive approach, lead to cost savings and better outcomes.
These savings can be used to pay primary care doctors more. Usually, the primary care model features a three-tiered payment system. Reimbursement is based on a management fee to reward the primary care doctor as leader of the healthcare team. The doctor also receives a fee for services provided and additional reimbursement based on the quality of outcomes achieved. More pay—in tandem with a more prestigious role in the delivery system—will keep doctors in primary care and attract new physicians to the field.
From theory to practice
That is the theory, which soon will be tested. In July 2008, Congress approved 12 three-year Medicare medical home demonstration projects to take place in eight states, starting this year.
Medicare's payment guidelines for practices participating in these pilot programs could mean an extra $50 per patient per month. The AAFP has already completed a medical home demonstration project featuring 36 practices nationwide; the results are expected to be released in early 2009.
The concept seems promising, but there are challenges, such as that there may be too few primary care doctors available to implement medical homes in any broad way. Many primary care doctors must already limit time spent per patient to less than 10 minutes to merely tread water financially. Coordinating care and communicating more thoroughly with patients online or by e-mail takes time, which primary care doctors already lack.
The medical home model also depends on the widespread implementation of electronic medical records (EMR). Of the physicians Merritt Hawkins surveyed, 77% of those who have not implemented EMR in their practices said they do not have the money to do so. Many primary care doctors are struggling with increasing overhead and a significant number do not have the time, resources, or expertise to implement EMR.
Despite these obstacles, the medical home concept deserves a try, and it will be interesting to see how the Medicare pilot project comes out. Without this—or some other fundamental rethinking of how primary care is delivered and paid for—recruiting primary care doctors will become even more challenging than it is now.