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Addressing the primary care shortage
Recently, we looked at the dental care shortage. Let's turn to a similar issue: primary care.
When the Affordable Care Act is fully implemented, there will be 32 million more insured Americans looking for a primary healthcare provider, but some are worried that there won’t be enough doctors to go around. Primary care physicians provide preventative and acute services, act as a gateway to specialty care, and are often the first provider a patient sees when he has a medical problem. But it’s estimated that by 2015, there will be a shortage of 29,800 primary care doctors.
The issue is that, even though we need primary care providers the most, economic incentives drive medical students toward specialty care rather than general care. For many medical students, general care has a negative connotation because its practitioners make less money and are seen as less knowledgeable. A specialist will make much more than a primary provider – an average of $3.5 million more over her lifetime – even while holding the same amount of student debt. Specialists will bring in more money for hospitals, so hospitals create cardiology units over primary care units. Primary doctors in private practices have to deal with much more paperwork and red tape, and reimbursement rates from Medicaid and Medicare continue to fall, encouraging medical students to choose specialties over primary care.
There’s some room for hope. The number of medical students matched for primary health care residencies rose 20 percent between 2009 and 2011. The Affordable Care Act pledged $320 million dollars to expanding the primary care workforce, including $167 million for the Primary Care Residency Expansion program. But President Obama’s 2013 budget proposal would cut the number of Medicare-funded primary care residencies (already capped at 1996 levels) by 10 percent. This would likely shift hospitals’ primary care residencies to more profitable specialty residencies, undoing some of the progress made by the ACA.
One solution is to turn to nurse practitioners to fill the gap. Nurse practitioners have graduate school educations and can provide many preventative and acute services. A 2009 Rand study found that when compared to physicians, NPs deliver equal quality care at a lower cost, attain high patient satisfaction, and provide more disease prevention and health education. We need to encourage the idea that nurse practitioners can provide excellent primary care, especially to insurers. Private insurance plans are often reluctant to contract with NPs as primary care providers.
Primary care is a necessary service. We’re dramatically reducing the number of uninsured, and we’re working to make health care affordable for all. But if people can’t access care, we have made no progress. We must remember that the goal is not simply universal coverage, but universal access.