AAMC Reporter: October 2008

A Word from the President: "The Primary Care 'Crisis'"

With all the recent media attention about declining interest in primary care, I found myself thinking about something Donald Berwick, M.D., president and CEO of the Institute for Healthcare Improvement has said: "Every system is perfectly designed to produce the results it produces." Given our fragmented health care delivery system, and a reimbursement structure that values "rescue care" and procedures more than cognitive work (thereby placing primary care at a disadvantage), concerns about a primary care workforce shortage should not surprise us.

The primary care problem is one of the most complex issues we face. While each of us in health care approaches the matter from a different angle, many professional specialty groups argue that we should boost the number of primary care physicians within their ranks. In my view, attempting to address the issue through focused "workforce shaping" is a backward approach. Instead, we must start with the end in mind, and collaboratively design a delivery system that ensures high-quality, patient-centered care, and then develop the reimbursement system and workforce configuration we need to support it.

Before discussing the implications of these changes for academic medicine, it is important to understand why narrowly focused workforce shaping is counter to our long-term interests, and how new delivery models such as the medical home offer great potential (to borrow from Dr. Berwick) for producing the results we do want to produce. When I visit with various specialty boards and other groups, I am often asked why the AAMC does not "mandate" specific numbers of primary care training positions. (Some suggest that a student's prospective discipline and/or specialty choice should even strongly factor into admission decisions.) Others cite the relatively low salaries of primary care physicians (combined with increasing amounts of student debt) as a key reason why medical students are not attracted to primary care.

However, if our objective is to provide high-quality, patient-centered care (especially as our population expands and ages, and the projected number of Americans with chronic health conditions soars 25 percent by 2020), achieving that goal is not as "simple" as telling students what kind of doctor they should be. The reality is that our current system is "demand-based" and demand has typically favored specialists.

So, where does that leave us? It turns our focus to a financing system that lacks incentives for primary care, and a model of care delivery that is acute care and procedurally focused. Many of you may be familiar with the expression, "Folly is hoping for A, while rewarding B." This is exactly what the current financing structure does by rewarding fragmented, specialized care while we continue to hope for coordinated, patient-centered care. We talk about the importance of wellness and prevention, yet continue to function in an environment where episodic rescue care is rewarded. We emphasize the growing importance of teamwork and continuity of care, but find ourselves working in a system that rewards individual face-to-face visits with a limited range of providers. In the end, neither patient nor doctor is satisfied.

The time has arrived to examine new models of financing and delivery, which will in turn be the linchpin to instituting a new reimbursement structure and achieving our goal of patient-centered care. One approach to changing health care delivery is the medical home. While not a new concept (the American Academy of Pediatrics articulated the concept in 1967), the medical home has been gaining traction in public policy venues and professional forums as an important tool for transforming health care. A medical home ensures around-the-clock access to medical consultation, respect for a patient's cultural and religious beliefs, and the comprehensive coordination of a patient's care among providers and community services. Additionally, instead of focusing on the person providing care, the medical home focuses on the functions and properties of care delivery.

Earlier this year, the AAMC Executive Council adopted a position statement on the medical home developed by our Advisory Panel on Health Care that emphasized three cornerstones: patient-centered care, alternative delivery/care methods, and appropriate payment for services. We believe the medical home concept position statement offers great potential for addressing a multitude of longstanding concerns. However, we are cognizant that more research is needed to develop the evidence base, including the best ways to implement the medical home; how to incorporate functions of the medical home into health care delivery for both the healthy and the chronically ill; how best to measure performance; and, importantly, the impact on patient outcomes.

While shifting to a new care model will not be easy, it aligns with our ongoing culture change in academic medicine from an individualistic, expert-centered environment to the new one characterized by greater teamwork and interprofessional collaboration. With so many of our institutions co-located with various health professional schools, we have a golden opportunity to facilitate interprofessional learning on this issue.

Changing the financing system also will be difficult because of the perception that any improvement in payment to one group of physicians might penalize another. Therefore, as we start to consider new alternatives to delivery and financing, it will be important to have some of the difficult conversations we have been avoiding, and to ally with other health care and policy organizations along the way.

Addressing the primary care problem through specialty-focused workforce shaping ignores the complex network of underlying financing and delivery issues that have characterized our health care system for decades. By designing a health care delivery system directed toward high quality patient-centered care and rewarding providers in a manner aligned with promoting the health of the public, professional interests will be served and the "right" numbers of disciplines and specialties will follow.

Darrell G. Kirch, M.D., AAMC President and CEO

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