Background

Primary care, characterized by continuity of care, an established relationship between patient and physicians, was once the central grounding of our healthcare system.  However 60 million Americans, or nearly one in five, lack adequate access to primary care due to a shortage of primary care physicians in their communities.[1]  Health reform has placed growing attention on increasing access to and availability of primary care services by increasing coverage, improving reimbursement and quality of working conditions for primary care professionals.

What are the major features of primary care? 
Primary care comprises four main features:[2]

• A first contact for any new health issue or need
• Long-term, person-focused care
• Comprehensive care for most health needs
• Coordination of care when it must be received elsewhere (i.e. with a specialist)

The primary care workforce includes different types of providers, mainly general practitioners, general internal medicine practitioners, and family physicians, as well as physician assistants (PAs), nurse practitioners (NPs), nurses, and care coordinators.[3]  Health systems focused on primary care have been found to be associated with more effective, equitable, and efficient health services; residents of countries more oriented to primary care (such as the UK, Canada, Cuba )often report better health outcomes at lower costs. [4]

The United States healthcare system has been facing a decline in its primary care workforce, infrastructure and access to primary care services for several years.  A number of factors, including poor reimbursements to primary care physicians, low comparative income, and poor quality of work life due to high patient loads, have contributed to more doctors choosing to train and practice in specialty medicine. This trend has lead to a shortage of primary care providers across the country—likely contributing to fragmented care, inappropriate use of specialists, and less emphasis on prevention.

Although 56% of patient visits in America are primary care, only 37% of physicians practice primary care medicine, and only 8% of the nation’s medical school graduates go into family medicine.[5],[6]  People who are uninsured, low-income, members of racial and ethnic minority groups, or living in rural or inner-city areas are disproportionately likely to lack a usual source of care.[7],[8]  

The current shortage of primary care physicians is fostered by the payment system.  Fee-for-service compensation system pays physicians based on the volume of care they deliver, with counseling, diagnosis, or dispensing prescriptions, all of which are core primary care services difficult to reimburse as opposed to specialty care which includes more procedures.  Wide income disparities exist between family physicians, whose annual income by one estimate averages $173,000, and those practicing specialties such as radiology ($391,000) and cardiology ($419,000). [9]  Studies indicate that graduating medical students perceive the lifestyle associated with primary care physicians as unfavorable, requiring more hours and less predictability than specialties.[10]  Graduating medical students faced with repaying loans of averaging over $100,000 are often inclined to enter a higher-paying field.  Those going into primary care may find themselves confronted with the common issue of low job- satisfaction. 

A higher ratio of specialists to population has been correlated with higher mortality rates while a higher ratio of primary care physicians to population is better for health.[11]  One theory is that patients with a usual source of primary care tend to use more preventive health care and have health problems treated at earlier stages. Many experts believe that the decline in primary care has contributed to overspecialization of care, fragmentation and inefficiency in the health system. Half of specialist visits are for routine follow-up, a misuse of expensive care.[12]

The 2010 Patient Protection and Affordable Care Act (ACA) is estimated to extend coverage to 16 million more people by 2014.  The legislation includes several provisions aimed at improving access to primary care, and compensating providers who take on newly covered patients . Major initiatives include new training grounds for primary care workforce, improved reimbursement especially for Medicaid patients, and new models for primary care services within a coordinated health system.

Training
ACA is expected to add 15,000 new providers to the workforce by 2015.The 2009 Economic Stimulus package included $300 million for the National Health Service Corps which recruits the primary care workforce in underserved areas.  An additional $230 million in award grants will go to “teaching health centers” to start primary care residency programs.

Financial incentives
ACA includes 10% bonuses for primary care providers under the Medicare fee schedule starting in 2011. Primary care service reimbursements will increase at the state level from Medicaid rates to Medicare rates by 2014.

ACOs
ACA legislation highlights the potential of Accountable Care Organizations (ACO), patient-centered, integrated services, to improve coordination in the healthcare system. ACOs include central “medical homes’ where primary care is accessed, and coordination takes place between specialists. The ACO’s patient-focused approach is thought to both curb costs and improve quality of care, with outcomes monitored by cost-effective outcomes criteria and patient assessments and financial incentives for multi-specialty providers to collaborate and coordinate patient care. [13]

CHCs
ACA increases the number of community health centers (CHCs), which provide continuous health care, coordination of care, and a large variety of health and welfare services.  CHCs have been associated with a host of positive health outcomes and focus on primary care to underserved populations.

Prevention
New universal coverage of recommended preventive care will improve patient need for and access to primary care providers on a regular basis. With a number of preventive services covered without cost sharing in all insurance plans (in the “essentials benefit package”) primary care will be sought more regularly.