Wither primary care?

he report from the American College of Physicians (ACP) didn’t pull any punches. Primary care is on the verge of collapse. Senior physicians are retiring or leaving the field; medical students are avoiding the discipline like the plague; health care capital is in full retreat; new technology investments are lagging. With demand for primary care services expected to skyrocket, the timing couldn’t be worse. As the demographic bulge of baby boomers begins to turn 60, the ranks of Medicare patients will grow from 39 million to 72 million by 2030, then comprising nearly one fifth of the population. By 2015, the number of Americans with a chronic medical condition will swell from the current 120 million to 150 million. To care for all these patients, the corps of general internists will need to expand from 106,000 in 2000 to 147,000 in 2020. On the supply side, the news is just as troubling. Over a third of American physicians are over 55 years of age and many are expected to retire in the next decade. And just when the pipeline should be increasing, it’s drying up with a steep decline in interest in primary care careers among medical students. The student’s concerns about the field mirror those of their attendings and senior practitioners ... too little respect, too much work, long hours, endless paperwork, administrative hassles ... not to mention poor pay. And better compensation is right where the ACP report, The Impending Collapse of Primary Care Medicine and Its Implications for the State of the Nation’s Health Care, aims most of its recommendations. A couple of the proposals are novel and destined for a studied, if not chilly, reception. A couple are old-fashioned and conventional enough to make Wilbur Mills proud. One of the new initiatives is a mechanism of delivering primary care dubbed the advanced medical home. These certified medical practices would provide comprehensive, coordinated, preventive services with advanced technology to assure efficiency, value, quality and patient satisfaction. The other nontraditional proposal is a dramatic expansion of pay-for-performance programs that would reward physicians financially from sources such as Medicare Part A hospital funds. These resources would permit practices to invest in health information technology and data collection tools. Collectively, this money could be used by medical organizations to develop evidence-based standards and strategies to optimize chronic care. The two more traditional ACP recommendations involve amending a couple of familiar fixtures around Washington, DC—the sustainable growth rate calculations and the resource-based relative value schedule. To better understand these issues, a brief review of Medicare history is in order. When Medicare began in 1965, physicians were paid on the basis of their usual and customary charges—no fee schedules, no price controls, no volume limits—none of that. Predictably, spending soared at a 13% annual rate and in 1975 President Ford and Congress instituted the first limitations on physician fees, capping any increases to a rate termed the Medicare Economic Index. But with no concurrent restraints on the volume of services, annual spending grew 15% annually from 1975 to 1991, far outpacing other economic indicators. In 1992, Medicare began its first attempt to control the number and intensity of services with volume performance standards, or VPS. health policy in focus