Primary Care and Rural Areas

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"The primary care physician and health reform”,[1] by Robert H. Brook and Roy T. Young of the RAND Corporation, appears In the April 21, 2010 issue of JAMA. Rather than review the various components of the new Patient Protection and Affordable Care Act (PPACA), as I have recently on this blog, they focus on the need to increase the number of medical students entering primary care, an issue I have also previously addressed. It is a good piece and worth reading, but contains this interesting paragraph:

“One approach to this situation is to do nothing. As a result, the number of primary care physicians in practice will continue to decline. Patients who want a primary care physician will probably need to pay some kind of retainer and enroll in a concierge-type practice. Those who cannot afford this luxury will have to endure a medical care system that is even more fragmented than it is today.”

Clearly, they do not endorse this as a desirable plan, and go on to suggest that the alternative is to find a way to get 50% of American medical student graduates beginning with those entering June 2010 to enter family medicine, general internal medicine or general pediatrics (which raises the question of: Why not those who are already in medical school?) They emphasize both the importance of closing the salary gap (which we have heard many times) and redefining the role of the primary care physician, something we hear less about. The basis for this is contained in an earlier paragraph:

“The scope of practice for primary care physicians is contracting…the 200 000 physicians who identified themselves as office-based primary care clinicians… manage most of the care for diabetes, hypertension, and obesity; address acute problems such as viral or bacterial infections; and provide general examinations. On the other hand, a large proportion of the visits for conditions that could be managed by primary care physicians such as rheumatoid arthritis, epilepsy, depression, angina pectoris, and other chronic conditions are diagnosed and managed over time by specialists. The role of primary care physicians in the hospital has also narrowed, driven by the emergence of hospitalists and the trend to move a substantial portion of medical care to outpatient facilities.”

Taken together, the two paragraphs that I have quoted contain the implicit assumption that “the patient” we are discussing lives in a major metropolitan area with a large number of physicians, especially subspecialty physicians. However, at least 20% of Americans live in rural areas where this is not true, and many others live in underserved (read: poor) urban and suburban areas. While 23% of family physicians practice in rural areas, they are the only primary care specialty (and we can include here nurse practitioners and physicians assistants) that distribute themselves in this way; NPs and PAs, as well as general pediatricians and what remains of general internists cluster overwhelmingly in urban areas and their suburbs. When the only doctors in town, and for a long way around, are family physicians, they are going to manage the rheumatoid arthritis, epilepsy, depression, angina, etc. And they are most unlikely to charge concierge fees for their patients to be able to access them. However, rural areas remain underserved because 23% of family doctors, while parallel to the percent of rural people, is still too low a percent of all doctors.

I do not mean to be critical of Brook and Young; their commentary is good and makes excellent points, not the least of which is that even people living in urban and suburban areas want to have, and deserve, primary care physicians: “Virtually everyone would like to have a primary care physician—a trusted physician who provides comprehensive, continuous care.” I also commend their clear statement that most of the chronic conditions cared for by specialists – in metropolitan areas, where there are specialists – can be perfectly well taken care of by primary care physicians in either urban or rural settings. I mean only to point out that even the most thoughtful and well-meaning commentators can miss the special and critical needs of rural people, and make assumptions that do not apply to inhabitants of those areas.

The irony is that while insurers, including Medicare, pay higher rates to subspecialists for caring for conditions that generalists could care for, as Brook and Young point out, generalists are reduced to spending more of their time doing procedures, which are more highly reimbursed, in order to make ends meet. This takes away from the time that they can spend with patients being the “trusted physician who provides comprehensive, continuous care”. Producing enough primary care physicians to provide this care to the 80% of people in urban and suburban areas, as well as to usually be the only physicians in rural communities is going to be a big challenge. The only way this is going to happen is to bring the vast difference in income expectations for students dramatically down, and fast.

The fastest way, which should begin immediately, is for Medicare to readjust its fee schedule in such a way that proceduralists can do the procedures, subspecialists can care for the rare and unresponsive or conditions in their narrow area, and generalists can care for the complexity of the whole patient, and for all of them equal amounts of work will bring in much more nearly equal amounts of income. This will mean reducing the income of subspecialists and proceduralists as well as increasing the income of family doctors, but it is a much better solution for the population’s health than turning primary care doctors into rare, concierge-type commodities.

[1] Brook RH, Young RT, “The primary care physician and health care reform”, JAMA Apr21,2010;303(15):1535-6
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