We need more generalist physicians. And a new health system so that they can be effective.

We don’t have enough primary care physicians in the US to properly (or, often and in many places, even improperly) care for our people. We all need a primary care doctor, and some of us need specialists. But rarely does a specialist have the time, interest, or expertise to manage all of your problems, and also do the recommended preventive work. Unfortunately, primary care physicians rarely do either, especially when it involves managing the care delivered by many different specialists, who can be unaware of what treatments the other is recommending and of how it might conflict with treatment they are giving. Doing this properly takes a lot of work and time.

For example, you mention to your cardiologist that you have knee pain. They say “I don’t do knees; here’s a referral to an orthopedist”. They’re done. If you go to your primary care doctor, they will examine you, try to figure it out and maybe treat it. But if they refer you to an orthopedist, they will follow up, read the report, look at the x-rays, read the recommendation, and try to explain to you what it all means. In short, a specialist referring to another specialist saves time and work; a primary care doctor referring to a specialist generates more work for themselves.

But there are not enough primary care doctors to do this, and those that exist are not given sufficient time by their employers (most are employed by hospital systems or large groups, often owned by private equity) to do it right. Because – and this is the most important thing – these hospital systems and especially private equity are, like insurance and pharma companies, in the business of making money, and only incidentally providing health care. Yes, many doctors are also interested in making money, but this is not their only or primary concern.

So, because most doctors are employed, and because primary care doctors may work much more for much less money, we have a dramatic shortage of primary care doctors in the US. A recent issue of Your Local Epidemiologist describes this in some depth.

One approach to primary care is that which Sweden has adopted, as documented here by the Commonwealth Fund.

Sweden is aligning primary care access goals with physician workforce policy more explicitly. Rather than treating physician training as separate from care delivery, Sweden is using workforce policy as a tool to strengthen continuity, accessibility, and person-centered primary care. To support this goal, the Swedish National Board of Health and Welfare analyzed primary care workload and physician capacity, established a benchmark of one primary care physician per 1,100 residents, and issued recommendations to guide regional workforce planning toward that target.

The Commonwealth Fund notes that

The United States faces a similar problem. Although physician training strongly influences where physicians ultimately practice and what specialties they choose, federal graduate medical education (GME) financing remains largely tied to algorithms based on hospital funding patterns established decades ago. The Centers for Medicare and Medicaid Services lacks authority to measure workforce outcomes associated with the nearly $21 million in Medicare funding that supports physician training. The result is a system that often produces workforce outcomes misaligned with patient needs, specifically not enough primary care physicians, general surgeons, and psychiatrists.

Commonwealth adds “Sweden’s recent reforms suggest a different model: define national access goals first, then align workforce policy around them.”

What a novel idea! Imagine figuring out what you are trying to achieve and then designing a system of achieve it! This is completely different from how health policy, including (or perhaps especially) physician supply and makeup is done in the US. (Well, except for for-profit companies who know what their goal is – make more money by any means necessary, which is never providing you with the best, most comprehensive and effective, or accessible, healthcare.) The system we use is to … do the same old thing. Pay subspecialists more, allow students to choose which specialty they want, and expect that somehow enough will choose primary care, despite the fact that they will make far less and often (not always, depending on the other specialty) works more, will almost be always employed by a large hospital system or group practice owned by private equity, and be on a hamster wheel of “productivity”, which means they cannot see enough patients, cannot deliver adequate care to the people they do see, and for themselves achieve limited professional satisfaction in having the control necessary to influence positively the health of their patients. 

As I have written before (e.g., Changes in the RUC: None.. How come we let a bunch of self-interested doctors decide what they get paid?, July 21, 2013; Pay primary care more: Kennedy may be getting this one right!, July 23, 2025 ), there is no mystery on how to change the income levels of primary care physicians relative to subspecialists. The Medicare payment “pie” is divided up between specialties mostly on the recommendations of an AMA-appointed group of physicians called the “RUC”, which is dominated by subspecialists. CMS, whichadministers Medicare, doesn’t have to follow the RUC’s recommendations, but usually does. And the RUC’s makeup of about 15% primary care physicians guarantees that primary care will be underpaid by Medicare. And, since almost all insurance company reimbursements are based on multiples of Medicare payment, this translates to the whole system. CMS could set up, or require the AMA to set up, a RUC that was, say, half primary care doctors!     

A word on the term “primary care”. While it has become the standard phrase in the US, and we can’t get away from it, it is not a great one. It was popularized by internists (adult medicine doctors) to distinguish those more properly called “general internists” from their internal medicine brethren who did mostly hospital work (“secondary care”) including intensive care (“tertiary care”), and then expanded to include general pediatricians and family physicians. Of course, family physicians are mostly all (90%) in what is now called “primary care”, and they (or the also commonly used “general practitioners”) are the mainstay of outpatient care physicians for the populations of most countries. Family physicians differ from other “primary care” physicians in that they are trained to provide comprehensive care for people of all ages, with all problems (referring when necessary) across the lifespan, including caring for children, old people, delivering babies, caring for folks in the hospital, in nursing homes, and doing lots of different procedures.

Unsurprisingly, it is hard to find even family physicians doing all these things now, except sometimes in rural areas where there are fewer physicians in other specialties. It has always been true that the privileges granted to family physicians have been largely determined by how much other physicians can make doing that work; many will be “first assistant” surgeons (fairly well paid) except when their communities have a glut of surgeons who “need” the work = income. Many years ago, it was discovered that only about 10-15% of graduating family medicine residents in Texas were interested in delivering babies in rural Texas; however, this was compared to 0% of OB-Gyn residents!

So let’s start with identifying what we want to achieve: enough primary care physicians, distributed broadly enough across the country in rural and urban areas, for every single person to have one. For those primary care (or family, or generalist) physicians to be paid enough relative to subspecialists that students are attracted to the field. For them to have enough time budgeted to manage complex problems and even more complex interactions between patients and other doctors. This is especially a need for older adults, who are most likely to be seeing multiple specialists for multiple problems. Relying on ERs or Urgent Care is a very poor and inadequate alternative.

That requires a complete reworking of how our health system functions. Covering everyone, such as by the improved and expanded Medicare for All system called for by the S. 1506 and HR 3069 bills, is an absolutely necessary part of this, but is not alone sufficient. We also need to restructure physician payment to encourage enough primary care that people can easily access it and it can be effective, implementing completely Starfield Four Pillars of Primary Care: [first] Contact, Continuity, Comprehensiveness, and Coordination (Starfield B. Primary Care: Concept, Evaluation, and Policy. New York, NY: Oxford University Press; 1992). If ANY of these are missing or incomplete, we have an inadequate health system – as we in fact do.

No messing about at the edges. No "reforms" that reform little. No saying we cannot afford universal health care, something every other developed country does, because our insurance companies need to make huge profits. No denying the need for an immediate steps to ensure an adequate primary care workforce because we don’t want to pay subspecialists less.

This must happen now, happen yesterday. There is no morally acceptable alternative.

 

                                       

More residency slots: Good, but not going to solve the primary care shortage...

The Center for Medicare and Medicaid Services, CMS, recently announced that it will be funding an additional 440 residency positions in 135 hospitals in 37 states. This is a good thing, and a step in the direction of reducing the glaring shortage of physicians in the US. CMS already funds most of the residency positions, something which is probably not intuitively obvious to those not involved in post-graduate medical education, but it is so even if it is not clear why (as opposed to, say, Congress directly appropriating such funding). This is important because while you are a doctor (physician) on graduation from medical school, you can’t obtain a license to practice anywhere without residency training (e.g., family medicine, pediatrics, surgery, psychiatry, radiology, etc.). Thus, past efforts to increase the number of physicians by increasing the number of medical schools (or the class size in existing medical schools) fail, because the residency pipeline has been static. It has only, perhaps, decreased the number of international medical graduates filling those positions. 

CMS further states, per this piece in MedPage Today, that 2/3 of those slots will be in primary care and psychiatry, two areas in which the shortage of physicians and other clinicians is particularly acute. This is also good, but will continue to have limited impact, at least until we see exactly which specialties are getting those positions. “Primary care” is not a specialty in which there is a residency; usually the term is used to include family physicians, general pediatricians, and general internists (as well as those general practitioners who completed only one year of post-graduate training, ie., internship, when that was sufficient to receive a license). The problem is mostly with internal medicine. After completion of a 3-year internal medicine residency, the large majority (about 80%) of graduates go on to complete a fellowship in an internal medicine subspecialty (cardiology, nephrology, pulmonary medicine, endocrinology, etc.). They do not practice primary care. In addition, about half the remainder become hospitalists, caring for people in the hospital only, leaving only a small number of internal medicine residency graduates to practice primary care. While many pediatrics graduates also sub-specialize or become hospitalists, the percents are much lower. On the other hand, about 90% of family medicine graduates practice outpatient primary care. In addition, it likely includes OB/Gyn which is not primary care.*

It would be good if we could get an accurate accounting. There are “general medicine” or “primary care medicine” residency programs among the internal medicine programs which produce higher percentages of primary care outpatient practitioners -- but still not all, or even close to the 90% of family medicine. We need to know if the new CMS positions that are designated “primary care” include internal medicine; if they do, obviously the output, the number of new outpatient primary care doctors, will be significantly lower. Why should they be unclear about this? It is in the interests of many institutions to keep it fuzzy. Medical schools have long reported on the percent of their graduates entering primary care, and they have included all those entering internal medicine (and sometimes OB/Gyn or even Emergency Medicine) as well as pediatrics and family medicine, inflating the percent that is ostensibly primary care. This practice has been called “the Deans’ lie”. The Association of American Medical Colleges (AAMC), quoted in the MedPage Today piece, has a similar reason to obfuscate the truth; their members are those same medical schools (and the teaching hospitals associated with them) and their leaders, both in AAMC and in the individual schools, are overwhelmingly non-primary-care subspecialists.

One of the main reasons for the shortage of primary care physicians, and thus this purposely-inaccurate effort to paper over the dearth of them, is that, while physicians overall make much more than the average person, there is a great disparity in income between the specialties, often being 4-5 times as much for certain specialists as others. The shortage of primary care physicians and psychiatrists that this change is making a small effort to rectify is very likely because pediatricians, family physicians and psychiatrists are on the low end of the physician income scale. The table below, from “PhysiciansThrive.com”, is one example, although it may actually understate the income of the top specialties.

 

 

The lowest-paid physicians are doing well compared to most Americans, but they often come out of school with $250K + debt, which is, of course, owed with compound interest. The income gap between specialties has to be narrowed, and some studies suggest that if primary care physicians made 70% of what other specialists do, money would largely cease to be an issue in student specialty choice. But how could we do that? Isn’t it really complicated?

Well, not as much as you might think. A recent installment of the New York Times feature “The Ethicist” responds to the question from a reader “Should I Feel Bad About Joining a Concierge Medical Practice?”. This in itself is a complex, but separate, question. However, the Ethicist notes in their response that one of the reasons it is hard to find a primary care physician is that 

‘Medicare, which effectively anchors compensation levels throughout the health-care system, reimburses physicians according to “relative value units,” and those are largely determined by an advisory committee dominated by specialists. Procedures are valued more than conversations.’

I was surprised to see this addressed in this column; while it is absolutely true, it is rarely discussed. The comment makes 3 points which together drive the income disparity:

1.     CMS sets reimbursement rates for Medicare, but it essentially drives all reimbursement as insurance companies use Medicare rates (or multiples of them) to determine their own payments.

2.   These Medicare rates are set by “relative value units”, or RVUs, so that some sort of equivalence can be made. For example, how many comprehensive examinations by a primary care doctor or assessments by a psychiatrist or chest x-ray interpretations by a radiologist is worth one gall bladder removal by a surgeon or joint replacement by an orthopedist? This is essentially dividing up a pie of set size; when one “gains” another “loses”.

3.  While CMS sets these RVU ratios, they usually rely upon the recommendations of a little-known group called the “RUC”, appointed by the AMA. As the Ethicist notes, this committee is overwhelmingly specialists. And, so, not surprisingly, the distribution of the pieces of the pie tend to favor those specialists, and, indeed, procedures are valued more than conversations. And “conversations” kind of minimizes the communication between people (patients) and their primary care doctors, as people’s stories greatly inform both the diagnosis and the best treatment (and the one the patient is going to accept and follow through on), and are essential for the patients to know what is going on. And presumably interactions with psychiatrists are more than simple “conversations”. (I have written about the RUC several times, including Doctors' incomes and patient coverage: both need to be more equal, Jan 26, 2014 and Pay primary care more: Kennedy may be getting this one right!, July 23, 2025.) 

So there is a clear-cut way to fix these disparities: CMS simply needs to adjust the RVU basis, increasing the value of “conversations” and really thinking and assessment and decision making relative to procedures. Of course, this means the highest-paid subpspecialists would make less than they do now, and so they are going to fight it, as are their organizations and groups like the AAMC. But really, even if they take a significant cut, they are a long way from the Food Bank!

The question is: Will CMS do this? Pressure from you, the people who can’t get into a doctor, is definitely going to help!

 

*Primary care is comprehensive care of the needs of the patient, with referral to specialists when needed; internists and geriatricians and pediatricians limit the ages of their patients but they provide comprehensive care for them. While some women only see an OB/Gyn, they only provide care for a woman’s reproductive tract, not comprehensive care.

 

The WiSER program to erode your Medicare coverage: Not WISE for you!

While much about American health insurance is infuriating, starting with it treating the healthcare system as a vehicle for making money rather than providing healthcare, “prior authorization” (PA) is one of its most infuriating, and dangerous, practices. It means that before you can get the treatment your physician has recommended, indeed often before you can see the physician you want, the insurance company must authorize it. This practice is ubiquitous in commercial health insurance, including “Medicare Advantage” (MA), a program that allow an insurance company to collect the money allocated for you by Medicare. This means that if you receive a terrible diagnosis, such as lung cancer and your oncologist recommends a specific treatment, it is entirely possible that they will deny coverage for it, especially if your cancer is rare, or requires an expensive drug. You can file an appeal, but even if it is eventually granted, the process takes time, and meanwhile you are sick and your cancer is advancing.

But if you have Traditional Medicare (TM), this has not been a problem. TM covers virtually all doctors and hospitals in the country, covers most treatments, and does not subject the individual to PA, or decide that another (usually cheaper and possibly less effective) treatment, or even no treatment might be better for you. Or that a different doctor or hospital that is “in network” (for them) would be a better choice even if their track record is inferior. The absence of PA is a major reason why many health experts recommend TM over MA. 

Back in January, 2023 I wrote about the proposed ACO/REACH program at CMS (Privatizing Medicare through "Medicare Advantage" and REACH: The Wrong Way to Go!), which would allow companies (many owned by private equity) to purchase primary care practices, and voilà!, all those doctors’ patients were now in the company’s ACO and subject to restrictions on their care, including PA, without having to do anything at all and thinking they were safe because they were in TM! The REACH name was dropped but the program still continues; a friend in northern NJ was just informed he is now part of an ACO because they have acquired his doctor’s practice!

And other assaults on TM and the patients it covers continue. If you live in Arizona, as I do, or in 5 other states (New Jersey, Ohio, Oklahoma, Texas, Washington), even if you have TM you will suffer the indignity and damage of PA as Medicare implements a 6-year “pilot program” called WiSER (Wasteful and Inappropriate Services Reduction). No longer will you be able to get any Medicare-approved procedure from any Medicare-accepting doctor at any Medicare-accepting hospital (ie, virtually all doctors and hospitals). Medicare will contract with private companies that will utilize artificial intelligence (AI) algorithms to decide whether you can get the treatment. As with ACO/REACH, you have no choice, as participation is “voluntary” by state, but not by individual Medicare recipient. Actually, then it is worse than ACO/REACH, which you could get out of by changing your primary care physician (provided you could find another one!); WiSER will require you to move out of state!

Maybe the AI algorithms know better than you or your doctor. After all, isn’t reducing wasteful and inappropriate services a good thing? If you believe that the high cost of health care is the result of your using inappropriate and wasteful services, you might want to consider that the companies Medicare contracts with to do the PA will be paid “based on a share of averted expenditures.” That is, they will be paid on commission, receiving a percentage of the money saved by denying your care! But that won’t affect their decisions at all, right?

In reality, the use of “inappropriate and wasteful services” by you and your family and friends is not the reason for the high cost of health care. The reason is the enormous administrative costs of the US healthcare system, including the huge amounts made by for-profit insurance companies and pharmaceutical companies (and the eight-figure salaries of their CEOs and other executives), as well as health care providers (hospitals and health systems and the physicians, usually employed by them). This is a system found nowhere else among wealthy countries, every single other one of which comprehensively covers the care of all their people at much lower per-capita cost.

Bringing PA into Medicare is not “wiser”. It is the exactly wrong way to go. What we need is the expansion of Medicare to include everyone in the US, birth to death, and the improvement of that system by covering all health needs, including mental, dental, hearing, vision, and eliminating the 20% hospital co-pay Medicare recipients now are responsible for (and must buy Medigap insurance to cover). The “administrative costs” now being taken out of the “healthcare” system by companies would more than pay for it.

We would then have a system designed to provide health care for the American people, not profit for corporations. Imagine that!

 

adapted from a piece originally written to be a guest essay in the Arizona Star, but not published