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.

 

                                       

Pay primary care more: Kennedy may be getting this one right!

I have recently written strong criticisms of Secretary of Health and Human Services Robert F. Kennedy, Jr. and his positions on a number of issues, including most importantly vaccines (see RFK, Jr.: The Secretary of Health and Human Services is Dangerous to Your Health!). Not only is he wrong about vaccines being dangerous, he is in fact creating major danger by discouraging their use. The polio vaccine essentially eliminated a disease that was a major scourge in the US as well as the rest of the world, as did the measles vaccine. Many other vaccines protect our children – and adults – from other serious viral diseases like influenza, COVID, mumps, chicken pox, rubella, shingles, and human papillomavirus (HPV) which causes cervical cancer, as well as bacterial diseases including diphtheria, tetanus, pertussis, and Hemophilus influenza b. The last is something most people have not heard of, but early in my career was a major cause of morbidity and death in infants and young children from meningitis, pneumonia, and epiglottitis, which caused their throats to swell rapidly and choke off their breathing. Many others have articulately expressed this concern, including the pediatrician Perri Klass in the New York Times. While these diseases affected people of all social classes, they were more prevalent among the poor and minority groups such as the people I cared for at Chicago’s Cook County Hospital. Indeed, research has demonstrated tremendous benefits from vaccines on the health of children and other populations that go far beyond just the decrease in the specific diseases that they target to decreasing all-cause mortality!

Kennedy is wrong about many other things, if not all of as of such immediate potential danger as urging people to not get vaccinated. These include nonsense like suggesting that people who eat right and exercise won’t get disease, that raw (unpasteurized) milk is better for you, and that “natural” is always better (which, even if we could agree on a definition of “natural”, it isn’t). One recent example is his arguing for Coke to use “natural” cane sugar rather that high-fructose corn syrup, both of which are sugar and have calories and in large amounts are bad for you.

But there turns out to be one area where Kennedy and I seem to agree, which is the need to take concrete action to increase the number of primary care physicians. Lots of people, including politicians, healthcare providers, and health policy experts, express concern about the shortage of primary care, but have done nothing to address the real cause of this problem – that primary care physicians (and the nurse practitioners and physician’s assistants working with them) get paid a lot less than do physicians in other specialties. Kennedy appears to be doing something other than wringing his hands. On several occasions I have written about the RUC, the AMA committee that decides how to divide up the pie of Medicare dollars among specialists by deciding how much each thing doctors do is worth relative to other things that they do. (Changes in the RUC: None.. How come we let a bunch of self-interested doctors decide what they get paid? July 21, 2013, Doctors' incomes and patient coverage: both need to be more equal July 26, 2014, and most recently, Not enough primary physicians OR Nurse Practitioners: It's the money, stupid!, June 27, 2024).

Not to get too technical, there is a set amount of Medicare dollars and the RUC decides (or recommends to CMS, which almost always accepts those recommendations) how many physical exams, say, are equivalent to one gall bladder surgery, considering (theoretically) both difficulty and time. This makes a tremendous difference in physician income and, I would argue, specialty choice by medical students. And, over the years, the amount of time it takes for doctors to do some things, particularly procedures, changes. Colonoscopies used to be estimated to take an hour and a quarter, but now are routinely done in 30 minutes. Cataract surgeries take a fraction of the time that they once did. This can result in physicians billing for more procedures than the model assesses as possible in a day. In contrast, the time it takes for a physical exam, or to listen to an interpret a person’s story, hasn’t changed significantly. The composition of the RUC, according to the AMA, represents all specialties, but its membership has a low proportion of primary care doctors – five of the 32 seats. Unsurprisingly, then, specialist-performed procedures are valued more highly than cognitive work. And, very important, these rates (relative value units) do not affect only Medicare payments – virtually all insurers pay based upon Medicare rates, so it is the whole health system! Prior to this new regulation, alternative models for allocating payment have been developed, such as this 2025 publication from the National Academies of Science, Engineering, and Medicine (NASEM).

So, now, maybe, a change. The NY Times reports that, buried in an 1800-page HHS regulation, are proposed changes in the RUC methodology that would benefit primary care. This would be real action! In addition to reassessing these relative values, the action would also look at the current practice of reimbursing more for the same procedures done in a hospital than in a doctor’s office, a major way that hospitals make money. And, for those who think “of course it costs more to do something in a hospital”, this is a technicality; it simply means that the hospital owns the practice or clinic. So two, say, skin biopsies performed in similar doctor’s offices across the street from each other are now reimbursed at very different rates if one is owned by a hospital. This is absurd and inequitable, and getting rid of it makes terrific sense!

The diffusion of medical services to people and communities is primarily driven not by the health needs of the populations in different areas but by the potential to make the most money for health care providers. These are largely, and increasingly, hospitals and health systems, as well as enormous insurance-company and private-equity owned practices rather than individual or small group physician-owned practices. So, we get enormous hospital campuses and medical facilities in major cities and wealthy suburbs and little or nothing in poor neighborhoods and rural areas. This should change. The only reason for decisions about what healthcare services to provide and where to provide them should be the health needs of people, and not on how much profit can be made.

The new HHS regulation will be a big step in this direction if it redirects Medicare (and thus all insurer) funds to primary care, and does not preferentially favor hospital-owned practices. To the extent that he is responsible for it, Kennedy should be congratulated. However, while it is a big step, it is not a solution. The next, necessary, step is a universal health insurance program where every single person is covered and covered by the same system, and where establishment (and closure) of health facilities, and the services that they provide or do not, is entirely based on the health needs of the people. Of course, there will be a lot of resistance – highly paid specialists will resist the proposed HHS reimbursement changes, and the institutionalized powerful insurance companies and other big players who are making lots of money from “healthcare” will oppose more comprehensive changes. Indeed, they already are, with highly funded social media campaigns against universal health care.

We are glad for this first step, but we need to keep fighting to get a comprehensive health program – like those of every other wealthy country!

Not enough primary physicians OR Nurse Practitioners: It's the money, stupid!

“Like doctors, more nurse practitioners are heading into specialty care”, a recent article in the Washington Post (June 17, 2024) by Michelle Andrews, a contributing writer for KFF News, and McKenzie Beard, makes the point that

Nurse practitioners have long been a reliable backstop for the primary-care-physician shortfall, which is estimated at nearly 21,000 doctors this year and projected to get worse. But easy access to NPs could be tested in coming years. Even though nearly 90 percent of nurse practitioners are certified to work in primary care, only about a third choose the field, according to a recent study.

That study, called ‘No One Can See You Now: Five Reasons Why Access to Primary Care Is Getting Worse (and What Needs to Change)’ was published by the Millbank Memorial Fund, and goes on at length to explain those reasons, and what needs to change.

Spoiler Alert: Like physicians, primary care nurse practitioners make less money, often for more work, and far less restricted scope of practice. Or, borrowing from an old political mantra, “It’s the money, stupid!” Or, as the WaPo article quotes Candice Chen, an associate professor of health policy and management at George Washington University, “We get what we pay for.”

It is, of course, more than just the raw amount of money. It is also how much NPs – and physicians – are paid for the amount of work that they do. This work is undervalued for primary care, based upon the notion that, somehow, being expert in a narrow specialty and knowing a lot about a little, is worth more than having a broad knowledge and being able to help a lot of people, most people, a great deal. Thus, subspecialists dramatically limit their practices to what they feel most expert at and expect the primary care clinician to do everything else. This often includes preparing people for a procedure and following them up after, which are both completely the responsibility of the person doing the procedure. Subspecialists particularly like to send paperwork back to primary care. “Your primary care doctor (or NP) will have to take care of this.” Implication: ‘Unlike primary care clinicians, I do important things.’

I would argue that managing people’s health is doing important things. Which is what the primary care clinician (family physician, general internist, general pediatrician, or the NPs that work in these fields) does. Managing the actual person, you, not just one of your diseases, or one aspect of one of your diseases; being knowledgeable about you, your life, and the interactions of all your conditions and the impact that they have on the rest of your life.

How might this manifest? Let’s say you have knee pain. You go to your family physician, who examines it, and decides that you need an x-ray. They review the x-ray and the report, and decide that you might benefit from seeing an orthopedist. They fill out the referral. Then, after the consultation and recommendation from the orthopedist, they review it, and decide how to implement the treatment. That is a lot of work. The orthopedist was done in a few minutes. Guess who gets paid, altogether, more?

Like the physicians that employ them, NPs are often very expert in their limited area (say, heart failure management), but often do not know how to manage that problem in the context of a person whose other diseases or medications may complicate that. This is where the (underpaid) primary care clinician, physician or NP, has to come in. It is a lot of responsibility, a lot of work, and often a lot of extra hours. One NP profiled in the WaPo article is taking training to become a dermatological NP. This is one of the medical fields with the highest pay/work ratios. Most of its work is not emergent and can conveniently be scheduled during the day during the week, and is less likely than many other specialties’ work to interfere with treatment for other conditions. And it is very highly reimbursed.

Should people be paid based upon the amount and difficulty of their work? If we did, people doing the most difficult work that everyone agrees needs to be done but that most people do not want to do (e.g., picking up the garbage, doing farm work in the hot sun) would be paid more than those who get fancy offices and lots of perks and boss folks around (e.g., CEOs). But difficult can have other definitions; this is really a separate discussion. In health care, for physicians (and now NPs) it should be how they contribute to the system. Currently the usual measure is money, that is, how much a given practitioner brings into the practice, or more commonly now, to their employer (often a health system), which is based on how much payors (insurers) pay for different things. That amount is not God-given, but a matter of policies that could be changed. Two mechanisms through which the amount of reimbursement is set are the RUC and the facility fee. The RUC is a group of non-governmental physicians appointed by the AMA that makes recommendations on how Medicare money should be divided up between specialists – like “one gallbladder removal is worth 6 complete examinations”, or whatever. Medicare is not required to accept their recommendations, but they usually do. And – surprise – the RUC is mostly made up of subspecialists, not primary care clinicians!

The facility fee is an amount that Medicare (and other insurers, see below) tack on to the physician fee if the practice is owned by a health system rather than a physician, and is often several times the fee for the procedure. To be clear, this means that if I receive a procedure today from a physician in their office and you get the same procedure in the same office by the same physician next week, but in the interim that practice has been acquired by a health system, the charge will be MUCH more. Medicare or your insurance may pay it, or most of it, but your co-pay will be much higher, and all of our premiums go up. This practice is hardly ever made apparent or explained in advance to patients (“Hi, thanks for calling. Just to let you know, Dr. Smith’s practice was just acquired by the MuchProfit Health System, so you will be charged three times as much for your procedure as you would have been last week.”) This is so insidious (not to say evil, but it is evil) that even doctors are often surprised, as revealed in the essay by Dr. Danielle Ofri in the New York Times (June 17, 2024) ‘Even Doctors Like Me Are Falling Into This Medical Bill Trap’ and the follow-up letters and comments from other physicians.

The fact that facility fees and the RUC are about Medicare does not mean that they do not affect the fees, cost, and reimbursement from other insurers. Almost all insurers payment rates are set as multiples of Medicare. That is, if Medicare pays $100 for something, they may pay $150 or $200 (and, more recently, those multiples are lower, with patient responsibility higher). Changing these two factors, facility fees and RUC allocations, for Medicare will affect all insurers and make a real difference in income (which is why most subspecialists and hospitals oppose them).

Should primary care clinicians be paid more, or subspecialists less, or somewhere in between? Whichever, by decreasing the difference more clinicians are likely to enter primary care specialties. And, whichever, the raking off of facility fees to increase the wealth of hospitals, not to mention the pocketing of huge profits by insurers, has to stop.