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Supporting Primary Care – Little Talk and No Action

January 13, 2014

Here we go again. There is yet another round of evidence of how the physician workforce hole we’ve dug for ourselves keeps getting deeper, but there has been still no substantive payment reform on the government side (Medicare/Medicaid) or the private payer side.

One recent study appeared in the journal Academic Medicine. Clese Erikson and colleagues surveyed a random sample of 4th-year medical students in 2010. Only 13% of the students stated they were very likely to become primary care physicians. The way the researchers framed the question was important. Spin doctoring by the medical schools over the years has led politicians to believe that about half of medical students choose primary care fields. The schools include internal medicine residents, of whom over 90% do not provide ambulatory primary care; and pediatric residents, of whom over half do not provide ambulatory primary care when they finish their training. I’ve even seen some medical school primary care reports in the past that included general surgeons and ER docs. Compare this 13% number to the fact that other developed countries have nearly 50% in primary care (the U.S. is at about 30% now).

Another study measured how much Medicare pays for cognitive services (thinking, like primary care) vs. procedural services. It measured the payment per hour of actual work for two common procedures – colonoscopy and cataract extraction – and compared them to a common primary care outpatient code. Previous studies have found a difference of up to 12 times with this comparison. These authors made an extra effort to identify all of the time required to do the procedures, such as obtaining consent and explaining the findings of the procedure to patients and family members. The authors concluded that these two procedures still paid between 368% and 486% more than primary care at MEDICARE rates. It is safe to assume that this ratio is even worse in the private sector.

No, money is not the complete solution to balance the U.S. physician workforce. However (and I’m not making this up), when I worked with administrators at CMS (Center for Medicare and Medicaid Services) during my Innovation Advisor year, a high-placed official actually and seriously asked me, “Do you think if primary care physicians were paid more that more medical students would choose primary care?”  It took all of my limited self-control to not laugh, scream, or cry.

Other pieces of the solution to get more medical students into family medicine are concepts such as respect, encouragement in medical schools, and a new NIH family medicine research institute. (There is no NIH institute or large foundation funding for primary care research, but there is for nursing, social work, alternative medicine, aging, etc.). Proper payment will go a long way to addressing these issues as well. Even if the medical school culture could be changed first (which it won’t, by the way), students aren’t stupid. They can peer into the future, which is why programs such as primary care loan repayment schemes make a small difference in moving the medical student choice dial.

The fundamental reason there is such a huge income disparity between primary care and the ologists is the CMS fee schedule and documentation, coding, and billing rules. Over 90% of private insurers use ratios of the schedule, so the impact of CMS goes well beyond Medicare and Medicaid.

There was a 10% tweak in the Obamacare law to raise primary care pay. It only lasts for two years and was implemented very slowly. Compare this number with the ratios I just mentioned and the fact that some ologists easily make three times more than primary care physicians on average. Only the most committed students would choose primary care, and its not enough for the needs of the country.

One gets what one pays for. In the U.S., we value ologist high-tech procedures and open access to ERs, so we are left to enjoy worse health at a higher cost than the rest of the developed world.

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9 Responses to Supporting Primary Care – Little Talk and No Action

  1. Sue on January 14, 2014 at 8:40 am

    “One gets what one pays for.” Not the patient that is for sure.

    • Richard Young MD on January 14, 2014 at 9:59 pm


      My comment was made in the broadest societal sense. I agree that patients often demand services of little to no value because they don’t really share in the cost.

      Thanks for the comment,
      Richard Young, MD

  2. Robert on January 20, 2014 at 9:16 am

    Better pay is the absolutely essential, though not sufficient in and of itself, first step in saving primary care. No one seems more willing to ignore this than the leadership of the AAFP. They should be focused on this like a laser, and instead they do everything possible to avoid directly addressing it. Their cluelessness is absolutely incomprehensible to practicing physicians.

  3. Julian on January 24, 2014 at 12:41 pm

    As a third year medical student that really wants to go into primary care, it is very frustrating to hear someone ask “would more students go into primary care if it paid more?” That is like asking if someone would be more willing to accept a job if he was fairly compensated for it. NO DUH!

    If the individuals in charge of creating the cost structure of medical payments and reimbursements focused on primary care, the health outcomes of our country (“the best in the world”) would be able to compete with every other first world nation. It is sad and scary that I, along with many others, am turned away from family medicine because of the issues of compensation and fear of not being able to live a happy life due to loan debt and unsubstantial reimbursements. This problem is going to take a while to fix and all I can say is that if it were fixed there would be no question in my mind about going into family practice.

    Julian Barkan, MPH

    • Richard Young MD on January 26, 2014 at 5:26 pm


      I share your frustration. Couple of thoughts:

      First, in no way do we have the best healthcare system in the world. We pay exorbitant amounts of money for lousy outcomes compared to the rest of the developed world. If I read your message correctly, I don’t believe you’re making the “best in the world” claim. I’m just encouraging you to fight back every time you hear someone say it.

      Second, in spite of the payment disparity, I still love what I do and couldn’t imagine doing anything else. If I looked at retinas all day or did nothing but knee carpentry, I’d go stir crazy from the boredom. I love the variety and breadth of family medicine. Here is a link to another post I wrote explaining this further:


      Good luck with the career choice. If you want to see a residency where family physicians still believe in and practice full-scope gonzo family medicine, come check us out at the John Peter Smith FMRP in Fort Worth. Don’t believe what Dr. Oz tells you. The old-fashioned country family doctor is alive and well.

      Richard Young, MD

    • Donald on January 30, 2014 at 8:27 am

      I have referenced this thread on the AAFP website, under the topic titled “‘Four Pillars’ Blueprint Charts Course for Physician Workforce Reform.”

      Sadly, based on last night’s virtual meeting, I doubt if anyone at the AAFP will pay attention. The bubble they have encased themselves in seems to be completely impenetrable.

      • Richard Young MD on January 30, 2014 at 10:55 pm


        I hear you. In my naive optimism, I thought there was enough concern about PCMH and other pushes by the AAFP (EMRs are the answer to everything, population management, etc.) expressed that it will at least give them pause to not just keep barreling down the mountain. The four pillars model should be replaced with a 3+1 model: whatever specific pushes the AAFP decides to support all built on top of payment reform (and there could be several reasonable options to experiment with).

  4. Donald on February 7, 2014 at 11:49 am

    Dr. Young:

    If you haven’t seen it already, check out Dr. Jan Gurley’s devastating take-down of the PCMH:


    This is the type information we should be throwing in the face of the AAFP leadership every chance we get.

  5. Richard Young MD on February 9, 2014 at 5:39 pm


    Very nice. Thanks for bringing it to our attention.

    Richard Young

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