The ACP Advocate Blog
by Bob Doherty
Tuesday, June 30, 2009
Does President Obama have the right Rx for primary care?
Last week, President Obama made his most extensive comments yet on the crisis in primary care. In his responses to two questions - one from a nursing student and the other from a medical student - during a town hall meeting hosted by ABC News, Obama had this to say:
"Well, first of all, we need more people ... who are going to school and committed to the kind of primary care that's going to be critical to us bringing down costs and improving quality. We're not going to be able to do it overnight. Obviously training physicians, training nurse practitioners, that takes years of work. But what we can do immediately is start changing some of the incentives around what it takes to become a family physician.
Right now, if you want to go into medicine, it is much more lucrative for you to go into a specialty. Now, we want terrific specialists, and one of the great things about the American medical system is we have wonderful specialists and they do extraordinary work. But, increasingly, medical students are having to make decisions based on the fact that they're coming out with $200,000 worth of loans. And if they become a primary care physician, oftentimes they are going to make substantially less money, and it's going to be much harder for them to repay their loans.
... But what we're also going to have to do is start looking at Medicare reimbursements, Medicaid reimbursements, working with doctors, working with nurses, to figure out how can we incentivize quality of care, a team approach to care, that will help raise and elevate the profile of family care physicians and nurses as opposed to just the specialists who are typically going to make more money if they're getting paid fee-for-service.
... And one of the things that I'd like to explore -- and I've been working with the administration and with Congress -- are their loan forgiveness programs where people commit to a certain number of years of primary care. That reduces the costs for their medical education. That would make a significant difference.
If we provide the right incentives I think we're going to start seeing more young people say that going into medicine is a satisfying, fulfilling profession -- especially if we can eliminate some of the paperwork and bureaucracy that they have to deal with right now ...
But I also think that one of the big potential areas where we can make progress is ... how can we get nurses involved in more effective ways. If you look at what's happening in some states, like Massachusetts, where they tried to create a universal system -- and they haven't quite gotten there yet -- they have had a problem with an overload of patients.
... One of the areas where we can potentially see some saving is a lot of those patients are being seen in the emergency room anyway, and if we are increasing prevention, if we are increasing wellness programs, we're reducing the amount of emergency room care, then that frees up doctors and resources to provide the kind of primary care that will keep people healthier, but also allow them to see more patients and hopefully give more time to patients, as well."
It is good to hear the President describe primary care as "critical" to improving quality and bringing down costs. He also seems to have a good grasp of the reasons that young people aren't going into primary care, including high student debt, poor pay, and excessive paperwork.
Obama doesn't believe, though, that the answer is to just train more primary care physicians and pay them more. Instead, he wants reforms to "raise and elevate" the roles of both primary care physicians and advanced practice nurses under a "team approach" that "incentivizes" quality of care. And he wants to help reduce the debt of both doctors and nurses that go into primary care.
Today's question: Do you agree with Obama's prescription for the primary care workforce crisis and the roles of both physicians and nurses?
About the Author
Bob Doherty is Senior Vice President, American College of Physicians Government Affairs and Public Policy; Author of the ACP Advocate Blog
Email Bob Doherty: TheACPAdvocateblog@acponline.org.Follow @BobDohertyACP
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