Editor’s Note: There is widespread agreement that the nation’s primary care infrastructure is woefully inadequate. For example, at the Senate hearing on his nomination to be Secretary of Health and Human Services, Sen. Tom Daschle spoke of health care as a pyramid, with primary care at the bottom and specialized care at the top. He stated: “Every country starts at the base of the pyramid with primary care, and they work their way up until the money runs out. We start at the top of the pyramid, and we work our way down until the money runs out. And the money runs out. And so few people get good primary care and wellness. And so we have to change the pyramid. We have to start at the base.”

Below, in the first part of a two-part blog post, Kevin Grumbach discusses some of the reasons for the deficient state of primary care, as well some of the consequences of this situtation and its impact on efforts to expand coverage. In part two of his post next week, Grumbach, one the nation’s leading experts on primary care and the health care workforce, will set forth a plan to revitalize primary care in the United States.

For students of political history mindful of the inability of the Clinton administration to successfully navigate the legislative odyssey of universal health insurance, defeated by the siren ads of Harry and Louise and the Scylla and Charybdis of critics on the Right and Left, the question of whether President-elect Obama will be able to deliver on his pledge to expand health care coverage looms large. Central to the debate over health care reform is the matter of financing coverage for the tens of millions of Americans without health insurance. But what if this time a new administration prevailed in achieving expanded health insurance coverage, but there was no one home to provide preventive and comprehensive primary medical care to the millions of newly insured Americans?

The lessons of the Massachusetts Health Care Reform Plan of 2006 make it clear that an expansion of insurance coverage quickly uncovers the debilitating problem of the crumbling infrastructure of primary care. In Massachusetts, inadequate primary care capacity resulted in many newly insured residents not being able to find a medical home and gain access to medical care. In this post, I discuss the nation’s deteriorating primary care infrastructure and explain why health care reform efforts will not fully succeed unless they address the crisis in primary care, and I propose several concrete actions that the Obama administration and Congress should take to revitalize primary care.

The Crisis In Primary Care

As the Massachusetts experience indicates, primary care physicians are becoming an endangered species in the U.S. Over the past decade, the number of graduates of U.S. medical schools entering family medicine training programs plummeted by 50%, as did the number of graduates of internal medicine residency programs pursuing careers in adult primary care. Similar decreases in primary care interest have been observed among physician assistants. For both private medical groups serving the well-insured and community health centers caring for disadvantaged populations, successfully recruiting primary care physicians has become the number-one physician resource problem. Although the overall supply of physicians per capita in the U.S. is increasing, the trajectory of the supply of primary care physicians for adult patients is now falling behind the growth of the adult population, with the gap projected to widen dramatically over the next decade.

This workforce crisis is creating the equivalent of medical homelessness for millions of Americans seeking primary care, even among the insured. In 2007, 29% of Medicare beneficiaries seeking a new personal doctor reported a problem finding a primary care physician, up from 24% in 2006.

The Growing Gap In Pay And Resources Between Generalists And Specialists

Why are so few young physicians entering careers in primary care? One answer is money. Doctors in primary care fields have always expected to earn less than specialists, but the gap in fees and earnings between primary care physicians and specialists is widening. The net income of primary care physicians, adjusted for inflation, decreased by 10.2% from 1995 to 2003. Growing medical student indebtedness, with many graduates facing an educational debt of $150,000 or more, magnifies the impact of the widening primary care–specialist payment gap.

But there is more to the payment gap than simply a matter of disparities in take-home pay. More consequential is the lack of investment in the core infrastructure of primary care. Specialists, who spend many of their work hours in operating rooms, hospital wards, come-and-go surgery and endoscopy centers, and imaging facilities, have much of their practice infrastructure — operating room nurses, inpatient electronic medical records, high-tech equipment — provided by hospitals, at the hospital’s expense, or have the cost of technology incorporated into the relatively high allowed charges for procedurally oriented services. Primary care physicians spend most of their work hours in ambulatory care in their own offices and clinics, paying all practice overhead from their own billings.

Purchasing and maintaining an office-based electronic medical record (EMR) and hiring an extra staff person to work with diabetic patients on self-management skills are daunting expenses for a small primary care office operating on the slender margin of “evaluation and management” billing codes. Equally problematic is obtaining the technical assistance to effectively deploy these types of modernization and practice improvement resources.

As a consequence of this undercapitalization of primary care, too many primary care physicians work in outmoded offices with inadequate staffing and resources to support the innovative models of team care required of a twenty-first-century, patient-centered medical home. Not surprisingly, these practice environments are producing burnout among primary care clinicians, turning off medical students to careers in primary care, and failing to provide patients the care they need and deserve.

A crumbling primary care foundation destabilizes the entire health system. Evidence from research comparing nations, regions within the U.S., and individual patients’ experiences makes it clear that health systems built on a solid foundation of primary care deliver more accessible, effective, affordable, and equitable care than systems that fail to invest adequately in primary care. A recent Government Accountability Office report found that “ample research concludes in recent years that the nation’s over-reliance on specialty care services at the expense of primary care leads to a health system that is less efficient. . . . Research shows that preventive care, care coordination for the chronically ill, and continuity of care — all hallmarks of primary care medicine — can achieve better health outcomes and cost savings.”

A recent example of how a modest investment in the primary care infrastructure yields manifold benefits is found in the North Carolina Medicaid program. The North Carolina Medicaid program linked patients to a primary care medical home, provided technical assistance to practices to improve chronic care services, directly hired a cadre of nurses to collaborate with practices in case management of high-risk patients, and added a $2.50 per member per month care coordination fee for each patient registered with the practice, contingent on practices reporting clinical tracking data. The result was a classic win-win value: lower costs (independent evaluations estimate an annual savings to Medicaid of at least $161 million) and better quality of care (a reduction in emergency room visits and hospitalizations for poorly controlled asthma).

This evidence is not lost on many stakeholders, who are recognizing the imperative of investing in primary care. IBM, with the participation of many other larger employers, AARP and other consumer groups, and professional associations, has organized the Patient-Centered Primary Care Collaborative to promote policy changes in both the private and public sectors to support primary care. Purchasers and consumers alike are increasingly recognizing that the current expensive, uncoordinated system that lacks a solid primary care foundation is not delivering good health care value.