Viewpoint

Where Have All the Primary Care Physicians Gone?


Richard G. Stefanacci, DO
Scott Guerin, PhD

You can probably remember a time when primary care physicians (PCPs) dominated the health care landscape in the same way there seemed to be a Blockbuster video rental store on every corner. Go further back, and you’ll find the iconic television show Marcus Welby, M.D., which depicted the PCP—although PCP is a more recent coinage—as being everywhere, knowing everyone, and caring for everything.

Richard G. Stefanacci, DO

Richard G. Stefanacci, DO

American health care has been slowly moving away from dependence on the PCP for decades. Many trace the decline back to the years immediately after World War II. Physicians who went into the military as generalists came out with training as specialists. When they returned to civilian life, they commanded premium pay relative to their PCP counterparts—and dominance of American health care by specialist had begun.

Now, we are hearing about projected shortages of PCPs; the Association of American Medical Colleges, for example, has predicted a shortfall of between 12,000 and 31,000 by 2025. To help fill this gap, some medical schools have responded by offering three-year fast-track medical degrees. New York University, Texas Tech University, and Columbia are among the few medical schools offering these programs.

Scott Guerin, PhD

Scott Guerin, PhD

Managed care organizations (MCOs) and health systems are involved as well. Instead of subsidizing the work of PCPs to support their existence, they are paying for other kinds of health care workers and expanding the responsibilities of people in nonclinical jobs. This is occurring in the form of patient navigators and care coordinators who are taking over some of the orchestration of patient care, and in the form of pharmacists through the provision of some services like vaccination and advice about medications.

Implications

Meanwhile, hospitalists are taking on increased responsibilities from PCPs in hospitals and “SNFists” function as PCPs inside skilled nursing facilities. Other specialists are replacing the role of traditional PCPs by managing patients with chronic diseases, such as cardiologists who see patients with congestive heart failure, pulmonologists for those with chronic obstructive pulmonary disease, and nephrologists for dialysis.

This disappearance of PCPs will have implications for new delivery models. The rules for attributing patients to ACOs may need to change. Patient-centered medical homes have been built with the PCP as the foundation and the chief clinician in charge. MCOs are having to rethink the role of the PCP in the makeup of clinical panels and the delivery of quality measures.

Furthermore, the environment in which PCPs work is changing significantly because of the Medicare Access and CHIP Reauthorization Act (MACRA). This legislation will push PCP compensation, in a decisive way, away from fee for service (FFS) toward value-based reimbursement. MACRA is two-pronged. The Merit-Based Incentive Payment System (MIPS) combines, and so ends, the separate Physician Quality Reporting System, the Value-based Payment Modifier, and Meaningful Use programs. In addition, it initiates an alternative payment option for working within risk-based models. The startling fact is that the first performance year is scheduled to begin in 2017, just months away, with the payment adjustment year occurring in 2019.

So what will PCPs do? Some options could be: (1) retire soon to avoid changes; (2) become affiliated with an IDN that provides management services, such as MACRA support; (3) stop Medicare FFS to focus only on Medicare Advantage patients; or (4) opt out of Medicare FFS to provide concierge medical services. Beyond this shift, the continued erosion of primary care practice by non-PCPs such as SNFists, patient navigators, and nurse practitioners will surely mean that the corner PCP office serving FFS Medicare patients is quickly going, going, gone…

Richard Stefanacci, DO, is chief medical officer for the Access Group, a medical director for AtlantiCare Post-Acute Services, and is a member of Managed Care’s Editorial Advisory Board. Scott Guerin, PhD, leads the Government Policy Systems team for the Access Group.

UP NEXT

Managed Care
By Peter Wehrwein
Managed Care
By Peter Wehrwein
2019 Year in Preview
By Richard Mark Kirkner