Giving Compass' Take:

• Authors from Brookins explain how policy changes can break down barriers that prevent medical professionals from becoming primary care physicians. 

• Hoe can funders help to ensure that there are enough primary care physicians available access all parts of the country? 

• Learn about NYC's effort to close the primary care gap. 

In a Brookings white paper we published in December 2018, we came to the following principal conclusions: First, the income gap between the earnings of PCPs and specialists is the major driver of physicians’ choice between these groups of specialties and the main reason why physicians in training tend to favor specialization over primary care. Second, Medicare’s system of paying physicians for services furnished to Medicare beneficiaries, and its emulation by other payers, is a major contributor to the income gap. Based on these observations, we recommended two complementary measures to improve the mix of PCPs and specialists by reducing the income gap – that Medicare should change the Physician Fee Schedule (PFS) and its method of updating to channel more income to PCPs and less to specialists,[1] and that the US should develop a loan forgiveness program for physicians who practice primary care.

It may not be obvious how both changes in the Medicare PFS and loan forgiveness would lower the PCP/specialist income gap. Raising Medicare fees for services furnished by PCPs and lowering fees for services provided by specialists would alter PCP and specialist revenues in a manner that would reduce the gap. Loan forgiveness available only to PCPs would raise the discounted present value of lifetime earnings of PCPs relative to specialists, which would be another way of reducing the income gap. These measures are complementary because loan forgiveness operates at the early stage of medical training and practice, while PFS changes have their greatest effect as physicians’ fee-for-service practices mature.

Neither of these ideas is particularly new but, in our view, their potential power to improve US healthcare is underappreciated and obscured by numerous views of the problem that distract policymakers from arriving at the right conclusions. Here are five common beliefs that share that defect:

  1. Student debt and its need for repayment cause physicians to specialize.
  2. Medicare’s system of subsidizing graduate medical education should be amended to encouraging teaching hospitals to expand primary care residency positions.
  3. Increasing Medicare payments for Evaluation and Management (E&M) services is a sufficient way of reducing the PCP/specialist income gap.
  4. Subsidies to PCPs should be tied to existing social goals, such as improving access in underserved areas.
  5. The PCP shortage can be solved by expanding the number and responsibilities of Advanced Practitioners such as Physician Assistants (PAs) and Nurse Practitioners (NPs).

Read the full article about primary care physicians by Bruce Steinwald, Paul B. Ginsburg, Caitlin Brandt, Sobin Lee, and Kavita Patel at Brookings.