Lori Melichar Gadkari, PhD, MA, is a senior program officer at the Robert Wood Johnson Foundation (RWJF), in the Research and Evaluation Unit.

Yesterday the New England Journal of Medicine published the results of a study co-funded by the Robert Wood Johnson Foundation, Johnson & Johnson, and the Gordon and Betty Moore Foundation. “Perspectives of Physicians and Nurse Practitioners on Primary Care Practice” finds that 96 percent of nurse practitioners and 76 percent of physicians agreed with the Institute of Medicine report recommendation that “nurse practitioners should be able to practice to the full extent of their education and training.” The new study is authored by Karen Donelan, ScD, EdM, Catherine M. DesRoches, DrPH, Robert S. Dittus, MD, MPH, and Peter Buerhaus, PhD, RN.

When asked how increasing the supply of nurse practitioners would potentially affect the United States health care system, the authors found that the majority of physicians (73%) said increasing the supply of primary care nurse practitioners (PCNPs) would lead to improvements in the timeliness of care. A much smaller majority of physicians (52%) said increasing the supply of PCNPs would lead to improvements in access to care for people in the country. 

However, the new survey found significant disagreement between primary care physicians and PCNPs about whether increasing the supply of PCNPs would improve patient safety and the effectiveness of care, and whether it would reduce costs. There was also a large professional divide about proposed changes to PCNPs’ scope of practice, putting PCNPs in leadership roles, and the quality of care that PCNPs provide.

More U.S. medical students “matched” to primary care residency positions this year than in 2012, according to data from the National Resident Matching Program (NRMP). Almost 400 more students chose primary care fields— internal medicine, family medicine, and pediatrics—than last year.  NRMP is a private, non-profit organization established in 1952 to provide a mechanism for matching the preferences of applicants for U.S. residency positions with the preferences of residency program directors.

Of the 17, 487 graduating seniors who participated in Match Day 2013, 3,135 matched to internal medicine—a 6.6 percent increase from last year. The number of seniors who matched to pediatrics (1,837) represents a 105 percent increase over last year.

This year’s Main Residency Match was the largest in NRMP history, with more than 40,000 student and independent registrants. NRMP attributes the increase to three new medical schools graduating their first classes, and expanded enrollment in existing medical schools.

Conducted annually by the NRMP, The Match uses a computerized mathematical algorithm to align the preferences of applicants with the preferences of residency program directors in order to fill the training positions available at U.S. teaching hospitals.

Read a NRMP news release about this year's Match Day results.

A report completed this month by the Congressional Research Service (CRS), which conducts analysis for members and committees of Congress, examines how the Affordable Care Act (ACA) will affect the nation’s supply of physicians. In particular, the report focuses on the workforce’s size, composition and geographic distribution.

Size
The health care system cannot work effectively or efficiently without a physician workforce of appropriate size. Too few physicians means delayed care, and too many physicians can mean unnecessary or duplicate care. But measuring the size of the physician workforce—and the future physician population—is challenging, and estimates vary. The CRS report notes that “predicting the timing, content, and effect of policy change is difficult, which adds to the uncertainty of the projections.”

The ACA authorizes funding for additional medical residency training programs through the Health Resources and Services Administration (HRSA) and the ACA’s own Prevention and Public Health Fund. It requires that Medicare-funded residency training slots be redistributed from hospitals that are not using them or that have closed, to hospitals seeking to train additional residents. It also includes provisions designed to increase physician productivity and the volume of physician services available. The law encourages care coordination—in medical homes and accountable care organizations, for example—and expands the non-physician workforce that can augment or substitute for physician services.

Two new studies show the nation’s younger primary care physicians may find it hard to recover from their medical school debt.

Primary care physicians who graduate with a median amount of debt and have a salary that is typical for the field can pay off their debt within 10 years, even if they live in a high cost residential area, according to a study from researchers at Boston University and the American Association of Medical Colleges, published in Academic Medicine. But young primary care doctors with debt that is above average—$200,000 or more—may have to employ “trade-offs and compromises” to support their repayment. These may include: extended repayment plans, increasing the interest repaid and the number of repayment years, living in a lower-cost area, or joining a federal loan forgiveness program that requires a service obligation such as practicing in a medically underserved area.

There are more sobering statistics for primary care doctors: a study in the Journal of the American Medical Association finds their earnings have grown more slowly than the salaries of other health care professionals. From 1987 to 2010, the average doctor’s earnings grew 9.6 percent; pharmacists’ earnings increased by 44 percent, and dentists earnings grew by 23 percent.

“It is possible that there are some specialties that have done extremely well in the past 10 or 15 years,” Amitabh Chandra, PhD, study co-author and Robert Wood Johnson Foundation Health & Society Scholars program faculty member at Harvard University, told Reuters Health. The slow growth for doctors—compared to other medical professions—is most likely due to lagging salaries of primary care physicians, he said. "If as a country we want more people to go into primary care, this anemic, jaundiced earnings growth is not going to be a motivator to get people to join primary care.”

What do you think? Should more be done to help medical students who go into primary care lower or repay their debt? Are slow-growing salaries a deterrent for medical students to enter this field? Register below to leave a comment.

Read the study in Academic Medicine.
Read the study in the Journal of the American Medical Association.

The United States will need 52,000 additional primary care physicians by 2025 to meet demand that is growing due to three trends: population growth, population aging and insurance expansion. That is a key finding from a study published in the November/December issue of the Annals of Family Medicine. The researchers estimate that population growth will account for the majority of the needed increase in primary care doctors.

Given the current number of visits to primary care physicians and an expected population increase of 15.2 percent, the researchers predict that office visits to primary care physicians will increase from 462 million in 2008 to 565 million in 2025. This trend will be especially evident among people 65 and older, a segment of the population that is expected to grow by 60 percent. Population growth will require an additional 33,000 physicians, the study says, and aging another 10,000.

Insurance expansion under the Affordable Care Act will also require additional physicians, the researchers find. Eight thousand physicians will be needed to meet that growth.

The 52,000 additional primary care physicians would represent a 3 percent increase in the workforce.

Read the study.

Feeling financial pressure to pay back student loans, medical students are choosing higher-paying specialties over primary care to secure higher incomes, according to a study published in Medical Education. In the 18-year-long study, researchers found that 31 percent of medical students who originally aspired to enter primary care had switched to a higher paying specialty by graduation.

The study, which followed more than 2,500 medical students at New York Medical College and the Brody School of Medicine at East Carolina University, asked students about their debt, income and career choices. Students were asked during their first year of medical school, and again in their fourth, to estimate their debt and anticipated income. They also rated how important income was to them, in terms of living comfortably, providing for their families and having an “adequate financial reward for the years of training required.”

The researchers found that students intending to pursue specialties anticipated higher debt, placed a greater importance value on income, and anticipated higher earnings after graduation than their primary care counterparts. They note that students interested in primary care were not altogether without income concerns, but those who did not switch before graduation may have rationalized their choice “by convincing themselves that income is less important than they originally believed.”

“Although many factors influence career choice, money is a significant concern,” the study says. “Medical students in the USA are graduating with increasing levels of debt and debt load appears to be pushing students toward higher-paying careers… Long-term legislative solutions may have to include more substantial corrections of specialty-specific income expectations and forgiveness of debts for those entering [primary care] careers.”

Read the study abstract.

Americans’ visits to physicians had become less frequent in recent years, at least in part because of patients’ financial concerns.  But they’re apparently beginning to pick up again. American Medical News reports that recent data from insurers, consultants and analysts shows physician visit volume has risen, and that patients are reporting fewer problems affording care.

Among the encouraging data points:

- A June research note from analyst Charles Boorady of Citigroup Investment Research shows physician visit volume rose by 4.8 percent over the second quarter of 2012. The number is good news on its own, but the trend line it represents may be just as telling: The comparable quarter of 2011 saw an 8.9 percent decline.
- In a March Gallup poll, 80.9 percent of respondents said they had no problem affording needed health care. Though this number is slightly lower than in February 2011, it is up from the 77.7 percent who responded similarly when the recession hit in late 2008.
- Data from Truven Health Analytics, formerly Thomson Reuters Healthcare, finds that visits to family doctors, internists, ob-gyns and pediatricians rose in May and June.

Though an easing of financial pressures could be behind the rising number of patient visits to physicians’ offices, the American Medical News story notes that some experts think the Affordable Care Act may also be playing a part: Now that many preventive services are covered free of charge, more patients may be seeking out these services.

What do you think? What’s behind the trend in increased physician visits? Is it due to patients’ finances, health reform, both or neither? Register below to leave a comment.

Read the American Medical News story.
Read the RWJF Human Capital Blog’s previous coverage of declines in physician visits here and here.

The Department of Health & Human Services (HHS) has awarded $9.1 million to medical students participating in the National Health Service Corps’ Students to Service Loan Repayment Program. In exchange for funds to repay their medical school debts, the 77 students in the pilot program commit to provide primary care services in communities with shortages of health professionals and limited access to care.

After their residencies, participants will spend three years full-time, or six years half-time, working in clinical practice in underserved or rural communities. They can receive annual student loan repayment funds of up to $30,000 while in the program.

The pilot program, created by the Affordable Care Act—the health reform law—aims to help alleviate a shortage of primary care professionals. “This new program is an innovative approach to encouraging more medical students to work as primary care doctors," HHS Secretary Kathleen Sebelius said in a statement.

Read more about the shortage of primary care providers and efforts to recruit primary care physicians in underserved areas.

Convincing a medical student, sometimes tens of thousands of dollars in debt, to take a lower-paying job or move to a low-income, rural community can be a tough sell. So perhaps it’s not surprising that many new physicians gravitate toward high-paying specialties or urban sprawls with modern-day conveniences. But with an aging population and millions of people poised to gain insurance coverage under the health reform law, the nation is in desperate need of general primary care physicians, particularly in rural and underserved areas.

Last week, NPR reported on a technique that one rural community has used successfully to recruit primary care providers – “mission focused medicine.” At the Ashland Health Clinic in southwest Kansas, CEO Benjamin Anderson is recruiting primary care providers not by pointing to all the advantages the community offers, but by highlighting its most severe needs. And to further appeal to prospective providers’ desire to do meaningful work, Anderson offers candidates eight weeks off to do missionary or other service work overseas. Anderson hopes to find providers who are engaged and motivated by the challenges associated with providing care in a rural community.

“When you recruit a mission-focused provider…,” Anderson said, “they want to know that there's no Spanish-speaking provider in more than a one-hour drive. They want to see houses that are falling down, widows that are uncared for. They want to know that there's need and that by them coming there, they would fill a disparity that would otherwise not be filled.”

Specialization also poses a challenge to building the primary-care workforce, the Washington Post reports. A medical resident who chooses a specialty over general primary care has the potential to earn millions more over a lifetime, making it an attractive option to the often deeply in debt medical student.

Last summer the White House launched the Primary Care Residency Expansion, providing financial support for three-year primary care residency training programs at 82 hospitals around the country. Participating residents are required to work in underserved areas. All of the 172 slots funded in the first year of the program have been filled, the story reports.

What do you think? How can we recruit more primary care physicians for general practice or in underserved areas? Register below to leave a comment.

Listen to the NPR story.

Read the Washington Post story.

As the health care system is transformed, hospitals are trying to lure primary care physicians away from private practice, the Washington Post reports this week. With new emphasis on care coordination among health care professionals, hospitals are seeking to take over existing practices or hire away doctors and new graduates to work alongside nurses and specialists.

Reaction among doctors is mixed. A salaried job comes with greater security, and gives physicians access to otherwise costly technologies like electronic medical records. On the other hand, physicians may have less flexibility in the amount of time spent with patients and how they care for them.

Read the story from the Washington Post.

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