Incentives for Everything But Primary Care

Two interesting and related items recently dropped into my inbox concerning the future availability of primary care clinicians.  As most people are aware, primary care services are becoming increasingly scarce – and has been seen here in Massachusetts expanding insurance coverage may only increase this strain.  In addition, there is some good evidence that a  major reason for our higher health care spending is having too many specialists and not enough primary care clinicians. So increasing the number of primary care clinicians might be part of the solution to controlling health care spending.

Incentives to Become a Specialist
The first article in my inbox was a Washington Post story stating that only 2% of graduating medical students were contemplating going into primary care.  However, what the JAMA study actually found is that 2% of those entering Internal Medicine residency programs were planning on going into primary care. The Wall Street Journal correctly noted that the study also found that 12% of students are planning on going into pediatrics, and 5% into family medicine.  However, that means that 8% of physicians in training who will be treating adults in the future are planning on being primary care clinicians…. And even if some of those specialists go into research or other non-clinical careers, the percentage of primary care clinicians for adults will likely not be more that 10%

The reason why so many graduating medical students were planning on becoming specialist was clearly stated in the opening sentence of the Wall Street Journal article: “Yes, higher pay is prompting many U.S. med students to choose lucrative specialties over primary care….”

Incentives to Become a Researcher
The second piece in my inbox was a notice from the NIH about their loan repayment programs for recent doctoral program graduates.  When I worked at the NIH in the early 1990s I helped start a loan repayment program for researchers working on AIDS related research.  At that time there was tremendous need for more people to focus on HIV and AIDS research, and that loan repayment program was restricted to NIH-based employees.  What struck me about the NIH’s notice was how much their loan repayment programs have grown: They now fund 1,600 researchers each year with a budget of $70 million.  While many of the individuals benefiting from these programs are not physicians, they do include pharmacists, psychologists and dentists.

Conclusions and Thoughts About Overall Priorities
What I found interesting – and somewhat concerning – is that if increasing the number of primary care physicians is a high priority, and Medicare is being advised to take steps increase financial incentives for primary care, (something I’ve written about previously), then why have the NIH’s loan repayment programs expanded to draw more clinicians into research?  Certainly research is a worthy endeavor and a great career, but the current structure of the programs given our national priorities, the expansion of NIH’s funding (which helps support researchers salaries), and the growth in the private biomedical research industry, all together beg the question about how these loan repayment programs fit into our overall national strategy and NIH’s funding priorities?

I’m sure that some people will criticize me for questioning these NIH programs, but I look forward to hearing their perspectives – both on the loan repayment programs and how incentives for primary care should be increased.

I’m also concerned about the JAMA study’s findings because they point out that changing financial incentives for primary care may not happen soon enough – and clearly today’s students haven’t gotten any messages that these incentives will likely change in the future.  However, they may be getting their information from their teachers – who likely directly and indirectly relate the financial and life-style attributes of primary care versus specialty careers.  While Medicare and other payers cannot make promises about how their reimbursements will be structured years or decades from now, perhaps there needs to be more educational efforts directed at medical students and residents about what the future financial incentives for physicians may look like.

Clearly there is much work to be done in this area to ensure a greater supply of primary care clinicians and to drive research efforts forward with appropriate priorities.

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