The United States currently faces a shortage of primary care physicians, primarily due to compensation issues. The pay disparities between primary care physicians and specialists, along with the payment system utilized by Medicare and other health plans, which prioritize procedures over comprehensive care, impact the career choices of medical students. Consequently, there has been a significant increase in doctors pursuing specialization, resulting in fewer opportunities for primary care. Enhancing access to primary care is crucial for enhancing population health and achieving equitable outcomes. Unfortunately, primary care has historically received inadequate investment, accounting for less than 5% of healthcare spending in 2020.
Proposed legislative measures seek to bolster primary care by providing more training opportunities and improving access to community health centers. However, the matter of compensation has yet to be addressed. Given Medicare's substantial influence in the healthcare market, its payment amounts establish the standard for private health plans. Currently, the Medicare payment system favors procedural specialties, leading to a scarcity of primary care physicians. To counteract this shortage, primary care must be adequately and differently compensated, starting with Medicare reform. The Association of American Medical Colleges projects that the anticipated deficit of primary care physicians could reach up to 48,000 by 2034.The earnings disparity between primary care doctors and other specialists is widely recognized. Primary care doctors, including family medicine practitioners, internists, and pediatricians, currently earn an average annual salary ranging from $250,000 to $275,000. On the other hand, many specialists earn considerably higher incomes. This imbalance in earnings plays a significant role in the shortage of primary care physicians.
The lower salary associated with primary care often dissuades medical students from pursuing this field. Although student debt is a common concern among medical students, it is not the sole determinant influencing their choice of specialty. Nonetheless, various initiatives have been implemented to address this issue and attract medical professionals to work as primary care physicians in underserved areas.
One such initiative is the Geisinger Commonwealth Loan Repayment Program, which aims to recruit primary care physicians by offering loan forgiveness and financial incentives. By easing the burden of student debt, this program encourages medical students to consider primary care as a viable and rewarding career option.
The Centers for Medicare & Medicaid Services (CMS) have also taken steps to rectify the payment imbalance between primary care and specialized services. One of the measures implemented by CMS is the expansion of billing codes for primary care services. These expanded codes provide a more accurate representation of the complexity and value of primary care services, ensuring that they are appropriately recognized and reimbursed.
Of particular importance is the introduction of a new billing code for complex patient evaluation and management services. This development is regarded as a crucial step in payment reform by advocacy organizations such as the American College of Physicians. By recognizing the intricate nature of primary care services and compensating physicians accordingly, this billing code addresses the longstanding discrepancy in payment between primary care and specialized services.
Efforts to bridge the earnings gap between primary care physicians and specialists are essential to mitigating the shortage of primary care doctors. By offering financial incentives and implementing payment reforms, initiatives like the Geisinger Commonwealth Loan Repayment Program and the expanded billing codes from CMS work towards attracting and retaining primary care physicians.A confrontation has ensued over recent changes to the Medicare payment system for doctors, highlighting ongoing tension in the rules. The American College of Surgeons, along with 18 other specialty groups, have expressed their opposition to the new code, claiming it is unnecessary. They argue that the implementation of the code would primarily benefit primary care providers who already have the flexibility to bill more for complex visits.
However, the true issue lies in federal law, which mandates that changes to Medicare physician payments must maintain budget neutrality. This means that any payment increases for primary care providers would result in payment decreases for other healthcare professionals. Christian Shalgian, director of advocacy and health policy for the American College of Surgeons, emphasized the need to find a way to fund the new code if it is to be kept. He stated that his organization will continue to oppose its implementation until this matter is properly addressed.
Nevertheless, while there is a general agreement that the primary care system needs strengthening, many believe that simply changing billing codes is not enough. Primary care physicians often dedicate significant time and effort to tasks that are not fully compensated by the current fee-for-service system, such as emails, phone calls, and reviewing lab results. To address this, some argue for a different approach, suggesting that primary care physicians be paid a fixed amount per patient on a monthly basis, referred to as capitation.
Paul Ginsburg, a senior fellow at the University of Southern California Schaeffer Center for Health Policy and Economics, supports this idea, asserting that providing a per capita payment alongside an advance monthly payment and additional funds for other services would be more advantageous.
However, if implementing a single code to Medicare's payment rules has already proven to be challenging, overhauling the entire physician payment system would be an even more daunting task. MedPAC and the national academies have offered guidance to Congress on the general direction of such a transformation. Additionally, there are targeted efforts in Congress, including a proposed bill to allocate funds to Medicare physician payments and a proposal to address budget neutrality. Nevertheless, whether lawmakers have a strong inclination to take action remains uncertain.