The ACA and Primary Care: The View From AAFP

Laurie Scudder, DNP, NP; Reid Blackwelder, MD


September 27, 2013

In This Article

Editor's Note:
The shortage of primary care providers in the United States is long-standing and expected to worsen with the implementation of the Affordable Care Act (ACA) and the enrollment of 20-30 million previously uninsured Americans. Medscape spoke with Reid Blackwelder, MD, President, American Academy of Family Physicians (AAFP), about current workforce issues in primary care, anticipated changes as the ACA rolls out, and the important issues facing primary care.

Medscape: First, can you speak about the current supply of family physicians? Is the trend toward smaller numbers of physicians choosing family medicine finally reversing? What efforts are the AAFP specifically making to increase the number of family physicians?

Dr. Blackwelder: As you look at what healthcare reform is trying to accomplish, the need for creating, maintaining, nurturing, and growing a very strong primary care workforce is evident. One of the things I have to say early on is that "primary care" is an important term that people are using a lot lately. But it means different things in different contexts.

Primary care specialities include general internal medicine, general pediatrics, and family medicine. Obstetrics/gynecology is considered primary care in some states, but it really is a state-to-state issue. A great number of internal medicine specialists -- up to 90% of their graduates -- end up limiting their practice and aren't really doing general primary care. About 50% of those in pediatrics also limit their practice and therefore are also not primary care.

Family medicine in many ways is the primary primary care specialty. We're very pleased that in the past 3 years, we've seen a very slight increase in medical students choosing family medicine. However, it's not enough, and we need to see a greater increase in that number. We are hopeful that some of our efforts can certainly affect that.

We are facing a shortage of about 45,000 primary care physicians by 2020 if we are to meet current patient care expectations. That shortage is not necessarily, nor even primarily, from the ACA. Our country has been aging. We have more people going into the Medicare population. There are other factors that contribute to the challenge. All of these come together in the recognition that we must have a stronger primary care base.

As far as some of the AAFP activities are concerned, we are very much addressing advocacy in a couple of areas. One of the most important areas in terms of both the current and future workforce is payment reform. As the country is talking about the value of primary care, a large part of that value is represented by payment. Therefore, a very important way of helping medical students choose to go into family medicine or primary care specialties will be to make the payment more appropriate.

There's a huge gap right now between the salaries that consultants vs limited practice specialists make. This is an issue across the board for primary care. Research shows that nurse practitioners and physicians assistants are going into subspecialty practice. This trend is affecting their primary care workforces as well.

Another area of emphasis for us is graduate medical education (GME) funding. A large part of GME funding for the training of medical students after graduation is paid by Medicare. Right now, that money goes primarily to hospitals. As the country is shifting away from hospital-based care to Accountable Care Organizations (ACOs) and other approaches, we are suggesting that that money could be better utilized and go farther if there was a shift in where it went.

There is currently a bill in Congress proposing a budget-neutral pilot to demonstrate how sending funds directly to community-based teaching health centers as opposed to tertiary care hospitals affects primary care. Representatives Cathy McMorris Rodgers (R, Washington) and Mike Thompson (D, California) are the sponsors of that bill. It is a budget-neutral pilot project that expects to show one way to improve the efficiency and cost-effectiveness of training primary care physicians. This is a big area that we're continuing to look at.

Finally, another important focus is making sure that we do everything we can to reach out to medical students early on. One of our biggest efforts is through our Family Medicine Interest Groups, which are on medical school campuses across the country. We are always looking for creative ways for family physicians, general internal medicine, general pediatricians -- folks who are on the front lines -- to have encounters with medical students early in their training. That is a critical way of helping students see how exciting family medicine is and how much value it provides to the country. Waiting until students are in their third and fourth years to make those kind of connections often is too late.


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