How federal policy has worsened the U.S. primary care shortage
Loud and clear warnings forecasting the current shortage of primary care physicians in the United States date back to the early 2000s.
A CNN report summarizing the findings stated that “many [primary care physicians] said they are overwhelmed with their practices, not because they have too many patients, but because there’s too much red tape generated from insurance companies and government agencies.”
In response, one would have expected that policymakers, when assessing the merits of a proposed healthcare initiative or regulation, would weigh the measure’s likely impact on making primary care practice less burdensome. Yet, such consideration was apparently given little weight when the Health Information Technology for Clinical Health (HITECH) Act was passed as part of the 2009 American Recovery and Reinvestment Act. HITECH broadened the authority of the Centers for Medicare & Medicaid Services (CMS) to utilize pay-for-performance (P4P) programs as a means of physician compensation. Needless to say, HITECH’s passage struck a major blow to physician autonomy.
Further reading: How physicians can deal with uncertainty
In a 2009 interview, President Obama acknowledged the PCP shortage and the difficulty in attracting physicians to choose a career in primary care, stating: “…keep in mind that the status quo is we don’t have enough primary care physicians. We’ve got to create more primary care physicians. And what we want to do is to provide a powerful set of incentives for more and more young people who are interested in healthcare … to go into primary care.” But the situation only worsened with the birth of the Medicare Annual Wellness Visit (AWV), courtesy of the Affordable Care Act.
As I outlined in Medical Economics last year, the AWV is a burdensome, inflexible Electronic Health Record (EHR) box-checking encounter scripted by CMS, with a weak evidence base and a one-size -fits all approach.Thus, the net result of HITECH’s enactment in 2009 followed by the passage of Obamacare the following year, was a further erosion of PCP autonomy and a further reduction in primary care’s appeal.
Which makes the expansion of P4P through the enactment of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) even more disheartening. That MACRA was passed by an overwhelming majority in both houses of Congress underscores what little interest policymakers have in attracting more physicians into the field of primary care.
For the PCPs, CMS’s embrace of P4P didn’t just limit autonomy, it replaced autonomy with compromise and conflict of interest. Some examples of the conflict: Does the physician engage female patients in a discussion of the pros and cons of mammography screening and risk falling short of the threshold percentage required for CMS “reward” revenue? Or does one simply go along with CMS guidelines, limiting mention of evidence raising doubts about the benefits of this screening measure?[5