A higher proportion of primary care physicians (PCPs) in the general population is linked to greater life expectancy and slightly lower cardiovascular, cancer, and respiratory mortality, according to a study published online yesterday in JAMA Internal Medicine. Yet the per capita supply of PCPs is declining.
Between 2005 and 2015, the mean density of PCPs showed an 11% relative decline nationally — despite an increase in numbers of PCPs — and rural regions were hardest hit, reports Sanjay Basu, MD, PhD, assistant professor of medicine at Stanford University, California, and colleagues.
The correlation between more PCPs and lower mortality suggests “that observed decreases in primary care physician supply may have important consequences for population health,” the authors write.
“Many believe that a well-functioning health care system requires a solid foundation of primary care,” the authors continue. “However, persistent payment disparities between primary care and procedural specialties continue to erode the US primary care physician workforce.”
The researchers assessed the relationship between US mortality and the supply of primary care and specialist physicians during the 10-year period. The researchers relied on US population and claims data from 3142 US countries, 7144 primary care service areas, and 306 hospital referral regions to calculate shifts in life expectancy and cause-specific mortality.
Although the raw number of US PCPs increased from 196,014 to 204,419 over the decade, the average density of PCPs decreased from 46.6 to 41.4 per 100,000 people. Neither county poverty level nor race/ethnicity were linked to PCP supply.
The relative loss was uneven, however. Whereas urban counties lost an average 2.6 PCPs per 100,000 people, rural areas lost an average 7 per 100,000.
“Owing to small populations, rural counties can appear to have large variations in primary care physician density,” the authors report. “Thus, the absolute changes were also analyzed and varied from a loss of 32 to a gain of 37 primary care physicians, with a median loss of 1.0 physician per county.”
Meanwhile, both the absolute number and density of specialists increased in the 10-year period. Specifically, the number increased from 699,989 to 805,277 and the density rose from 68 to 71.3 per 100,000 people. Similar to the PCP trend, however, rural counties saw no average increase in specialists despite a nationwide increase of 3.4 specialists per county.
Meanwhile, for every 10 additional PCPs per 100,000 people, population life expectancy increased an average 51.5 days. That proportion was further associated with declines in cause-specific mortality for three conditions: cardiovascular (0.9%), cancer (1.0%) and respiratory mortality (1.4%).
The authors adjusted both models for a wide variety of factors, including specialist density, urban/rural area, median household income, percentage of population under the federal poverty threshold, percentage of people without health insurance, percentage enrolled in Medicare, inflation-adjusted costs of medical care, age-adjusted proportion of adults who smoked and who had obesity, local pollution levels, median home value, hospital beds per 100,000 people, education, unemployment, age, sex, and race/ethnicity.
Density of specialist physicians showed a similar trend, though with a lesser magnitude of benefit: an average 19.2 additional days of life expectancy for every 10 specialists per 100,000 people. Likewise, every 10 additional cardiologists per 100,000 people was linked to 49.4 fewer deaths per million people, and every 10 additional pulmonologists tracked with 10.5 fewer deaths per million.
The researchers note increased investment in primary care from the Centers for Medicare & Medicaid Services, as well as in some states such as Rhode Island and Oregon, but add that it will take time to see if those initiatives bear fruit.
“Other forms of investment, such as the National Health Services Corps, the Teaching Health Centers program and Title VII programs, also offer the opportunity to increase the density of primary care physicians, especially in underserved areas,” the authors add.
In an accompanying commentary, Sondra Zabar, MD, and colleagues from the New York University School of Medicine in New York City, emphasize that increased compensation is key to increasing PCP supply. “To increase access to primary care, especially in underserved areas, we must align incentives to attract individuals into primary care practice, innovate primary care training and greatly improve the primary care practice model,” they write. “Physician payment reform is a key to making all of this happen.”
Though increased primary care exposure, early clinical training in underserved areas, loan forgiveness, and primary care-specific training funding has helped, US medical students remain less attracted to primary care, they note. And increasing levels of medical student debt have only exacerbated the dearth of students entering primary care.
“This decline has been attributed to factors such as the desired income, level of debt, type of patients cared for, and perceived work hours and workload of a primary care physician,” they write. “Current low reimbursement levels for primary care and high burden reporting of quality and performance measures that monopolize many patient encounters make it difficult to support sustainable, satisfying, and impactful careers.”
Despite a variety of practice model innovations, payments are inadequate for costs in primary care, whereas specialist care reimbursement and aid from physician assistants “leaves enough time for the sub-specialist to have a satisfying professional and personal life.”
Incentives need to shift so that the ratio between primary and specialist care reimbursement is more equitable and remains appropriate for the best population health, the editorialists write.
“Underlying the current incentive structures is a devaluing of cognitive work and interpersonal interactions compared with performance of procedures,” particularly given the greater burden of administrative work and specialist referrals, they write.
“Higher pay and lifestyle preferences lead most students to choose non–primary care fields, even when their hearts say primary care,” and excellent primary care training and practice reform won’t overcome this barrier, the editorialists write.
“The cost of inaction will be increased morbidity and higher premature mortality in the US population,” they conclude.
The research was funded by the National Institutes of Health and Stanford University. One coauthor advises the Comprehensive Primary Care Plus Initiative at the Center for Medicare and Medicaid Innovation, and one coauthor advises Bicycle Health. The editorial authors reported no funding have disclosed no relevant financial relationships.
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