A lifeline for primary care.

n engl j med 360;26 nejm.org june 25, 2009 2693 levels.1 Overloaded primary care practices, whose doctors are aptly compared to hamsters on a treadmill, struggle to provide prompt access and high-quality care. Three major factors contribute to this crisis. First, primary care physicians earn far lower incomes than procedural specialists, reducing career attractiveness for medical students with high debt burdens. Second, the work-related stresses felt by primary care physicians tags primary care as the career with more work at less pay. Third, medical education favors training in non–primary care fields. Rescuing primary care requires national policies that address all three issues. Growing clamor that primary care’s plight may undermine important goals of health care reform has Washington policymakers concerned. Primary care has featured prominently in recent hearings held by Senate and House committees, and the New York Times has quoted President Barack Obama as saying that “we’re not producing enough primary care physicians.” The administration and Congress understand that after Massachusetts expanded health insurance in 2006, many newly insured adults were unable to find a primary care physician, raising the specter of theoretically universal access to care but no primary care to which to have access. Policymakers are also familiar with studies showing that health systems anchored in primary care have lower costs and better quality.2 A bold federal initiative to revitalize primary care is urgently needed as part of health care reform legislation. This initiative must be comprehensive, simultaneously addressing three interrelated issues: physician payment, practice infrastructure and organization, and the training pipeline (see table). For the first of these, physician payment, Medicare and most private insurers currently use the resource-based relative value scale, which was purportedly designed to reduce the payment gap between primary care physicians and procedural specialists. That gap, however, continues to widen. Under Medicare’s sustainable-growthrate approach to containing expenditures, spending on physicians’ services remains a zero-sum game: if expenditures for all physicians’ health care 20 09