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It seems unlikely that macrosystem improvement will occur in the near future. For small practices, rhetoric about efficiency and quality produces more problems than solutions. Pay for performance is a good example. In the 1990s, the "golden age" of health maintenance organizations and capitation, my partner and I were the beneficiaries of a bonus. The reward for a 3-month period — during which we earned a score above 95% in patient satisfaction, adhered to prevention guidelines, and provided same-day appointments and evening office hours — was $6.98.
In contrast, microsystem improvement is available now, through reversion to having patients pay for service. Five years ago, my practice stopped participating in all insurance programs with the exception of Medicare.3 We require no membership fee and adjust for financial hardship. We offer same-day appointments, after-hours coverage, lower overhead, and coordination with specialists. The demand for services from patients led us to add two more physicians to our practice. I offer this optimistic note to other primary care practices.
Jane H. Chretien, M.D.
Bethesda Physicians
Bethesda, MD 20814
bethesdaphysicians{at}verizon.net
References
The IMG migration has been described as a "brain drain," but given the constraints of rigid and suffocating domestic academic atmospheres and poor remuneration in their own countries, IMGs have tended not to return home.3 This situation appears to be changing, as shown by the trend of outsourcing images for reading by U.S.-trained IMG radiologists in their native countries.4 As IMGs, we believe that any examination of the future of primary care must involve a more detailed discussion of the role of IMGs and their contributions.
Rohit R. Das, M.B., B.S., M.P.H.
Boston Medical Center
Boston, MA 02118
rohit.das{at}bmc.org
Ranjani N. Moorthi, M.B., B.S., M.P.H.
Tufts–New England Medical Center
Boston, MA 02111
References
As is consistent with their role, 85% of nurse practitioners currently practice in primary care.1,2 Nurse practitioners are more likely than physicians to care for the underserved, work in rural areas, and provide health-promotion services.2,3 In 2005, schools of nursing enrolled more than 18,000 students in programs for primary care nurse practitioners and graduated more than 5000.2,4 More than 11,000 of these students were enrolled in programs for family nurse practitioners.4 In contrast, 1132 graduates of U.S. medical schools enrolled in family medicine residencies in the same year.
Clearly, the paradigm for the provision of primary care services is changing. The dwindling supply of primary care physicians suggests that nurse practitioners may become the future gatekeepers of primary care.
Kathleen Lent Becker, M.S., C.R.N.P.
Sara Carleton, B.S.N., R.N.
Grace Ihsiu Lin, M.S., R.N.
Johns Hopkins University School of Nursing
Baltimore, MD 21205
kbecker{at}son.jhmi.edu
References
Caroline Poplin, M.D., J.D.
6113 Wynnwood Rd.
Bethesda, MD 20816
cmpoplin{at}aol.com
An increasing shortage of faculty further threatens the discipline. Instruction in physical diagnosis, traditionally performed by internists, is now sometimes directed by anesthesiologists. My own patient panel has had several influxes of new patients as our residency alumni leave primary care and refer their patients back to the training site. Thus, I see both patients whom I inherited from my retired mentors and patients inherited from my prematurely retired trainees.
Let us again foster the social and political movement toward more equitable health care.
Stuart Oserman, M.D.
Advocate Lutheran General Hospital
Park Ridge, IL 60068
stuart.oserman{at}advocatehealth.com
However, the success of this model is predicated on macrosystem reform. The patient-centered medical home requires a different way of compensating physicians. Payments should reflect the value of services involved in coordinating care, support practices in acquiring needed information technologies, and reward measurable and continuous quality improvement.
We have a plan to make a patient-centered medical home a reality for all Americans. In return, government and payers must invest in primary care by eliminating a flawed system that rewards fragmented, high-volume, overspecialized, and inefficient care and adopting a payment system that facilitates high-quality and efficient care centered on the relationships of patients with their primary care physicians.
Larry S. Fields, M.D.
American Academy of Family Physicians
Leawood, KS 66211
Lynne M. Kirk, M.D.
American College of Physicians
Philadelphia, PA 19106
Oserman eloquently describes the distress of training programs for primary care physicians. But not all is dismal. Currents of reform are stirring in residencies in family medicine and general internal medicine, with the potential for making primary care training far more attractive.
The letter from Becker et al. about nurse practitioners brings up an important issue. Until recently, I believed that nurse practitioners would become the primary care clinicians of the future, and having worked with excellent nurse practitioners and physician assistants, I have great confidence in these advanced practice clinicians. The references provided by Becker et al. are compelling. But recently, I have heard many anecdotes of nurse-practitioner graduates who are having difficulty finding jobs in primary care (owing to the unstable finances of many primary care practices) and are opting for positions in cardiology or other specialties. It is too early to tell, but the next few years may show us whether this is the start of yet another trend away from primary care.
Thomas Bodenheimer, M.D.
University of California, San Francisco
San Francisco, CA 94134
References
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