PRIMARY CARE
CRISIS AND CHANGE
In the United States, primary care is in crisis. The ranks of primary care physicians are thinning, with many burning out and trainees shunning primary care fields. The following articles examine the current state of primary care in the U.S. and discuss potential solutions in the areas of training, practice, compensation, and systemic change.
SPECIAL ARTICLE
Growth in the Care of Older Patients by Hospitalists in the United States
In this analysis of Medicare data, the number of physicians in general internal medicine who were working as hospitalists increased from 6% in 1995 to 19% in 2006. During this period, the percentage of hospitals with at least three hospitalists increased from 12% to 47%.
N Engl J Med 2009;360:1102-12, March 12, 2009
Related Editorial: The Growth of Hospitalists and the Changing Face of Primary Care
PERSPECTIVE
The Independent Physician — Going, Going . . .
Stephen Isaacs, Paul Jellinek, and Dr. Walker Ray write that the percentage of U.S. physicians who own their own practice has been declining for at least the past 25 years. This trend raises the question of whether small, independent practices have any future — an important question, since nearly 9 of 10 Americans get their medical care from a physician in a solo or small practice.
N Engl J Med 2009;360:655-7, February 12, 2009
PERSPECTIVE
The Future of Primary Care — The Community Responds
On November 13, the Journal published six Perspective articles and a video roundtable in which experts discussed the current crisis in the United States and explored possible solutions. Readers and viewers were invited to contribute their ideas in an online forum. We present a small selection of these comments, with responses from the roundtable participants.
N Engl J Med 2008;359:2636-9, December 18, 2008
PERSPECTIVE
Home Delivery — Bringing Primary Care to the Housebound Elderly
As baby boomers enter their 60s, their increasing medical needs and a worsening shortage of primary care doctors are expected to fuel a crisis in health care for the elderly. Dr. Susan Okie reports that meeting their medical needs will most likely require increasing reliance on midlevel providers (nurse practitioners and physician’s assistants), as well as the use of multidisciplinary teams.
N Engl J Med 2008;359:2409-12, December 4, 2008
PERSPECTIVE
Innovation in Primary Care — Staying One Step Ahead of Burnout
Creativity is needed as physicians and managers struggle to make professional life sustainable for the United States’ shrinking pool of primary care doctors. Dr. Susan Okie reports on strategies to help office-based physicians “work smarter, not harder.”
N Engl J Med 2008;359:2305-9, November 27, 2008
PERSPECTIVE ROUNDTABLE
In a discussion moderated by Dr. Thomas Lee, four experts in primary care and related policy — Drs. Thomas Bodenheimer, Allan Goroll, Barbara Starfield, and Katharine Treadway — explore the current crisis in U.S. primary care and possible solutions for training, practice, compensation, and systemic change.
N Engl J Med 2008;359:e24, November 13, 2008
THE FUTURE OF PRIMARY CARE
The editors asked several experts to share their perspectives on the crisis in U.S. primary care. Their articles address the issue from six different angles.
The Need for Reinvention
T.H. Lee
Sustaining Relationships
K. Treadway
Transforming Practice
T. Bodenheimer
Reforming Physician Payment
A.H. Goroll
Refocusing the System
B. Starfield
Lessons from the U.K.
M. Roland
THE MEDICAL HOME MODEL
PERSPECTIVE
Beyond Pay for Performance — Emerging Models of Provider-Payment Reform
Both the enthusiastic adoption and somewhat lackluster early results of pay for performance have given rise to a broader payment-reform movement, with proposals and pilots emerging from a wide variety of stakeholders and policy leaders. Meredith Rosenthal describes these novel approaches.
N Engl J Med 2008;359:1197-200, September 18, 2008
PERSPECTIVE
No Place Like Home — Testing a New Model of Care Delivery
The federal government is preparing to test the concept of the “medical home” in the Medicare program. The demonstration program will operate for 3 years in rural, urban, and underserved areas in up to 8 states. John Iglehart reports.
N Engl J Med 2008;359:1200-2, September 18, 2008
PERSPECTIVE
Building a Medical Neighborhood for the Medical Home
Recent efforts to improve primary care in the United States have focused largely on the “medical home.” Dr. Elliott Fisher writes that unrealistic expectations about this approach abound, and insufficient attention is being paid to several important barriers to the clinical and financial success of the medical-home model.
N Engl J Med 2008;359:1202-5, September 18, 2008
HEALTH POLICY REPORT
Medicare, Graduate Medical Education, and New Policy Directions
In the context of the concerns of many experts about a looming shortage of physicians, the author discusses policy proposals to increase federal support for graduate medical education and to expand the supply of primary care physicians.
N Engl J Med 2008;359:643-50, August 7, 2008
PERSPECTIVE
Physician Workforce Crisis? Wrong Diagnosis, Wrong Prescription
The Association of American Medical Colleges has responded to the concern about a physician workforce crisis with calls for a 30% expansion of U.S. medical schools and a lifting of the current cap on Medicare funding for graduate medical education. Drs. David Goodman and Elliott Fisher write that before acting on these recommendations, we should carefully consider the accuracy of the diagnosis and the likely consequences of the prescription.
N Engl J Med 2008;358:1658-61, April 17, 2008
HEALTH POLICY REPORT
Grassroots Activism and the Pursuit of an Expanded Physician Supply
The author discusses the supply of physicians in the United States and the growing consensus that there will be a shortage of physicians in the future.
N Engl J Med 2008;358:1741-9, April 17, 2008
PERSPECTIVE
Spreading the Safety Net — Obstacles to the Expansion of Community Health Centers
Federal grants to community health centers will have increased to $2.2 billion in fiscal 2009, if Congress accepts President Bush’s proposed budget for this program. John Iglehart writes that the chaotic mix of private and public activities that make up the health care system has evolved in ways that present the centers with major challenges.
N Engl J Med 2008;358:1321-3, March 27, 2008
HEALTH POLICY REPORT
Coordinating Care — A Perilous Journey through the Health Care System
Patients with chronic illness often receive care from multiple providers in multiple settings and require coordination of their complex care. This report assesses the quality of the coordination of care, describes barriers to coordinated care, and discusses some solutions to improve care coordination in the United States.
N Engl J Med 2008;358:1064-71, March 6, 2008
SPECIAL ARTICLE
Outcomes of Care by Hospitalists, General Internists, and Family Physicians
Patients cared for by hospitalist physicians had modestly shorter hospital stays than patients treated by general internists or family physicians but similar in-hospital mortality.
N Engl J Med 2007;357:2589-600, December 20, 2007
Related Editorial: The Hospitalist Movement — Time to Move On
SPECIAL REPORT
Quality of Primary Care in England with the Introduction of Pay for Performance
In 2004, the United Kingdom invested $3.2 billion in a new program to reward general practitioners for the delivery of high-quality care. The authors report that the incentive program may have prompted a modest improvement in the quality of care.
N Engl J Med 2007;357:181-90, July 12, 2007
SPECIAL ARTICLE
Care Patterns in Medicare and Their Implications for Pay for Performance
The investigators found that patients typically saw many different physicians and that less than one third of patients’ visits each year were with the physician to whom their care would have been assigned. These findings raise doubts about the potential of current pay-for-performance approaches to improve the quality of care.
N Engl J Med 2007;356:1130-9, March 15, 2007
Related Editorial: Paying for Care Episodes and Care Coordination
PERSPECTIVE
The Rise of In-Store Clinics — Threat or Opportunity?
Dr. Richard Bohmer writes that in-store clinics are increasing in prevalence and appeal to payers, patients, entrepreneurs, and proponents of consumer-driven health care. Physicians, however, express concern about the quality of care and the potential impact on their businesses.
N Engl J Med 2007;356:765-8, February 22, 2007
Audio Interview: Dr. Richard Bohmer on the rise of in-store clinics
PERSPECTIVE
Primary Care — Will It Survive?
Dr. Thomas Bodenheimer writes that primary care is facing a confluence of factors that could spell disaster. Patients are increasingly dissatisfied, many primary care physicians are unhappy, and fewer and fewer U.S. medical students are choosing to enter the field.
N Engl J Med 2006;355:861-4, August 31, 2006
PERSPECTIVE
Primary Care — The Best Job in Medicine?
Changes in our health care system have made primary care medicine less satisfying for practitioners and less attractive to students and residents. But, Dr. Beverly Woo writes, with all the changes in our health care system, one thing remains constant: the needs of patients.
N Engl J Med 2006;355:864-6, August 31, 2006
Audio Interview: Dr. Beverly Woo on the rewards and challenges of primary care medicine
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