Much work to be done
"All the odds are stacked against them because of the way our payment systems are stacked up. They are incentivized to convert their primary care residency programs into specialty programs. They can generate more revenue that way and support some of the procedures and things that hospitals do that will bring in more revenue and make sure the bottom line is safe. I spend a lot of time looking at community-based hospitals that don't have a lot of margin. They are struggling and we don't want to see anything happen that would put those hospitals into even more jeopardy."
"The what-needs-to-be-done list is very long," she says. "A lot of people say it just can't be about GME or residency programs and we agree. We need changes in how we pay for care to strengthen the primary care workforce and incentivize people to go into primary care. We need payment and practice reforms. Primary care providers want to provide the best care, but when they feel like a hamster on a wheel they can't."
Even conceding payment and practice reforms, Chen says medical schools GME programs will still have a huge role in realigning the physician workforce. "It has to be done at the same time. If you don't, the educational system can hold back the reforms," she says.
"I would argue we have the best system in the world in terms of providing quality physicians. But there is no match in the kinds of physicians we are producing in terms of specialty and geographic distribution."
Poor distribution of physician placements
"How," asks Chen, "do we not only get the highest quality physicians but how do we get a workforce that matches the needs of the country and will support the payment and practice reforms that are aimed at getting us more comprehensive and cost efficient care?"
While the results from the 2003 legislation clearly fall short of the aspirations, Pugno says the mandate still raised the profile of primary care physicians.
"It's not a failure from the perspective that Congress is concerned about making the most of the money that they are putting into GME," he says.
"They fully recognize the need for more primary care. They fully recognize that we have maldistribution of physician placements and if we do more rural training we would have more physicians practicing in rural areas. So the basis from which they are coming and the things they are trying to fix are things we spent a decade trying to get them to recognize. So it is progress in the right direction. They just need to get some help tightening up how they write this legislation so they get the outcomes this legislation was designed to get."