MedPAC’s March 2019 Public Meeting

MedPAC’s March 2019 Public Meeting 

Medicare's role in the supply of primary care physicians (Ariel Winter, MPP) 

MedPAC, or the Medicare Payment Advisory Commission, is an independent congressional agency established by the Balanced Budget Act of 1997 to advise the U.S. Congress on issues affecting the Medicare program. The Commission's 17 members bring diverse expertise in the financing and delivery of health care services. MedPAC meets publicly to discuss policy issues and formulate its recommendations to the Congress. In the course of these meetings, Commissioners consider the results of staff research, presentations by policy experts, and comments from interested parties. 

In this session of MedPAC’s March 2019 Public Meeting, the topic was Medicare’s role in the supply of primary care physicians. Ariel Winter, a principle policy analyst for the Commission, began by reporting out on the current state of primary care accessibility for Medicare beneficiaries, discussing the pipeline of future primary care physicians and the current state of federal scholarship and loan programs for physicians, and presenting design ideas for a future program specifically targeted at encouraging physicians to provide primary care to Medicare beneficiaries. While the Commission has previously made recommendations to increase Medicare payments for primary care services, they are also looking into the possibility of another approach. It was first noted that this should be viewed as a second-best alternative to fixing the fee schedule, which is a root cause of the problem. 

Less and less medical school residents are choosing to practice general internal medicine, and evidence varies on what factors most significantly influence specialization decisions. Ideas for a future program specifically targeting students who will provide primary care to Medicare beneficiaries were addressed. A financial incentive may encourage some students who would not have otherwise chosen primary care, but it is difficult to anticipate how students would respond to such a program based on current evidence.  

While the evidence is mixed on the current efficacy of such programs, the design considerations must look at something that Medicare has the potential to control. Issues to consider include the potential size and budget of the program, financing options, whether the program should offer scholarships, loan forgiveness, or both, which specialties should be eligible, length of service commitment, and how to ensure that participants are providing primary care to Medicare beneficiaries. Current programs have shown mixed results and have key problems that should be considered when designing a new program. 

The Public Service Loan Forgiveness program is not specific to healthcare providers, nevertheless primary care physicians. While in 2018 approximately 17,000 applications were processed, only 55 were approved, showing that there is great confusion surrounding program requirements and a lack of guidance from the agency. The National Health Service Corps offers both scholarships and loan forgiveness, but they only require individuals to practice in health professional shortage areas for 2-3 years. Additionally, the program currently has 4500 unfilled spots—is this due to a lack of funding or a lack of interested individuals? The Primary Care Loan program provides low-interest loans to medical students who will commit to primary care practice for 10 years. Only a small share of these borrowers go on to practice in underserved or rural areas and only a small share are minorities. The Primary Care Loan program has, in recent years, decreased from 4500 to 2600 participants, showing that it is a less attractive program. Additionally, the program requires medical schools to contribute 1/9th of the loan amounts received by their students, which may disincentivize them from encouraging students to participate in the program. 

It was then addressed that while most Medicare beneficiaries report decent access to primary care providers, this is based on overall data and there are certainly specific geographic regions that are disproportionately affected by a lack of access and these areas should be identified and targeted with any future program.  

Questions arose as to whether certain primary care specialties should be focused on or left out, and as to whether nurse practitioners and physician assistants should be included. While there is not a lack of NPs, they are increasingly choosing to subspecialize. Comments from the Commission directed analysts to focus on physicians as the current growth rate of NPs and PAs is high, so it was felt that the resources were best targeted to physicians.  

It was also questioned whether we should instead be looking to fix the existing programs rather than making a new one. It was proposed that the solution may lie within looking for other ways to change the status or valuation of primary care specialties, which are often looked down upon by other medical specialties. It was noted that a survey showed role model influence impacted 50% of medical students in their decision of choosing a specialty, so this could be an important place to start. Control has a lot to do with respect, so it may be beneficial to give more flexibility or autonomy to primary care doctors in Medicare in order to raise their status.   

It was then proposed that Medicare GME dollars be redirected to creating incentives or training programs that give broader primary care experiences to students, not simply inpatient care. 

It was questioned whether it would be effective to distinguish a new program by focusing on geriatrics and palliative care, as they show particularly slow growth, especially so in geriatric internal medicine.  These specialties are even more differentiated and require longer visits, making them more economically challenging specialties. There was much agreement around the idea of focusing on geriatrics, as this would have an obvious unique benefit for Medicare beneficiaries. 

The first steps before implementing a new program will be to determine the ratio of additional primary care providers that these programs bring in compared to those who were going to become primary care physicians anyways, and to uncover what the biggest drivers are so that they can be directly addressed. It could be beneficial to talk to primary care focused medical schools and find out what they would spend the money on. This would leverage their expertise and we may find that the money would be better used to focus on recruiting or other techniques. 

Next steps included going into the field to talk to the students and professors at the programs that effectively foster primary care uptake, provide community hospital teaching, and focus on the social determinants of health before deciding on a program design. There was a consensus that a new program design should not be rushed into and the next steps will be very preliminary research, not concrete decisions.