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Ask the Expert

In this States in Action, we talk with Fitzhugh Mullan, M.D. Dr. Mullan is a professor of medicine and health policy at the George Washington University School of Public Health and Health Services, where he directs a program focusing on the influence of medicine and medical education on health care and public health. Previously, Dr. Mullen directed the Health Resources and Services Administration's Bureau of Health Professions, the National Health Service Corps, and other workforce programs.

What would you say are the key drivers behind the shortage and maldistribution of primary care practitioners in this country?

First, "pay parity" is lacking for primary care. They make less and this is both a financial and "signal" problem—lower pay sends the message that primary care is less important. Second, mission setting by medical schools that tend to promote specialism and demean generalism. Virtually every family physician in the U.S. has a story from medical school of a faculty member who told him/her, "You're too smart to be a family doctor."

To what degree does this shortage and maldistribution affect access to care?

Access to primary care is stretched thin everywhere. Worse, any kind of cost and/or quality-conscious change to the system will have to amplify the role of primary care, and the providers won't be there. For example, the state of Massachusetts experienced an acute shortage of primary care providers after they expanded coverage in their 2006 health reform.

How effective are tuition assistance, loan forgiveness, and other incentive programs (e.g., National Health Services Corp) for getting the right health care providers to practice where they are needed most?

These programs are very efficient and socially responsible. We need more of such incentives including applying the same principles to other shortage areas—primary care in general, public health, prison health care, global health service, etc.

How else can we steer students and practitioners toward primary care, given the "big money" is in other medical specialties?

The real fix is a big fix. A closed system that requires us—or some portion of us—to live off the same health care budget will immediately put primary care at the center of things since primary care represents the best shot at prudent, evidenced-based, organized delivery. This, of course, would raise the salaries and heft of primary care providers, and the workforce would, in time, re-balance itself. We have examples of that in capitated systems such as Kaiser Permanente and the Veterans Administration.

To meet primary care needs, do we need to change the traditional model of care delivery? If so, how?

Medical homes and accountable care organizations are good partial solutions that will take more advantage of the capabilities of primary care. As long as they remain islands in a sea of fee-for-service, however, their influence will be good but limited to the population of their "island."

What role can and should states play to promote access to primary care?

States can do a number of things: 1) use Medicaid to promote the use of primary care in organized delivery systems; 2) review the performance of state-sponsored medical schools in regard to primary care output; and 3) review any state GME/Medicaid monies in regard to the institutional performance of the hospital-based training programs in regard to primary care output. Reviews of state training support should include consideration of conditioning funding on performance in regard to primary care.

How can states and the federal government support and complement each other in this effort?

States and the federal government can collaborate on workforce research. Data collection and analysis would better equip us to engage the primary care and other workforce issues. A national workforce commission to examine and make policy recommendations in this area, as proposed in the Senate reform bill, would be very helpful.

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