Legal and policy drivers of the primary care physician shortage

The primary care physician shortage arose not by chance but from a series of deliberate policy decisions embodied in various laws and regulations. Proposals for reform will only succeed by restructuring those programs, and identifying their biasing effects is an important first step. In particular, Medicare's payment scale for physicians, the Resource-Based Relative Value Scale, bases reimbursement rates on input from a little-known body known as the Specialty Society Relative Value Scale Update Committee (RUC) that is heavily dominated by specialists and whose structure contains inherent biases against primary care. It has effectively counteracted the original policy goal behind the payment scale of promoting primary care. Medicare also funds residency training programs for specialists and offers entrepreneurial opportunities to specialists who perform procedures in outpatient centers. Those opportunities are not available to primary care practitioners. Beyond Medicare, NIH funding emphasizes research related to technology-based treatments rather than cognitive tools that characterize primary care. Reforms to these programs to encourage more physicians to choose careers in primary care fall into two broad categories. First, reimbursement arrangements can be restructured to bundle payments for all physician services into single amounts. Second, research funding can be expanded into ways to enhance primary care practice.