OVERALL, the important messages of the policy paper, if followed, would significantly improve the ability of healthcare organizations such as ours-The Institute for Family Health, a not-for-profit primary care-based Federal Qualified Health Center (FQHC), serving the needs of underserved patients residing within urban (New York City), suburban (Dutchess County), serving mostly rural (Ulster County) and poor rural (Town of Wawarsing, Village of Ellenville, NY), providing over a quarter million OPD visits/per year to provide the highest quality, lowest cost services to our patients. Transparency is a required element of not-for-profit healthcare corporations in New York State.
From my point of view, however, the issues presented in the article represent overall 2 major considerations:
1. Managing the roles of the government and insurers, whether private or public.
2. The need to implement clinical practices that improve patient outcomes at lowest possible costs with specific guidelines as described.
Our FQHC has limited ability to effect consideration number one. We can make efforts to influence legislators and insurers, but without significant joinings with other provider entities, we will not be able to play a major role here.
In terms of clinical practices improvements, the description of what is needed-C8, D9, E11, F12, 13, and G17, as examples, is at the heart of what primary care is all about.
Empowering consumers to take personal responsibility, providing care management, utilizing pharmaceuticals in the most efficient and cost-effective manner, etc, are basics for family practice and all primary care disciplines.
In my opinion, the article has relegated to "rescue primary care" almost as an afterthought (G17) with the same recommendations for "state special commissions" that have been tried for 25 years as a starting point. The need to train more primary care physicians to meet the needs of your article is an "up front" problem that needs much more attention. Medical students are not entering primary care for the many reasons you are completely familiar with-essentially income limitations, professional status, long-working hours, and dedication to continuing care universally to all patients regardless of ability to pay. Unless specific proposals to correct these issues are not resolved, the basic premise of the article falls short of the ultimate goals the article rightly proposes.
Specifically, the largest number of unfilled resident training positions in 2006 were for family physicians and 2007 is slightly worse. Perry Pugno, MD, MPH, director of the Division of Medical Education of the AAFP, stated, "this is further evidence that the market-driven industry of health care is failing to meet America's present and expanding need for access to an efficient and cost-effective primary care system"*,+(Table 1). The JAMA article (March 1, 2006) on health manpower also concluded "the largest numbers of unfilled positions were for family physicians." The Massachusetts Medical Society reported "a severe shortage" of family physicians, and noted the current shortage of primary care physicians, particularly in rural and underserved urban areas.
At this point, however, no definitive process to change reimbursements and/or financial incentives to promote primary care legislatively appears in Congress's horizon. According to Kevin Burke, of the Government Affairs Office of the AAFP in Washington, DC, only a "concept paper"++ is being circulated, which may augment primary care income around care management systems "in 2 or 3 years."
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