The National Residency Exchange: A Proposal to Restore Primary Care in an Age of Microspecialization

Glen Cheng

doi:10.1177/009885881203800103

The National Residency Exchange: A Proposal to Restore Primary Care in an Age of Microspecialization

Published online by Cambridge University Press: 06 January 2021

Glen Cheng

Show author details

Glen Cheng*: Affiliation:
Rutgers Law School—Newark; New Jersey Medical School, The College of New Jersey

Article contents

Abstract
References

Get access

Rights & Permissions

Abstract

Healthcare deficiencies in the United States have long been perpetuated by a shortage of primary care providers. A core purpose of the Patient Protection and Affordable Care Act (PPACA) is to provide health insurance for America's approximately fifty million uninsured. Implementation of universal health insurance, however, does not mean sufficient healthcare access for all, since the supply of physicians does not and will not meet demand. For reasons reviewed in this Article, the current physician shortage mainly impacts primary care providers. This shortage is particularly troubling because increased provision of primary care relative to specialty care has been associated with improvement in health outcomes, disease prevention, cost effectiveness, and coordination of care. This Article highlights provisions in the PPACA that impact primary care physicians. Finally, this Article proposes the creation of a universal primary care loan repayment program and a national residency exchange designed to alleviate the U.S. primary care crisis by facilitating optimal distribution of resident physicians in each medical specialty based on community need.

Type: Article
Information: American Journal of Law & Medicine , Volume 38 , Issue 1 , March 2012 , pp. 158 - 195

DOI: https://doi.org/10.1177/009885881203800103 [Opens in a new window]
Copyright: Copyright © American Society of Law, Medicine and Ethics and Boston University 2012

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

1 Cf. Barack Obama, U.S. President, Remarks at the Annual Conference of the American Medical Association (June 15, 2009) (transcript available at http://www.whitehouse.gov/the_press_office/Remarks-by-the-President-to-the-Annual-Conference-of-the-American-Medical-Association/) (“[T]he other day, a friend of mine, Congressman Earl Blumenauer, handed me a magazine with a special issue titled, ‘The Crisis in American Medicine.’ One article notes ‘soaring charges.’ Another warns about the ‘volume of utilization of services.’ Another asks if we can find a ‘better way than fee-forservice for paying for medical care.’ It speaks to many of the challenges we face today. The thing is, this special issue was published by Harper's Magazine in October of 1960 … .”).

2 WORLD HEALTH ORG. [WHO], Health Systems: Improving Performance, at 200-03 annex tbl.10, The World Health Report 2000 (2000).

3 Id. at 192-95 annex tbl.8 (indicating that America spent 13.7% of its GDP on healthcare in 1997); see KAISER FAMILY FOUND., TRENDS IN HEALTH CARE COSTS AND SPENDING (2009), http://www.kff.org/insurance/upload/7692_02.pdf (last visited Oct. 16, 2011). Warren Buffet analogized healthcare costs to an economic “tapeworm” on U.S. businesses, noting that “it's not practical to continue devoting roughly 17 percent of the nation's gross domestic product to health care.” Josh Funk, Buffett Says Health Care Costs Hurt US Economy, NEWSDAY.COM, Mar. 1, 2010, http://www.newsday.com/business/buffett-says-health-care-costs-hurt-u-s-economy-1.1786521.

4 Medicare Physician Payments: Hearing Before the H. Comm. on Small Bus., 111th Cong. (2008) [hereinafter Medicare Physician Payments] (statement of Herb Kuhn, Deputy Administrator, Centers for Medicare and Medicaid Services) (citing Keehan, Sean et al., Health Spending Projections Through 2017: The Baby-Boom Generation Is Coming to Medicare, 27 Health Aff. w145 (2008))CrossRef Google Scholar, available at http://www.hhs.gov/asl/testify/2008/05/t20080508a.html. “There is no place on the world economic leader board for countries that spend 25 to 30 percent of their total output on health … .” Medicare Physician Payments, supra (quoting Michael Leavitt, U.S. Sec’y of Health and Human Servs.).

5 MEDICARE PAYMENT ADVISORY COMM’N, REPORT TO THE CONGRESS: IMPROVING INCENTIVES IN THE MEDICARE PROGRAM, at xi (2009) (“[T]he health care delivery system we see today is not a true system: Care coordination is rare, specialist care is favored over primary care, and quality of care is often poor… . Medicare's fee-for-service (FFS) payment systems reward more care—and more complex care—without regard to the quality or value of that care.”).

6 See BARBARA STARFIELD, PRIMARY CARE: BALANCING HEALTH NEEDS, SERVICES, AND TECHNOLOGY 105-11 (1998).

7 42 U.S.C. § 300e (2006).

8 See Iglehart, John K., Reform of the Veterans Affairs Health Care System, 335 New Eng. J. Med. 1407, 1409 (1996)CrossRef Google Scholar PubMed. But cf. Shern, David L. et al., Medicaid Managed Care and the Distribution of Social Costs for Persons with Severe Mental Illness, 165 Am. J. Psychiatry 254, 258-59 (2008)CrossRef Google Scholar (noting that though managed care saves on healthcare costs in the short term, when it deflects those costs onto vulnerable populations, society does not save on healthcare costs in the long run).

9 See Aikin, Linda H. & Sage, William M., Staffing National Health Care Reform: A Role for Advanced Practice Nurses, 26 Akron L. Rev. 187, 207-08 (1992)Google Scholar; Prechel, Harland & Gupman, Anne, Changing Economic Conditions and Their Effects on Professional Autonomy: An Analysis of Family Practitioners and Oncologists, 10 Soc. F. 245, 256–265 (1995).Google Scholar

10 See Steinbrook, Robert, The End of Fee-for-Service Medicine? Proposals for Payment Reform in Massachusetts, 361 New Eng. J. Med. 1036, 1036-37 (2009)CrossRef Google Scholar PubMed. Two health researchers note, “U.S. health insurers currently pay doctors, hospitals, and clinics most of what they charge for such services.” Kerr, David J. & Scott, Mairi, British Lessons on Health Care Reform, e21 New Eng. J. Med. 1, 1 (2009)Google Scholar. In many cases, the cost-effectiveness of the new procedure or technology is unknown.

11 The shortage of primary care physicians negatively impacts morbidity and mortality in foreign health systems as well. See generally WORLD HEALTH ORG., Primary Health Care - Now More Than Ever, at 43-57, World Health Report 2008 (2008).

12 Pub. L. No. 111-148, 124 Stat. 119 (codified as amended in scattered sections of 42 U.S.C. (2011)).

13 Initially, proposed bills envisioned a government-run insurance plan (the “public option”) that would compete with private insurance companies, in addition to a requirement that all Americans have health insurance. See America's Affordable Health Choices Act of 2009, H.R. 3200, 111th Cong. (2009).

14 One example of this lack of healthcare access is the effect that universal healthcare legislation in Massachusetts had on primary care physician wait times. See Sack, Kevin, Universal Coverage Strains Massachusetts Care, N.Y. TIMES, Apr. 5, 2008Google Scholar, at A1 (noting wait times of up to one year for new patients to see a family physician).

15 Landon, Bruce E. et al., Prospects for Rebuilding Primary Care Using the Patient-Centered Medical Home, 29 Health Aff. 827, 827, 833 (2010)CrossRef Google Scholar PubMed.

16 Letter from Council on Graduate Med. Educ. to The Honorable Kathleen Sebelius, Sec’y of Health & Human Servs., et al. 1 (May 5, 2009), ftp://ftp.hrsa.gov/cogme/cogmeletter.pdf [hereinafter COGME Letter].

17 See COMM. ON IMPROVING THE ORG. OF THE U.S. DEP't OF HEALTH AND HUMAN SERVS. TO ADVANCE THE HEALTH OF OUR POPULATION, INST. OF MED., HHS IN THE 21ST CENTURY: CHARTING A NEW COURSE FOR A HEALTHIER AMERICA 107 (Leonard D. Schaeffer et al. eds., 2008) (observing the need for 16,261 additional primary care physicians to meet demand in currently underserved areas in the U.S.); Kane, Gregory C. et al., The Anticipated Physician Shortage: Meeting the Nation's Need for Physician Services, 122 Am. J. Med. 1156, 1157 (2009)CrossRef Google Scholar PubMed (reporting similar findings by the Alliance for Academic Internal Medicine, which represents internal medicine physicians in teaching hospitals).

18 COUNCIL ON GRADUATE MED. EDUC., U.S. DEP't HEALTH & HUMAN SERVS., FOURTEENTH REPORT, COGME PHYSICIAN WORKFORCE POLICIES: RECENT DEVELOPMENTS AND REMAINING CHALLENGES IN MEETING NATIONAL GOALS 2-3 (1999) [hereinafter COGME FOURTEENTH REPORT]; see also ASS’N OF AM. MED. COLL., AAMC STATEMENT ON THE PHYSICIAN WORKFORCE 2-3 (2006) (recommending increasing overall enrollment in medical schools by thirty percent as of 2015).

19 COMM. ON THE FUTURE OF PRIMARY CARE, INST. OF MED., PRIMARY CARE: AMERICA's HEALTH IN A NEW ERA 31 (Molla S. Donaldson et al. eds., 1996).

20 Id. at 27 (citation omitted). The Institute of Medicine's study on healthcare further noted that “[s]ome experts and groups have included nurse practitioners and physician assistants” in the definition of primary care. Id. Studies have demonstrated that nurse practitioners are able to deliver certain primary care services with similar efficacy to primary care physicians. See Mundinger, Mary O. et al., Primary Care Outcomes in Patients Treated by Nurse Practitioners or Physicians: A Randomized Trial, 283 JAMA 59, 62–68 (2000)CrossRef Google Scholar PubMed; M. Laurant et al., Substitution of Doctors by Nurses in Primary Care (Protocol), COCHRANE DATABASE SYST. REV. CD001271 (2005). But see Freed, Gary L. et al., All Primary Care Trainees Are Not the Same: The Role of Economic Factors and Career Choice, 125 Pediatrics 574, 576 (2010)CrossRef Google Scholar (arguing that there may be important differences in the primary care disciplines that could preclude generalization of observations from one discipline to the others). General surgery, as a generalist field, is also closely associated with primary care. Cf. Letter from Joseph W. Stubbs, President of Am. Coll. of Physicians, to Bill Nelson, U.S. Senator (May 15, 2009), http://www.acponline.org/advocacy/physician_shortageact.pdf (expressing the support of the American College of Physicians (ACP), the largest national group of internal medicine physicians, for a bill preferentially providing for the increase of residency positions in both internal medicine and general surgery).

21 Starfield, Barbara et al., Contribution of Primary Care to Health Systems and Health, 83 Milbank Q. 457, 462-63 (2005)CrossRef Google Scholar PubMed.

22 Starfield, Barbara et al., The Effects of Specialist Supply on Populations’ Health: Assessing the Evidence, W5 Health Aff. 97, 98–99 (2005)Google Scholar (analyzing mortality data from 1996-2000 for 99.9% of U.S. counties, and demonstrating significantly lower rates of all-cause mortality and heart diseasespecific mortality for counties with higher ratios of generalist physicians to specialist physicians); Shi, Leiyu, Primary Care, Specialty Care, and Life Chances, 24 Int’L J. Health Servs. 431, 431 (1994)CrossRef Google Scholar PubMed (showing significant positive association between availability of primary care and decreased mortality, but no similar association for availability of hospital beds or specialist physicians).

23 Shi, Leiyu et al., Income Inequality, Primary Care, and Health Indicators, 48 J. Fam. Prac. 275, 277–279, 278 fig.1, tbl.1 (1999)Google Scholar PubMed.

24 See M. RENEE ZEREHI, AM. COLL. OF PHYSICIANS, HOW IS A SHORTAGE OF PRIMARY CARE PHYSICIANS AFFECTING THE QUALITY AND COST OF MEDICAL CARE? 3 (2008) [hereinafter ZEREHI, PHYSICIAN SHORTAGE] (citing SHIN-YI WU & ANTHONY GREEN, PROJECTION OF CHRONIC ILLNESS PREVALENCE AND COST INFLATION (2000)), available at http://www.acponline.org/advocacy/where_we_stand/policy/primary_shortage.pdf.

25 DAVID C. GOODMAN ET AL., DARTMOUTH INST. FOR HEALTH POL’Y & CLINICAL PRAC., REGIONAL AND RACIAL VARIATION IN PRIMARY CARE AND THE QUALITY OF CARE AMONG MEDICARE BENEFICIARIES 10, 11 figs.8 & 9 (Kristen Bronner ed., 2010).

26 Id. at 10, 11 fig.10.

27 Id. at 12 fig.11.

28 MICHELLE M. DOTY ET AL., THE COMMONWEALTH FUND, ENHANCING THE CAPACITY OF COMMUNITY HEALTH CENTERS TO ACHIEVE HIGH PERFORMANCE: FINDINGS FROM THE 2009 COMMONWEALTH FUND NATIONAL SURVEY OF FEDERALLY QUALIFIED HEALTH CENTERS, at 4 exhibit 3 (2009).

29 See id. at 12; Landon et al., supra note 15, at 827.

30 Lewis, Charles E. et al., The Counseling Practices of Internists, 114 Annals Internal Med. 54, 57–58 (1991).CrossRef Google Scholar PubMed

31 Turner, Barbara J. et al., Breast Cancer Screening: Effect of Physician Specialty, Practice Setting, Year of Medical School Graduation, and Sex, 8 Am. J. Preventive Med. 78, 78 (1992)CrossRef Google Scholar PubMed (“We conclude that all physicians need to improve their screening rates. However, intervention programs should first target those physicians with the greatest deficiencies in breast cancer screening performance and knowledge; these include medical specialists and older physicians in primary care specialties.”).

32 O’Malley, Ann S. & Forrest, Christopher B., Immunization Disparities in Older Americans: Determinants and Future Research Needs, 31 Am. J. Preventive Med. 150, 150 (2006)CrossRef Google Scholar PubMed.

33 GOODMAN ET AL., supra note 25, at 10-11 figs.6 & 7.

34 Id. at 10, 11 figs.8 & 9.

35 See STARFIELD, supra note 6, at 120-28; Pete Welch, W. et al., Geographic Variation in Expenditures for Physicians’ Services in the United States, 328 New Eng. J. Med. 621, 623, 626 tbl.4 (1993)CrossRef Google Scholar. Domestically, the areas of greatest cost-effectiveness are in the Midwestern states, which have the highest domestic generalist-to-specialist ratio of physicians. See SOLUCIENT 100 TOP HOSPITALS: NATIONAL BENCHMARKS FOR SUCCESS (2006); Holdenried, John R., Healthcare Reform: A Discussion with Thomas A. Daschle and Thomas A. Scully, 2 J. Health & Life Sci. L. 29, 45 (2009)Google Scholar (testimony of Thomas Scully) (“[T]he lowest costs in the [U.S. healthcare] system are in North and South Dakota. It's because they have a culture of primary care and taking care of patients.”); Thompson Healthcare, Hospitals in the Midwest Lead the Nation in Performance, According to Solucient Study, http://www.solucient.com/news_press/news20070312.shtml (last visited Feb. 10, 2011) (noting that of the Solucient 100 Top Hospitals in 2006, over half of the winning hospitals were from the Midwest region, which has the highest proportion of primary care physicians).

36 See De Maeseneer, Jan M. et al., Provider Continuity in Family Medicine: Does it Make a Difference for Total Health Care Costs?, 1 Annals Fam. Med. 144, 146-48, 148 tbl.3 (2003)CrossRef Google Scholar PubMed (“[P]rovider continuity in family medicine remains one of the most important explaining variables of total health care costs.”).

37 See, e.g., Greenfield, Sheldon et al., Outcomes of Patients with Hypertension and Non-insulindependent Diabetes Mellitus Treated by Different Systems and Specialties: Results from the Medical Outcomes Study, 274 JAMA 1436, 1436 (1995)CrossRef Google Scholar (demonstrating that outcomes for patients with diabetes and hypertension were similar between primary care providers and specialists).

38 See, e.g., Schreiber, Theodore L. et al., Cardiologist Versus Internist Management of Patients with Unstable Angina: Treatment Patterns and Outcomes, 26 J. Am. C. Cardiology 577, 579-80 (1995)Google Scholar PubMed (“Clinical outcome appeared nonsignificantly enhanced among cardiologist-treated patients [with unstable angina] relative to internist-treated patients … [again eliminating the statistical significance].”).

39 There are several different methods of evaluating healthcare rationing. See generally Atherly, A. et al., The Role of Cost Effectiveness Analysis in Health Care Evaluation, 44 Q.J. Nuclear Med. 112Google Scholar (providing an overview of different cost-effectiveness analyses). A commonly used valuation is based on the concept of cost per quality-adjusted life year, which is designed to measure the number of healthy years lived for individuals. See Greenberg, Dan, The Use of Quality Adjusted Life Year (QALY) as an Outcome Measure in Cost-Effectiveness Studies - An Overview, 16 Int’L Soc. Tech. Assessment Health Care 18, 18 (2000)Google Scholar.

40 See Fleck, Leonard M., Just Health Care Rationing: A Democratic Decisionmaking Approach, 140 U. Pa. L. Rev. 1597, 1603-04 (1992)CrossRef Google Scholar PubMed; Symposium, Health Reform in America: Getting Beyond Ideology to True Reform, 5 Ind. Health L. Rev. 463, 467 (2008)Google Scholar (testimony of Dr. Aaron Carroll, Assistant Professor of Pediatrics in the Children's Health Service Research Program, University of Indiana School of Medicine) (“[I]f you don't think we’re rationing healthcare in this country already, you’re really putting the blinders on. We ration by whether or not you have insurance. Forty-seven million Americans have no access to the system.”).

41 See Fleck, supra note 40, at 1617-34 (arguing for a democratic model of healthcare rationing); Symposium, supra note 40, at 467-68.

42 Kerr & Scott, supra note 10, at 3.

43 Schoen, Cathy et al., In Chronic Condition: Experiences of Patients with Complex Health Care Needs, in Eight Countries, 2008, 28 Health Aff. w1, w5, w6 exhibit 2 (2008)Google Scholar PubMed.

44 Id. The survey confirmed that thirty-three percent of U.K. adults surveyed had to wait up to two months or more to see a specialist. Id. at W6 exhibit 2, W7. One reason that healthcare rationing in other countries leads to long lines and poor healthcare is that many countries keep their systems underfunded. Since the United States spends so much of its GDP on healthcare, well-implemented reform of the U.S. healthcare system could lead to world-class excellence in healthcare delivery and health outcomes. See Symposium, supra note 40, at 467 (testimony of Dr. Aaron Carroll).

45 WORLD HEALTH ORG., supra note 11, at 50-52.

46 Kerr & Scott, supra note 10, at 2 (citing Denis Pereira Gray, A Dozen Facts About General Practice/Primary Care (2004), available at http://webarchive.nationalarchives.gov.uk/&+/www.dh.gov.uk/en/FreedomOfInformation/Freedomofinformationpublicationschemefeedback/Classesofinformation/WhitePaperonhealthandcareservicesinthecommunity/index.htm?IdcService=GET_FILE&dID=6286&Rendition=Web). But cf. Fry, John, Facts of Primary Care in USA and UK: Problems in Comparisons, 87 J. Royal Soc’Y Med. 666 (1994)Google Scholar PubMed (identifying some of the difficulties in making strict comparisons between national health systems).

47 Kerr & Scott, supra note 10, at 2.

48 P’SHIP FOR MEDICAID, REDUCING INAPPROPRIATE EMERGENCY ROOM USE AMONG MEDICAID RECIPIENTS BY LINKING THEM TO A REGULAR SOURCE OF CARE 2, available at www.mphca.com/_literature_43606/Reducing_Inappropriate_ER_Use_Among_Medicaid_Recipients_ -_Partnership_for_Medicaid; Falik, Marilyn et al., Ambulatory Care Sensitive Hospitalizations and Emergency Visits: Experiences of Medicaid Patients Using Federally Qualified Health Centers, 39 Med. Care 551, 551 (2001)CrossRef Google Scholar PubMed.

49 “Medicaid spent an estimated $8 billion for 22 million hospital [emergency room] visits in 2003.” P’SHIP FOR MEDICAID, supra note 48, at 2. Cf. Jessee, Sean, Comment, Fulfilling the Promise of the Medicaid Act: Why the Equal Access Clause Creates Privately Enforceable Rights, 58 Emory L.J. 791, 828 (2009)Google Scholar (arguing that there should be an enforceable right under 42 U.S.C. § 1983 and the equal access clause to ensure access to primary care for Medicaid recipients).

50 DENISE T. KRUZIKAS ET AL., AGENCY FOR HEALTHCARE RES. AND QUALITY, PREVENTABLE HOSPITALIZATIONS: A WINDOW INTO PRIMARY AND PREVENTIVE CARE, 2000, at 4 (2004), available at http://www.ahrq.gov/data/hcup/factbk5/factbk5.pdf. Note that certain vulnerable populations may need such intense medical attention that connection with a primary care physician alone may not decrease hospitalization rates in the short term. Weinberger, Morris et al., Does Increased Access to Primary Care Reduce Hospital Readmissions?, 334 New Eng. J. Med. 1441, 1445-46 (1996)CrossRef Google Scholar PubMed.

51 KRUZIKAS ET AL., supra note 50, at 4. Due to inflation and rapidly increasing healthcare costs, the potential savings are likely higher today than in 2000. While the precise per-patient cost savings of outpatient therapy versus hospitalization varies based on both the nature of the medical condition at issue and on individual outpatient and hospital pricing practices, economists confirm that outpatient management of medical conditions is invariably less expensive than hospitalization. See Davis, Karen & Russell, Louise B., The Substitution of Hospital Outpatient Care for Inpatient Care, 54 Rev. Econ. & Stat. 109, 109-19 (1972)CrossRef Google Scholar (reporting that while increased primary care intervention for Veterans Health Affairs (VA) patients increased rehospitalization rates over the short six month study period, patients in the intervention group reported higher satisfaction with their care).

52 JOSHUA T. COHEN & PETER J. NEUMANN, ROBERT WOOD JOHNSON FOUND., THE COST SAVINGS AND COST-EFFECTIVENESS OF CLINICAL PREVENTIVE CARE, 5-6, 17-19 (2009), available at http://www.rwjf.org/files/research/100709.policysnythesis.preventivecare.report.pdf.

53 ASS’N SCH. PUB. HEALTH, CREATING A CULTURE OF WELLNESS: BUILDING HEALTH CARE REFORM ON PREVENTION AND PUBLIC HEALTH 5 (2009).

54 GOODMAN ET AL., supra note 25, at 8 fig.3 (showing a linear relationship between the availability of family physicians in the community and the percentage of patients who visit a doctor at least once per year). Note that the relationship between mere number of physicians board certified in a primary care field and percentage of patients in a community that see a primary care provider at least once per year was not clear. Id. at 8-9. For example, a negative correlation was seen as the supply of internal medicine physicians increased. Id. at 9 fig.4. This suggests that because internal medicine physicians have numerous practice opportunities available in non-primary care settings, notably in emergency rooms or full-time hospital inpatient care, mere quantization of internal medicine physicians will not yield an accurate assessment of the availability of preventive medicine or outpatient care in a given community. Id. at 9. While increased primary care visits will incur increased outpatient costs, overall healthcare expenditures are lessened due to fewer hospitalizations.

55 See Beth Hamel, Mary et al., The Growth of Hospitalists and the Changing Face of Primary Care, 360 New Eng. J. Med. 1141, 1141 (2009)CrossRef Google Scholar.

56 Id. at 1142 (noting that the trend towards relying on hospitalists has relegated many primary care physicians to seeing patients solely in outpatient settings); see also Cebul, Randal et al., Organizational Fragmentation and Care Quality in the U.S. Health Care System, in The Fragmentation Of U.S. Health Care: Causes And Solutions 37, 46–53 (Einer Elhauge ed., 2010)Google Scholar (arguing that such fragmentation leads to significant healthcare waste and inefficiencies, and is exacerbated by current hospital organizational structures).

57 Studies suggest that primary care physicians are better suited than specialist physicians to properly refer patients to other specialists for specific diagnostic and treatment indications. See, e.g., Mahajan, Ravish J. et al., Appropriateness of Referrals for Open-Access Endoscopy -- How Do Physicians in Different Medical Specialties Do?, 156 Archives Internal Med. 2065, 2065 (1996)CrossRef Google Scholar (“Primary care physicians were significantly more likely to schedule patients for open-access EGD and colonoscopy for appropriate indications than were non-primary care physicians.”). But cf. DOTY ET AL., supra note 28, at 4 (noting that Federally Qualified Health Centers self-reported difficulty in getting sufficient access to specialty care for their patients).

58 See Politzer, Robert M. et al., Primary Care Physician Supply and the Medically Underserved: A Status Report and Recommendations, 266 JAMA 104, 105 (1991)CrossRef Google Scholar PubMed.

59 See Pugno, Perry A. et al., Results of the 2009 National Resident Matching Program: Family Medicine, 41 Fam. Med. 567, 571 (2009)Google Scholar PubMed (“[O]ver the past 12 years, family medicine has lost 1,257 US seniors in the Match or 53.7% of the record number of US seniors matching in 1997.”); id. at 567 (“[F]amily medicine still matched too few graduates through the 2009 NRMP to effectively address the nation's needs for primary care physicians.”); Salsberg, Edward et al., US Residency Training Before and After the 1997 Balanced Budget Act, 300 JAMA 1174, 1176, 1177 tbl.2 (2008)CrossRef Google Scholar PubMed (reporting a 2.8% decrease in family medicine and 24.6% decrease in preventive medicine during 2002-2007, when the majority of specialties experienced an increase in total residents).

60 Hauer, Karen E. et al., Factors Associated with Medical Students’ Career Choices Regarding Internal Medicine, 300 JAMA 1154, 1157 (2008)CrossRef Google Scholar PubMed. Even within internal medicine, many more residents intend to subspecialize rather than practice general internal medicine. See Colwill, Jack M., Where Have All the Primary Care Applicants Gone?, 326 New Eng. J. Med. 387, 389-90 (1992)CrossRef Google Scholar PubMed. According to an ACP survey, only twenty-three percent of third-year internal medicine residents planned to practice general internal medicine in 2007, compared to fifty-four percent in 1998. The data was still more alarming for first-year internal medicine residents, only fourteen percent of whom planned to pursue careers in general medicine. ZEREHI, supra note 24, at 4 (citing ACP, Internal Medicine In-Training Exam Survey Data).

61 M. RENEE ZEREHI, AM. COLL. PHYSICIANS, SOLUTIONS TO THE CHALLENGES FACING PRIMARY CARE MEDICINE: COMPREHENSIVE STRATEGIES FROM THE AMERICAN COLLEGE OF PHYSICIANS 2 (2009), available at http://www.acponline.org/advocacy/where_we_stand/policy/solutions.pdf.

62 Cardarelli, Robert, The Primary Care Workforce: A Critical Element in Mending the Fractured U.S. Health Care System, 3 Osteopathic Med. & Primary Care 11, 11 (2009)CrossRef Google Scholar PubMed (citing R. PHILLIPS ET AL., THE ROBERT GRAHAM CTR., SPECIALTY AND GEOGRAPHIC DISTRIBUTION OF THE PHYSICIAN WORKFORCE: WHAT INFLUENCES MEDICAL STUDENT AND RESIDENT CHOICES? (2009)).

63 Pugno et al., supra note 59, at 573; Medical Student Debt, AM. MED. ASS’N, http://www.amaassn.org/ama/pub/about-ama/our-people/member-groups-sections/medical-student-section/advocacypolicy/medical-student-debt.shtml (last visited Oct. 18, 2010). In New York, primary care physicians currently can expect an average starting salary between $111,000 and $118,000. N.Y. CHAPTER, AM. COLL. OF PHYSICIANS, THE FUTURE OF PRIMARY CARE: A REPORT ON PRIMARY CARE MEDICINE IN NEW YORK STATE 10 (2006) [hereinafter NYACP REPORT].

64 Cardarelli, supra note 62, at 11 (citing Steinbrook, Robert, Medical Student Debt--Is There a Limit?, 359 New Eng. J. Med. 2629, 2630 fig.1 (2008)CrossRef Google Scholar PubMed) (“The distribution of the 23% of students with total debt of $200,000 or more was 15% with $200,000 to $249,999 in debt, 6% with $250,000 to $299,999 in debt, and 3% with $300,000 or more in debt … .”). International medical graduates may have less debt and/or have entered into the field sooner, so they may not be bound by the same financial constraints. For example, postsecondary school training to receive a medical degree is only six years in Japan and England, compared to eight years in the U.S. See Kozu, Tadahiko, Medical Education in Japan, 81 Acad. Med. 1069, 1069 (2006)CrossRef Google Scholar PubMed; How to Get into UK Medical School, BRIT. BROADCASTING CO., http://www.bbc.co.uk/dna/h2g2/A717527 (last visited Oct. 18, 2010); see also Studying Medicine in Tunis, Tunisia, GLOBAL MED., http://www.globalmedicine.nl/index.php/studying-medicine-in/101-studying-medicine-in-tunis (last visited Oct. 18, 2010) (reporting that medical school education in Tunisia consists of five years of training and is provided free of charge to all students).

65 NYACP REPORT, supra note 63, at 10 (citing ASS’N AM. MED. COLLS., MEDICAL EDUCATION COSTS AND STUDENT DEBT, A WORKING GROUP REPORT TO THE AAMC GOVERNANCE (2005)).

66 Cf. Pugno et al., supra note 59, at 574 (“The turbulence of the US health care environment and increasing student debt support the appearance of medical students selecting careers that provide them both economic and practice security.”).

67 Id.

68 Iglehart, John K., The New Era of Medical Imaging – Progress and Pitfalls, 354 New Eng. J. Med. 2822, 2822 (2006)CrossRef Google Scholar PubMed; see also Bhargavan, Mythreyi & Sunshine, Jonathan H., Utilization of Radiology Services in the United States: Levels and Trends in Modalities, Regions, and Populations, 234 Radiology 824, 829–832 (2005)CrossRef Google Scholar PubMed (noting the rapid increase in high-technology modalities since 1998 and the trend towards rapidly increasing numbers of radiologists in practice).

69 Jack Sullivan, Overexposed, COMMONWEALTH MAG. (July 27, 2010), available at http://www.commonwealthmagazine.org/News-and-Features/Features/2010/Summer/Overexposed.aspx; see also KEN PATRIC ET AL., BLUECROSS BLUESHIELD OF TENNESSEE, HIGHTECHNOLOGY IMAGING: WHAT DOES THE PICTURE ACTUALLY REVEAL? 4 (2006) (“Tennessee has five times the per capita MRI capacity of Canada.”).

70 Sullivan, supra note 69; see also Letter from Ebel, Mark H., Future Salary and US Residency Fill Rate Revisited, 300 JAMA 1131, 1131 (2008)Google Scholar (noting “a strong direct correlation between higher overall salary and higher fill rates with US graduates” that has persisted since 1989).

71 Pugno et al., supra note 59, at 573.

72 Id.

73 See Freeman, Roger K., Thoughts on Medical Liability Costs and the Future of Health Care, 113 Obstetrics & Gynecology 576, 576-77 (2009)CrossRef Google Scholar PubMed (noting that obstetric claims, the highest risk category of medical malpractice lawsuits, often amount to more than fifty percent of hospitals’ medical malpractice costs, and that “obstetricians in many states pay upwards of $200,000 per year for medical liability insurance”). In attempts to control malpractice liability, Virginia created a no-fault system for obstetrical injuries, followed by Florida. See Birth-Related Neurological Injury Compensation Act, VA. CODE ANN. §§ 38.2-5000-2.5021 (2011); FLORIDA STAT. ANN. § 408.02 (2003).

74 Summary of Conclusions and Recommendations, in 2 INST. MED., MEDICAL PROFESSIONAL LIABILITY AND THE DELIVERY OF OBSTETRICAL CARE: AN INTERDISCIPLINARY REVIEW 1, 5-9, (Victoria R. Rostow & Roger J. Bulger eds., 1989). The study notes that “the number of obstetrical providers in non-metropolitan areas has fallen by approximately 20 percent in the last five years” and that “[t]he delivery of obstetrical services in rural areas is seriously threatened by this development.” Id. at 6.

75 See supra Parts II.B and II.C.

76 ASS’N SCH. PUB. HEALTH, supra note 53, at 5.

77 See, e.g., Cohen, Joshua T. et al., Does Preventive Care Save Money? Health Economics and the Presidential Candidates, 358 New Eng. J. Med. 661, 661 (2008)CrossRef Google Scholar PubMed.

78 See supra notes 50-53 and accompanying discussion for studies asserting that prevention does in fact reduce overall health expenditures.

79 See Goetzel, Ron Z., Do Prevention or Treatment Services Save Money? The Wrong Debate, 28 Health Aff. 37, 37–41 (2009)CrossRef Google Scholar PubMed.

80 See Maciosek, Michael V. et al., Priorities Among Effective Clinical Preventive Services: Results of a Systematic Review and Analysis, 31 Am. J. Preventive Med. 52, 54–60, 56 tbl.2 (2006)CrossRef Google Scholar PubMed (finding that aspirin chemoprophylaxis, childhood immunization series, tobacco-use screening, and brief intervention provided the greatest cost-effectiveness of all preventive methods surveyed).

81 See Conrad, Douglas A. et al., Penetrating the “Black Box”: Financial Incentives for Enhancing the Quality of Physician Services, 61 Med. Care Res. & Rev. 37S, 43S (2004).CrossRef Google Scholar PubMed

82 Hoskins, G. et al., Risk Factors and Costs Associated with an Asthma Attack, 55 Thorax 19, 21, 23 tbls.7 & 8 (2000)CrossRef Google Scholar PubMed (reporting that the average total costs per patient who suffered an asthma attack were 3.53 times higher than for patients who did not suffer an asthma attack); Shaw, Dominick E. et al., Asthma Exacerbations: Prevention is Better than Cure, 1 Therapeutics & Clinical Risk Mgmt. 273, 273 (2005).Google Scholar PubMed

83 Hauer et al., supra note 60, at 1159.

84 Pugno et al., supra note 59, at 574.

85 See McCarthy, Daniel, Note, The Virtual Health Economy: Telemedicine and the Supply of Primary Care Physicians in Rural America, 21 Am. J.L. & Med. 111, 120 (1995)Google Scholar PubMed (citing Gordon, Rena J. et al., Accounting for Shortages of Rural Physicians: Push and Pull Factors, in Health In Rural North America: The Geography Of Health Care Services And Delivery 153, 161 (Wilbert M. Gesler & Thomas C. Ricketts eds., 1992))Google Scholar; see also Teitelbaum, Howard S. et al., Factors Affecting Specialty Choice Among Osteopathic Medical Students, 84 Acad. Med. 718, 720, 722 tbl.2 (2009)CrossRef Google Scholar PubMed (reporting “prestige” as being “highly influential” in medical students who chose to enter nonprimary care specialties).

86 McCarthy, supra note 85, at 120; Gordon et al., supra note 85, at 161.

87 Teitelbaum et al., supra note 85, at 720, 722 tbl.2.

88 THE INST. FOR HEALTH & AGING, UNIV. OF S.F., ROBERT WOOD JOHNSON FOUND., CHRONIC CARE IN AMERICA: A 21ST CENTURY CHALLENGE 139 (1996), available at http://www.rwjf.org/files/publications/other/ChronicCareinAmerica.pdf.

89 See discussion supra note 28 and accompanying text.

90 INST. FOR HEALTH & AGING, supra note 88, at 2.

91 Id. at 2-3..

92 Thomas Bodenheimer, Primary Care – Will it Survive?, 355 NEW ENG. J. MED. 861, 861 (2006). The trend toward tying physician reimbursement to health management and outcomes is a potential concern, given primary care providers’ difficulties in implementing all recommendations for care and preventive management of chronic diseases. This difficulty will likely diminish over time if more medical graduates enter primary care. The testimony of Dr. Katharine Treadway is typical of primary care physicians:

6 years ago, I got a letter from a subspecialist, an oncologist, about my patient with breast cancer that was now 10 years old and inactive. And at the bottom of his note it said, “This visit took 30 minutes.” When I saw my 70-year-old patient, not only did I talk to her about her breast cancer, but we went through her neuropathic pain, her osteoarthritis, her hypertension, her hyperlipidemia, her grief over the recent loss of her husband, a complete physical exam including a Pap smear, arranging all of her labs, making sure I had done her prescriptions and arranged her screening colonoscopy. And he was reimbursed at a higher rate than I was.

Comments at Perspective Roundtable: Redesigning Primary Care, NEW ENG. J. MED. (Nov. 13, 2008), http://www.nejm.org/doi/full/10.1056/NEJMp0809050.

93 Østbye, Truls et al., Is There Time for Management of Patients with Chronic Diseases in Primary Care?, 3 Annals Fam. Med. 209, 212 (2005)Google Scholar.

94 Yarnall, Kimberly S. H. et al., Primary Care: Is There Enough Time for Prevention?, 93 Am. J. Pub. Health 635, 637 (2003)CrossRef Google Scholar PubMed.

95 See Østbye et al., supra note 93, at 212 tbl.4.

96 Gunselman, Stephanie, Note, The Conrad “State-30” Program: A Temporary Relief to the U.S. Shortage of Physicians or a Contributor to the Brain Drain?, 5 J. Health & Biomedical L. 91, 96 (2009)Google Scholar (citations omitted).

97 Nancy Shute, Need a Doctor? Too Bad, U.S. NEWS & WORLD REP., Apr. 7, 2008, at 73.

98 See Marc Siegal, When Doctors Opt Out, WALL ST. J., Apr. 17, 2009, at A13, available at http://online.wsj.com/article/SB123993462778328019.html (“[T]he Medicare Payment Advisory Commission reported in 2008 that 28% of Medicare beneficiaries looking for a primary care physician had trouble finding one, up from 24% the year before. The reasons are clear: A 2008 survey by the Texas Medical Association, for example, found that only 38% of primary-care doctors in Texas took new Medicare patients … . A 2005 Community Tracking Physician survey showed that only 50% of physicians accept [Medicaid].”).

99 Gunselman, supra note 96, at 96 n.33 (citing JENNIFER O’SULLIVAN, CONG. RES. SERV., MEDICARE: PAYMENTS TO PHYSICIANS 23 (Jan. 17, 2008)) (noting “[i]n 2005, Medicare rates were about 82.6% of private insurance payment rates”); Symposium, supra note 40, at 470-71 (“Medicare … is paying about forty cents on the charged dollar. And other health insurers are paying sixty to seventy percent of the charged dollar.”).

100 Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119 (2010) (codified as amended in scattered sections of 42 U.S.C. (2011)).

101 42 U.S.C.A. § 5501(a)(1) (West 2011). A similar incentive payment exists for general surgeons who provide “major surgical procedures” in Health Professions Shortage Areas between 2011 and 2015. See id. § 5501(b). “Major Surgical Procedures” are defined as “surgical procedures for which a 10-day or 90-day global period is used for payment under the fee schedule under section 1848(b) [of the Social Security Act, 42 U.S.C. 1395w–4(b)].” Id.

102 Id. § 5501(a)(1).

103 See Goodson, John D., Patient Protection and Affordable Care Act: Promise and Peril for Primary Care, 152 Annals Internal Med. 742, 743 (2010)CrossRef Google Scholar PubMed.

104 Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152, 124 Stat. 1029 (2010) (codified as amended in scattered sections of 42 U.S.C. (2011)).

105 See H.R. 4872, § 1202(a)(1)(C). Technically, section 1202 establishes a “floor” requiring that primary care services for Medicaid beneficiaries be reimbursed, at a minimum, at the same rate as if those services had been provided to Medicare beneficiaries. Id.

106 Id.

107 See ANN S. O’MALLEY ET AL., CTR. FOR STUDYING HEALTH SYS. CHANGE, COORDINATION OF CARE BY PRIMARY CARE PRACTICES: STRATEGIES, LESSONS, AND IMPLICATIONS 7-8 (2009), available at http://www.hschange.com/CONTENT/1058/1058.pdf.

108 See AM. ACAD. FAMILY PHYSICIANS, AM. ACAD. PEDIATRICS, AM. COLL. PHYSICIANS, & AM. OSTEOPATHIC ASS’N, JOINT PRINCIPLES OF THE PATIENT-CENTERED MEDICAL HOME 1-2 (2007), available at http://www.aafp.org/online/etc/medialib/aafp_org/documents/policy/fed/jointprinciplespcmh0207.Par.0001.File.tmp/022107medicalhome.pdf. The ACP, AAFP, and the VA have begun to implement the PCMH in recent years. See ZEREHI, supra note 61, at 25, 29-30; Iglehart, John K., No Place Like Home—Testing a New Model of Care Delivery, 359 New Eng. J. Med. 1200, 1201 (2008)CrossRef Google Scholar PubMed (noting that twenty-six state legislatures and many major employers have recognized the value of the PCMH model); Tew, James et al., The Behavioral Health Laboratory: Building a Stronger Foundation for the Patient-Centered Medical Home, 28 Families Sys. & Health 130, 130 (2010)CrossRef Google Scholar PubMed; Who Supports the PCMH Model?, AM. COLL. PHYSICIANS, http://www.acponline.org/running_practice/pcmh/understanding/who.htm (last visited Nov. 26, 2011) (listing twenty-three physician organizations that support the PCMH model); Patient-Centered Medical Home, U.S. DEP't VETERANS AFF., http://www.va.gov/PrimaryCare/pcmh/ (last visited Oct. 18, 2010). The Commonwealth Fund's 2008-2010 grants to help transform primary care “safety-net” clinics into PCMHs is an example of a private initiative to expand the availability of PCMHs. See Transforming Safety-Net Clinics into Patient-Centered Medical Homes, Year 2, THE COMMONWEALTH FUND, http://www.commonwealthfund.org/Content/Grants/2009/May/Transforming-Safety-Net-Clinics-into-Patient-Centered-Medical-Homes-Year-2.aspx (last visited Oct. 20, 2010). Employers have also begun to support PCMHs as a means to save on health insurance costs. See Sepulveda, Martin-J. et al., Primary Care: Can it Solve Employers’ Health Care Dilemma?, 27 Health Aff. 151, 156 (2008)CrossRef Google Scholar PubMed.

109 See AM. ACAD. FAMILY PHYSICIANS, supra note 108, at 1-3. A concept related to the PCMH is the accountable care organization (ACO), which is an organization of primary care physicians, specialists, and hospitals whose reimbursement is linked to the quality of care delivered to a defined population. KELLY DEVERS & ROBERT BERENSON, URBAN INST., CAN ACCOUNTABLE CARE ORGANIZATIONS IMPROVE THE VALUE OF HEALTH CARE BY SOLVING THE COST AND QUALITY QUANDARIES? 4 (2009), available at http://www.rwjf.org/files/research/acobrieffinal.pdf. One distinction between a PCMH and an ACO is the degree to which primary care is responsible for quality of patient care.

110 Cf. Atul Gawande, The Checklist, THE NEW YORKER, Dec. 10, 2007, http://www.newyorker.com/reporting/2007/12/10/071210fa_fact_gawande?currentPage=1 (noting the advantages of checklists and system redundancy in achieving optimal health outcomes in healthcare settings).

111 42 U.S.C.A. § 3502(a) (West 2010).

112 Id. § 3502(c)(3), (8).

113 Id. § 3502(c)(3).

114 Id. § 3502(c)(4).

115 Id. § 3502(d)(1)-(3).

116 Id. § 3502(a)(2). Studies report savings from $5 to $150 per patient per month attributable to the PCMH model. STEPHEN ZUCKERMAN ET AL., INCREMENTAL COST ESTIMATES FOR THE PATIENTCENTERED MEDICAL HOME 7-10 (2009), available at http://www.commonwealthfund.org/∼/media/Files/Publications/Fund%20Report/2009/Oct/1325_Zuckerman_Incremental_Cost_1019.pdf.

117 42 U.S.C.A. § 4002(a)-(c).

118 Id. § 4103(a). A “personalized prevention plan” includes (1) “a screening schedule for the next 5 to 10 years … based on recommendations of the [USPSTF],” and (2) “a list of risk factors and conditions for which … prevention interventions are recommended … and a list of treatment options and their associated risks and benefits.” Id. § 4103(b).

119 Id. § 2713(a)(1)-(23). The cost of the preventive service will be reimbursed by Medicare. See § 4104(b); cf. Law, Sylvia A. & Ensminger, Barry, Negotiating Physicians’ Fees: Individual Patients or Society? (A Case Study in Federalism), 61 N.Y.U. L. Rev. 1, 57 (1986)Google Scholar (exploring the pros and cons of forbidding “balance billing” and the legal impediments to negotiating with physicians to set reasonable and fair rates). Health and Human Services may opt to modify or eliminate coverage of preventive services that have received a USPSTF grade of C. § 4105(a); see also U.S. Preventive Services Task Force (USPSTF) Ratings, U.S. PREVENTIVE SERVICES TASK FORCE, http://www.uspreventiveservicestaskforce.org/uspstf07/ratingsv2.htm (last visited Nov. 19, 2011) (defining grade C preventive services as those for which “[t]here is at least moderate certainty that the net benefit is small”).

120 See discussion supra Part II.B; Calonge, Ned & Randhawa, Gurvaneet, The Meaning of the U.S. Preventive Services Task Force Grade I Recommendation: Screening for Hepatitis C Virus Infection, 141 Annals Internal Med. 718, 718 (2004)CrossRef Google Scholar (“[T]he USPSTF recommendations … are primarily aimed at the primary care clinician.”).

121 See Glen Cheng & William E. Halperin, Determinants and Impact of Mandated Health Benefit Review Laws and Commissions, PUB. HEALTH REP. (forthcoming).

122 See, e.g., Interpreting the U.S. Preventive Services Task Force Breast Cancer Screening Recommendations for the General Population, AM. CONG. OBSTETRICIANS & GYNECOLOGISTS (2009) (on file with author) (“The USPSTF has not issued recommendations for many vital preventive services in women's health care, such as preconception care, family planning counseling and services, and bundled services such as the annual well-woman examination. The USPSTF only makes and updates a handful of recommendations each year, far too few to address clinically appropriate preventive services that ought to be covered by any plan.”).

123 Cf. Calonge & Randhawa, supra note 120, at 719 (“Differences of opinion among independent experts regarding interpretation of current evidence are not unusual. An essential theme underlying all USPSTF recommendations is a commitment to evaluating the quality of scientific studies and synthesizing the results in a systematic and transparent fashion so that clinicians and patients can make informed decisions.”).

124 Cf. Univ. of Oxford, Oxford Centre for Evidence-Based Medicine – Levels of Evidence, CTR. FOR EVIDENCE-BASED MED. (March 2009), http://www.cebm.net/index.aspx?o=1025 (last visited Oct. 24, 2010) (describing the levels of evidence accorded to various types of clinical studies). For example, preventive medicine recommendations supported by Level 1a or 1b evidence could be mandated for full insurance coverage.

125 42 U.S.C.A. § 2713(a)(5) (West 2010) (“Nothing in this subsection shall be construed to prohibit a plan or issuer from providing coverage for services in addition to those recommended by [the USPTF] or to deny coverage for services that are not recommended by such Task Force.”).

126 The USPSTF has already been the target of politicization, as one of its recent evidence-based recommendations was specifically excluded from coverage by the PPACA. See id. (“[T]he current recommendations of the [USPTF] regarding breast cancer screening, mammography, and prevention shall be considered the most current other than those issued in or around November 2009.”) (emphasis added); see also Press Release, Joseph W. Stubbs, President, Am. Coll. Physicians, Statement on the Politicization of Evidence-Based Clinical Research (Nov. 24, 2009), available at http://www.acponline.org/pressroom/pol_ebcr.htm.

127 42 U.S.C. § 4001(a)-(f).

128 See id. § 4001(g).

129 About the NHSC, NAT’L HEALTH SERV. CORPS, http://nhsc.bhpr.hrsa.gov/about/ (last visited Jan. 21, 2011).

130 COUNCIL ON GRADUATE MED. EDUC., U.S. DEP't HEALTH & HUMAN SERVS., TENTH REPORT: PHYSICIAN DISTRIBUTION AND HEALTH CARE CHALLENGES IN RURAL AND INNER-CITY AREAS 2 (1998) [hereinafter COGME TENTH REPORT].

131 Loan Repayment, NAT’L HEALTH SERV. CORPS, http://nhsc.bhpr.hrsa.gov/loanrepayment/ (last visited Jan. 21, 2011).

132 U.S. DEP't OF HEALTH & HUMAN SERVS., NAT’L HEALTH SERV. CORPS AMBASSADOR TOOLKIT 9, available at http://nhsc.hrsa.gov/ambassadors/ambassadorstoolkit/ambassadorstoolkit.pdf.

133 Emergency Health Personnel Act of 1970, Pub. L. No. 91-623, 84 Stat. 1868 (1970) (codified as amended at 42 U.S.C. §§ 254d et seq. (2010)).

134 NAT’L ADVISORY COUNCIL ON THE NAT’L HEALTH SERV. CORPS, A NATIONAL HEALTH SERVICE CORPS FOR THE 21ST CENTURY 25 (2000), available at http://nhsc.hrsa.gov/downloads/servicecorps.pdf.

135 Emergency Health Personnel Act Amendments of 1972, Pub. L. No. 92-585, 86 Stat. 1290 (1972).

136 NAT’L ADVISORY COUNCIL ON THE NAT’L HEALTH SERV. CORPS, supra note 134, at 25.

137 Id. at 26.

138 Id.

139 See id. at 32.

140 See id.

141 See id. (“[C]linic directors felt the NHSC was essential for attracting quality health professionals to their sites.”); COUNCIL ON GRADUATE MED. EDUC., U.S. DEP't HEALTH & HUMAN SERVS., NINETEENTH REPORT: ENHANCING FLEXIBILITY IN GRADUATE MEDICAL EDUCATION 16-17 (1998) [hereinafter COGME NINETEENTH REPORT].

142 COGME TENTH REPORT, supra note 130, at 45-46; JOSIAH MACY, JR. FOUND., SUMMARY OF THE MEETING: DEVELOPING A STRONG PRIMARY CARE WORKFORCE (2009) (on file with author).

143 See Pollner, Philip & Parrish, Jerrold J., National Health Service Corps and Primary Care Training: A Mutually Beneficial Plan Affecting Physician Maldistribution, 228 JAMA 1405, 1405 (1974)CrossRef Google Scholar PubMed; see also discussion infra Part V.A.3 (regarding integration of residency training programs with community health centers).

144 See Pollner & Parrish, supra note 143, at 1405-06.

145 See 42 U.S.C.A. § 5301 (West 2010).

146 Id.

147 Id.

148 See id. § 5503.

149 Id.

150 Id.

151 Id.

152 See id.

153 Id.

154 See NAT’L RESIDENT MATCHING PROGRAM, RESULTS AND DATA: 2010 MAIN RESIDENCY MATCH 5 (2010), available at http://www.nrmp.org/data/resultsanddata2010.pdf.

155 See 42 U.S.C.A. § 5508.

156 Id. § 5508(a).

157 See id.

158 See supra note 86 and accompanying discussion.

159 42 U.S.C. § 292q.

160 Primary Care Loans, HEALTH RES. & SERVS. ADMIN., http://www.hrsa.gov/loanscholarships/loans/primarycare.html (last visited Nov. 21, 2011). The interest rate during the PCL repayment period is currently five percent per year. 42 U.S.C. § 292r(e).

161 42 U.S.C. § 5201(a)(1).

162 The PPACA changes the interest rate on default to “2 percent per year greater than the rate at which the student would pay if compliant in such year.” Id. Since the interest rate during the repayment period is five percent per year, see id. § 292r(e), the interest rate on default is now effectively seven percent per year.

163 The PPACA provides several provisions designed to promote primary care: by temporarily increasing payments to primary care providers, by redistributing unfilled positions in specialty training to primary care residencies, by increasing coverage of preventive services, and by providing substantially expanded support for the NHSC. See generally discussion supra Part IV.

164 See Marietti Byrnes, Kristine, Note, Is There a Primary Care Doctor in the House? The Legislation Needed to Address a National Shortage, 25 Rutgers L.J. 799, 836-41 (1994)Google Scholar (proposing that additional federal funds be allocated to schools that meet individualized quotas for training students that enter primary care residencies).

165 In 2008, the WHO reported that in the United States, 730,801 physicians were available to serve a population of 302,841,000, leaving one physician, regardless of specialty, for every 414 people. WORLD HEALTH ORG., WORLD HEALTH STATISTICS 2008, at 82 (2008), available at http://www.who.int/whosis/whostat/EN_WHS08_Full.pdf.

166 See About the NRMP, NAT’L RESIDENT MATCHING PROGRAM, http://www.nrmp.org/about_nrmp/index.html (last visited Feb. 10, 2011). Medical students typically obtain residency positions outside the NRMP when they are unable to match into a residency program through the NRMP. The exact number of medical students who match outside the NRMP is not available but is widely believed to be very small.

167 See NAT’L RESIDENT MATCHING PROGRAM, supra note 154, at 5.

168 See id. at 1.

169 See The Application Process, NAT’L RESIDENT MATCHING PROGRAM, http://www.nrmp.org/res_match/about_res/application_process.html (last visited Feb. 10, 2011). Individual residency programs may supplement the uniform NRMP application with their own questions and requirements.

170 It is becoming increasingly popular for U.S. medical students to apply to both a competitive “reach” specialty as well as a “safety” field to ensure their chances of matching into a residency position.

171 Generally, students rank any of the programs where they were interviewed. Similarly, residency programs will only rank students they interviewed. The matching algorithm favors the student ranking over the residency program ranking, determining the highest overall combined rankings for students and programs. See generally How the Matching Algorithm Works, NAT’L RESIDENT MATCHING PROGRAM, http://www.nrmp.org/res_match/about_res/algorithms.html (last visited Feb. 10, 2011).

172 See Announcement of Match Results, NAT’L RESIDENT MATCHING PROGRAM, http://www.nrmp.org/fellow/match_results.html (last visited Feb. 10, 2011); 2010 Main Match Schedule, NAT’L RESIDENT MATCHING PROGRAM, http://www.nrmp.org/res_match/yearly.html (last visited Feb. 10, 2011).

173 See Policies and Procedures for Reporting, Investigation, and Disposition of Violations of NRMP Agreements, NAT’L RESIDENT MATCHING PROGRAM, http://www.nrmp.org/fellow/violations.html (last visited Feb. 10, 2011).

174 Cf. 42 C.F.R. § 413.75-.83 (2010) (mentioning no such requirements for residency programs that receive Medicare Direct Medical Education payments).

175 See generally discussion supra Part III.

176 See NAT’L RESIDENT MATCHING PROGRAM, supra note 154, at 5.

177 See Malaty, Wail & Pathman, Donald E., Factors Affecting the Match Rate of Rural Training Tracks in Family Practice, 34 Fam. Med. 258, 258-61 (2002)Google Scholar PubMed.

178 See id.

179 For example, the 1980 Graduate Medical Education National Advisory Committee's report incorrectly predicted that market forces would compel medical graduates to increasingly enter primary care in the 1990s and beyond. See supra notes 138-39 and accompanying discussion.

180 COGME TENTH REPORT, supra note 130, at 11 fig.2-1, 12 fig.2-2 (depicting the trend over time towards physicians choosing practice in urban areas as opposed to rural areas); id. at 12 fig.2-3 (showing that of the generalist disciplines of general internal medicine, pediatrics, obstetrics & gynecology, and general surgery, only family medicine practitioners have distributed themselves reasonably proportionately between rural and urban areas). COGME noted that “[a]s experience in other countries has shown, some physicians will drive cabs in urban areas before they will migrate to isolated and underserved rural areas or set up practice in problematic inner-city areas.” Id. at 7; see also supra discussion Part III.C regarding physician disincentives for practicing in rural areas.

181 “20 percent of the United States population—over 50 million people—live in rural areas, but only 9 percent of the nation's physicians practice in rural communities.” COGME TENTH REPORT, supra note 130, at 11; see Geyman, John P. et al., Educating Generalist Physicians for Rural Practice: How Are We Doing?, 16 J. Rural Health 56, 58 fig.2 (2000)CrossRef Google Scholar PubMed (showing that primary care providers continue to be more prevalent than specialists in rural areas); Rosenblatt, Roger A. et al., Shortages of Medical Personnel at Community Health Centers: Implications for Planned Expansion, 295 JAMA 1042, 1043 (2006)CrossRef Google Scholar PubMed.

182 COGME TENTH REPORT, supra note 130, at 6-8, 8 fig.1-5.

183 The federal government finances a significant portion of medical education through Medicare and federal subsidized loan programs. See infra notes 211-13 and accompanying discussion.

184 See Geyman et al., supra note 181, at 57-58.

185 Cf. Byrnes, supra note 164, at 849-50 (describing Britain's requirements for specialty certification); Huang, Katherine, Note, Graduate Medical Education: The Federal Government's Opportunity to Shape the Nation's Physician Workforce, 16 Yale J. On Reg. 175, 202-03 (1999)Google Scholar (noting that President Clinton's Health Security Plan of 1994 would have authorized a National Council on GME to “ensure that 55% of new residents entered primary care programs, cap the total number of residents, allocate positions among institutions and medical specialties, and distribute payments from the trust fund”).

186 See New State Ice Co. v. Liebmann, 285 U.S. 262, 311 (1932) (Brandeis, J., dissenting) (“It is one of the happy incidents of the federal system that a single courageous state may, if its citizens choose, serve as a laboratory; and try novel social and economic experiments without risk to the rest of the country.”); Rapaczynski, Andrzej, From Sovereignty to Process: The Jurisprudence of Federalism After Garcia, 1985 Sup. Ct. Rev. 341, 408.Google Scholar

187 An alternative, indirect form of centralized regulation of physician distribution could be to allocate GME funds to hospitals based on the quality of their resident physician training programs and the risk-factor-weighted health outcomes of their patients. See Shuren, Jeffrey E., Financing the Nation's Graduate Medical Education: A Hybrid Approach, 33 Val. U. L. Rev. 181, 198 (1998)Google Scholar. Due to the relative improvement in health outcomes associated with increased primary care presence and an optimal distribution of specialists, over time, this form of efficiency-based distribution of GME funding could result in relatively increased funding for primary care residencies, though quality measurements would be theoretically and quantitatively difficult.

188 The reason for periodic, rather than annual, redistribution is that it takes at least a full year for residency programs to work out detailed contracts with training sites. These contracts must be carefully drafted to ensure that all shifts are covered, that there are enough patients to accommodate all residents, that there are enough residents to accommodate all patients, that there are a commensurate amount of teaching faculty and allied health professionals, and that there are enough teaching sites to accommodate all residents in each program.

189 See, e.g., Danis, Marion et al., Low-Income Employees’ Choices Regarding Employment Benefits Aimed at Improving the Socioeconomic Determinants of Health, 97 Am. J. Pub. Health 1650 (2007)CrossRef Google Scholar PubMed (describing the use of an NIH-developed survey tool to ascertain community preferences for distribution of limited health resources); Dorr Goold, Susan et al., Choosing Healthplans All Together: A Deliberative Exercise for Allocating Limited Health Care Resources, 30 J. Health Pol. Pol’Y & L. 563 (2005)CrossRef Google Scholar.

190 Cf. Shuren, supra note 187, at 191 (citing New York Health Care Reform Act of 1996, N.Y. PUB. HEALTH LAW § 2807 (McKinney 1996)) (describing New York's GME funding pool, through which general teaching hospitals can receive increased funds if they comply with state requirements such as increasing the percentage of residents training in primary care programs).

191 See Jacoby, Itzhak et al., Retraining Physicians for Primary Care: A Study of Physician Perspectives and Program Development, 277 JAMA 1569, 1569-73 (1997)CrossRef Google Scholar PubMed; Rattner, Susan L. et al., Assessment of Physicians’ Interest in Primary Care Training/Retraining, 72 Acad. Med. 1103, 1103-05 (1997)CrossRef Google Scholar.

192 See supra note 131-32 and accompanying discussion.

193 Britain, Canada, and Belgium have adopted similar specialization distribution plans to ensure equitable distribution of physicians in their communities. See Byrnes, supra note 164, at 847-49. Furthermore, in 1992, Kansas and California had proposed legislation requiring state-funded medical schools to meet quotas for training students entering primary care. Id. at 827-28 (citing Cal. A.B. 3593, Reg. Sess. (1992); Kan. S.B. 490, Reg. Sess. (1992)).

194 H.R. 2015, 105th Cong. § 4626 (a)(G)(3) (1997).

195 See JAMES A. REUTER, INST. HEALTH CARE RES. & POL’Y, GEORGETOWN UNIV., THE BALANCED BUDGET ACT OF 1997: IMPLICATIONS FOR GRADUATE MEDICAL EDUCATION 1-2 (1997) (providing several reasons for this inefficiency). The increased healthcare costs associated with AHCs is attributed in part to the medical research mission of many AHCs. See Bonham, Ann C. et al., Putting Evidence to Work: An Expanded Research Agenda for Academic Medicine in the Era of Health Care Reform, 85 Acad. Med. 1551, 1551-52 (2010).CrossRef Google Scholar PubMed

196 REUTER, supra note 195, at 6.

197 See supra notes 155-58 and accompanying discussion.

198 For a discussion of PCMHs, see supra notes 108-16. COGME has urged Congress to provide increased funding of residency programs that can supply primary care physicians to PCMHs. See COGME Letter, supra note 16, at 1.

199 See Lesnik, Juniper, Community Health Centers: Health Care as It Could Be, 19 J.L. & Health 1, 30–31 (2004)Google Scholar PubMed.

200 Community Health Center Program Information, U.S. DEPT. HEALTH & HUMAN SERVS., http://bphc.hrsa.gov/about/index.html (last visited Nov. 17, 2011).

201 See MICHELLE PROSER, NAT’L ASSOC. CMTY. HEALTH CTRS., THE ROLE OF HEALTH CENTERS IN REDUCING HEALTH DISPARITIES 8-13 (2003) (reporting a higher rate of preventive services delivered, fewer hospitalizations, and better management of chronic conditions for communities with a CHC than for those without one); MICHELLE PROSER & LISA COX, NAT’L ASSOC. CMTY. HEALTH CTRS., HEALTH CENTERS’ ROLE IN ADDRESSING THE BEHAVIORAL HEALTH NEEDS OF THE MEDICALLY UNDERSERVED, SPECIAL TOPICS ISSUE BRIEF #8, 3 (2004) (reporting that CHCs reduce healthcare disparities by providing mental health and substance abuse services to low-income families, minorities, the uninsured, and rural residents, who often have no other way to obtain behavioral healthcare).

202 Forrest, Christopher B. & Whelan, Ellen-Marie, Primary Care Safety-Net Delivery Sites in the United States, 284 JAMA 2077, 2079 tbl.1 (2000)CrossRef Google Scholar PubMed.

203 Id. at 2081.

204 Morris, Carl G. et al., Family Medicine Residency Training in Community Health Centers: A National Survey, 85 Acad. Med. 1640, 1640 (2010)CrossRef Google Scholar PubMed.

205 Id.

206 Id. at 1642.

207 See supra notes 63-65 and accompanying discussion.

208 Government subsidization could also be achieved through federal funding for M.D. degrees, though direct education grants would not allow for monitoring and enforcement of optimal specialty distribution.

209 See generally Office of Extramural Research, Ruth L. Kirschstein National Research Service Award (NRSA), NAT’L INSTS. HEALTH, http://grants.nih.gov/training/nrsa.htm (last visited Oct. 24, 2010). Note that postdoctoral NRSA recipients must “pay back” their tuition grants through service by engaging in health-related biomedical or behavioral research. Id.

210 See MD-PhD Training and Careers: A Guide for Potential Applicants, Current Trainees, and Advisors, ASS’N AM. MED. COLL., 12-17 (July 18, 2008), available at https://www.aamc.org/download/70698/data/mdphdtrainingandcareers.pdf.

211 Medicare funds hospitals in the form of Direct Medical Education payments for resident training, 42 C.F.R. § 413.75-.83 (2011), and taxes for Indirect Medical Education, which are meant to cover the higher operating costs incurred by teaching hospitals. See id. § 412.105; Social Security Act § 1886(h), 42 U.S.C. § 1395ww (2006); see also Rich, Eugene C. et al., Medicare Financing of Graduate Medical Education: Intractable Problems, Elusive Solutions, 17 J. Gen. Internal Med. 283, 285-87 (2002)CrossRef Google Scholar (detailing difficulties with the current Medicare GME funding scheme).

212 A typical salary for a resident physician ranges from $45,000 to $60,000, based on geographic location and year of residency. See FREIDA Online, AM. MED. ASS’N, https://freida.amaassn.org/Freida/user/viewProgramSearch.do (last visited May 18, 2011) (FREIDA Online is a searchable database containing annually-updated information from almost all ACGME-accredited residency programs in the United States).

213 Medical students currently may receive up to $8000 per year in Perkins Loans, which have an interest rate of five percent that is fully subsidized by the Department of Education during one's medical school career. Medical students may also borrow up to $20,500 per year in Direct Stafford Loans, which have an interest rate of 6.8%. Students may qualify for interest-subsidization for up to $8,500 in Stafford Loans per year. See US DEP't EDUC., FUNDING EDUCATION BEYOND HIGH SCHOOL: THE GUIDE TO FEDERAL STUDENT AID 5 tbl.1, 16-18, 18 tbl.4 (2011).

214 The practice requirement is intended to ensure that residency graduates go on to serve the public in the field in which they trained. The requirement of eight years of post-medical graduate practice for full loan repayment is modeled after the NHSC Scholarship Program, which provides full loan repayment for primary care physicians who serve for over five years in a HPSA. See infra note 215. Because most primary care physicians require three years of postgraduate training to become board certified (obstetrics & gynecology requires four years), they will require an additional five years of service in an HPSA to qualify for full loan repayment under the NHSC Scholarship Program.

215 The required period of residency training to become eligible for board certification varies from three years for primary care fields to seven years for neurosurgical fields, and even longer for certain surgical subspecialties. See FREIDA Online, supra note 212.

216 See BUREAU OF CLINICIAN RECRUITMENT & SERV., National Health Service Corps Loan Repayment Program, U.S. DEP't HEALTH & HUMAN SERVS. (December 2010), available at http://nhsc.hrsa.gov/downloads/loanrepayment.pdf (stating that the NHSC provides $170,000 in loan repayment over five years, and full loan repayment for NHSC scholars who serve for longer than five years).

217 See supra note 63.

218 A large portion of medical student loans are provided through the Federal Stafford and Perkins Loan programs. Recipients of Stafford and Perkins loans may be eligible for loan forgiveness if they serve in public service careers. See generally GAIL MCCALLION, CONG. RESEARCH SERV., STUDENT LOAN FORGIVENESS PROGRAMS (2005), available at http://projectonstudentdebt.org/files/pub/Loan%20Forgiveness.pdf.

219 The decision to opt in or out of the NREX would be required to be uniform for all residency programs within a particular institution. The institution-wide requirement would limit the number of hospitals that choose to opt out of the NREX, because, for strategic and financial reasons, it would be difficult to reach a consensus between all residency programs in a given hospital to opt out of the NREX. Hospitals generally depend significantly on Medicare for financial support of their residency programs. This financial dependence also explains why it would be very difficult for hospitals offering residency programs outside the NREX to compete against NREX programs by offering higher residency salaries. Though there would be no formal restriction on the amount of funding a hospital could offer to residents in non-NREX programs, the reality is that few, if any, hospitals would be able to compete with the Medicare-funded salaries and loan repayment opportunities that NREX programs would be able to offer their residents.

220 See supra notes 133-39 and accompanying discussion.

221 The Armed Forces Reserve Medical Officer Commissioning and Residency Consideration Program, or “Berry Plan” was a plan that allowed medical students to opt to serve two years in the armed forces medical service in exchange for exemption from the selective service draft. See Berry, Frank B., The Story of “The Berry Plan,” 52 Bull. N.Y. Acad. Med. 278 (1976)Google Scholar.

222 See Petersdorf, Robert G., Financing Medical Education: A Universal “Berry Plan” for Medical Students, 328 New Eng. J. Med. 651 (1993)CrossRef Google Scholar PubMed. Note that Petersdorf's proposal coincided with President Clinton's efforts to restructure the U.S. healthcare system, which were ultimately withdrawn due to lack of political consensus.

223 See Byrnes, supra note 164, at 820 n.112 (listing twenty-five such state statutes). Several states have passed limited initiatives for increasing funding for primary care residencies. See id. at 819-24.

224 See id. at 820-21. Though the success of state loan repayment programs varies widely, approximately sixty percent of participants in state loan repayment programs completed their required service. See id. at 822 n.114 (citing CHARLES E. LEWIS ET AL., A RIGHT TO HEALTH: THE PROBLEM OF ACCESS TO PRIMARY MEDICAL CARE 52-53 (1976)).

225 This Article assumes that the small proportion of medical students matching to a residency position outside of the NREX will remain similar to the proportion currently matching outside the NRMP. See supra note 166 and accompanying discussion.

226 NAT’L RESIDENT MATCHING PROGRAM, supra note 154, at 9.

227 These assumptions, which are intended to provide an approximate estimate of the annual costs of the primary care loan repayment program, are necessarily simplistic. For the purposes of actual implementation of the NREX, the author invites economists to perform a more detailed budget analysis.

228 See HEALTH RES. & SERVS. ADMIN., DEP't HEALTH & HUMAN SERVS., HEALTH PROFESSIONS TRAINING PROGRAMS – NATIONAL HEALTH SERVICE CORPS (NHSC) 1, 4 (2010), available at http://www.hhs.gov/recovery/reports/plans/pdf20100610/HRSA%20National%20Health%20Service%20Corps%20June%202010.pdf. $190.54 million of the costs went to direct loan repayments for participants in the NHSC loan repayment program, while $0.96 million covered federal administration and support costs.

229 This result is reached by the following equation: [number of individuals participating in the NHSC during fiscal years 2009-2010 / (total budget appropriations / 2 years)] = [3000 participants / ($191,500,000 / 2 years)] = $31,916.67 per participant per year.

230 A total of 6771 U.S. medical graduates filled primary care residency spots in the NRMP in 2010. See NAT’L RESIDENT MATCHING PROGRAM, supra note 154, at 5 (listing the number of spots filled by U.S. graduates per primary care specialty: 2829 in internal medicine, 1254 in family medicine, 1744 in pediatrics, 940 in obstetrics and gynecology, and 4 in combined internal medicinefamily medicine programs).

231 This estimate is based on the current number of primary care positions in the NRMP. The actual cost of the primary care loan repayment program will be based on the number of primary care positions in the NREX, which will be adjusted based on the primary care needs of each community.

232 The PPACA authorizes $1,154,510,336 to be appropriated for 2015. Patient Protection and Affordable Care Act, Pub. L. No. 11-148, § 5207 (2010).

233 See id. § 5207(a)(1)-(6) (providing $320,461,632 for 2010, increasing annually to $1,154,510,336 for 2015).

234 The PPACA authorizes an annual increase in funding from $414 million in 2011 to $1.1 billion in 2015. Note that not all of the funding authorized to be appropriated for the NHSC ends up being actually appropriated. For example, the PPACA authorizes up to $414,095,394 in funding to the NHSC for fiscal year 2011, while explicitly appropriating $290 million for the same year. Compare id. § 5207, with id. § 10503(b)(2). Thus it remains to be seen what the actual amount appropriated for the NHSC will be in the years 2015 and beyond. Nonetheless, the estimate provided in this Article is intended to demonstrate that the level of funding required for the primary care loan repayment program may well be achievable even via current funding projections in the PPACA.

235 Id. § 5207(a)(7) (detailing the formula for calculating the increased amount authorized to be appropriated by the NHSC for 2016 and each subsequent year).

236 Id. § 5209.

237 See Addressing Healthcare Workforce Issues for the Future: Hearing on Examining the Ways to Address Healthcare Workforce Issues for the Future, Focusing on Primary Care Professionals Before the S. Comm. on Health, Educ., Labor, and Pensions, 110th Cong. 25-26 (2008) (statement of Bruce Steinwald, Director of Health Care, Government Accountability Office) [hereinafter Primary Care Professionals] (finding that conventional payment systems undervalue primary care services relative to specialty services, and that primary care service reimbursements should be increased to reflect the improved outcomes and cost savings that they provide); ZEREHI, supra note 61, at 26-28.

238 Cardarelli, Roberto, The Primary Care Workforce: A Critical Element in Mending the Fractured US Health Care System, 3 Osteopathic Med. & Primary Care 11, 11 (2009)CrossRef Google Scholar PubMed (citation omitted). Note that in certain cases there also exist perverse financial incentives that reward primary care physicians for inappropriately referring patients to specialists. For example, capitation systems provide a physician with a fixed payment per month per patient. If a primary care physician refers a patient to a specialist, the referrer lets the specialist do the disease management and treatment, while receiving the same amount of income under the capitation system. See Meisel, Alan, Managed Care, Autonomy, and Decisionmaking at the End of Life, 35 Hous. L. Rev. 1393, 1410-11 (1999)Google Scholar PubMed.

239 Iglehart, John K., The American Health Care System: Medicare, 340 New Eng. J. Med. 327, 330 tbl.1 (1999)CrossRef Google Scholar PubMed (“Medicare's schedule of physicians’ fees, like the prospective payment system that pits different kinds of hospitals against each other, provokes conflict between medical generalists and specialists. These disputes have grown in prominence ever since 1989, when Congress directed [the Health Care Financing Administration] to develop a schedule of physicians’ fees.”). Of course, this zero-sum game could be avoided if more funding for physician compensation were poured into the healthcare system. Regarding the proposed ten percent bonus payment for primary care services provided for in the PPACA, half of the bonus is funded with “new money,” and half through slight reduction in payment for all other physician services. See discussion supra Part V.A.2; see also Letter from Joseph W. Stubbs, President of Am. Coll. Physicians, to Harry Reid, S. Majority Leader (Dec. 4, 2009), available at http://www.acponline.org/advocacy/where_we_stand/access/baucus.pdf (Dr. Stubbs's letter, written prior to the PPACA's enactment, requested that the primary care incentive payment bonus be funded in a way that does not decrease compensation for other physician services.).

240 Medicare's payment system has been criticized as a system “designed for specialty care and single problems.” Comments at Perspective Roundtable, supra note 92, at 8 (testimony of Dr. Katharine Treadway) (“There is nothing in the [RBRVS] system that allows you to take into account the fact that you’ve just seen somebody with congestive heart failure, hypertension, hyperlipidemia, coronary disease, renal insufficiency, and diabetes.”); see Primary Care Professionals, supra note 237, at 15-16 (noting that Medicare reimburses $103.42 for a half-hour primary care visit in Boston, but $449.44 for a colonoscopy that would take roughly the same amount of time).

241 RBRVS was implemented in the Omnibus Budget Reconciliation Act of 1989, Pub. L. 101- 239, § 6102, 103 Stat. 2106, 2169 (1989), which replaced the “reasonable-charge” formula initiated with Medicare's enactment in 1965. Gregg Bloche, M., The Emergent Logic of Health Law, 82 S. Cal. L. Rev. 389, 475 n.382 (2009)Google Scholar (noting that because the “reasonable-charge” formula fixed physician payment to the prevalent billing schedules in each region, doctors were incentivized “to raise their fees as quickly as the market would bear”).

242 42 U.S.C. § 1395w-4(c) (2006).

243 Id. § 1395w-4(b). The conversion factor is detailed in § 1395w-4(d).

244 Id. § 1395w-4(c)(2)(C).

245 Bloche, supra note 241, at 474-75.

246 See 42 U.S.C. § 1395w-4(d)(1)(A).

247 See generally AM. ACAD. PEDIATRICS, 2011 RBRVS (2011), available at http://www.aap.org/visit/rbrvsbrochure.pdf (providing a detailed description of the calculations involved in determining a payment under the RBRVS). The Medicare Conversion Factor for 2011 has been set as $33.9764. Id. at 6.

248 Iglehart, John K., Medicare's Declining Payments to Physicians, 346 New Eng. J. Med. 1924, 1925-26, 1927 tbl.1 (2002)CrossRef Google Scholar (providing examples of payment codes for evaluation and management that increased soon after adoption of the RBRVS, but noting that the success of the RBRVS in equitably redistributing physician payments is difficult because the physician fee schedule involves more than 7000 payment codes).

249 See David W. Johnson & Nancy M. Kane, The U.S. Health Care System: A Product of American History and Values, in THE FRAGMENTATION OF U.S. HEALTH CARE: CAUSES AND SOLUTIONS, supra note 56, at 325, 330.

250 See 42 U.S.C. § 1395w-4(c)(2)(F)(i); MEDICARE PHYSICIAN PAYMENT ADVISORY COMM’N, REPORT TO THE CONGRESS: MEDICARE PAYMENT POLICY 87 (2010). Even private insurers have long failed to implement reimbursement systems that accurately track the relative costs between generalist and specialist services. Ginsburg, Paul B. & Grossman, Joy M., When the Price Isn't Right: How Inadvertent Payment Incentives Drive Medical Care, w5 Health Aff. 376, 378–379 (2005)Google Scholar; see also Steinwald, Bruce & Sloan, Frank A., Determinants of Physicians’ Fees, 47 J. Bus. 510, 510 (1974)CrossRef Google Scholar (noting the effect of the trend towards specialization on increasing physician reimbursement rates).

251 See 42 U.S.C. § 1395u(b)(16)(B)(ii). E&M services consist of “primary care services … hospital inpatient medical services, consultations, other visits, preventive medicine visits, psychiatric services, emergency care facility services, and critical care services.” Id.

252 Non-E&M services include surgical procedures, invasive diagnostic procedures, and radiological imaging, most of which are provided exclusively by specialists.

253 See Bodenheimer, supra note 92, at 301-05. From 2000 to 2005, the number of colonoscopies billed to Medicare increased by forty percent, CT scans increased by sixty-five percent, and MRI scans increased by ninety percent. Id. In the same time, the number of office visits billed for established patients increased by twelve percent. Id.

254 The SGR is the rate at which Medicare payments under the RBRVS were designed to be maintained in order to control healthcare spending from year to year. See 42 U.S.C. § 1395w-4(f)(2).

255 Mina Matin, Splitting the Sustainable Growth Rate: A Proposal to Strengthen Medicare and Primary Care, HEALTH AFF. BLOG (Feb. 14, 2008), http://healthaffairs.org/blog/2008/02/14/splittingthe-sustainable-growth-rate-a-proposal-to-strengthen-medicare-and-primary-care/ (last visited Jan. 28, 2011).

256 See MEDICARE PAYMENT ADVISORY COMM’N, REPORT TO THE CONGRESS: ASSESSING ALTERNATIVES TO THE SUSTAINABLE GROWTH RATE SYSTEM 75-81 (2007).

257 See id. at 95-106.

258 See MEDICARE PHYSICIAN PAYMENT ADVISORY COMM’N, supra note 250, at 88-89. MedPAC also recommends that physician payments should be structured to incentivize both care coordination and optimal health outcomes. See id.; see also Aligning Incentives in Medicare: Hearing Before the Subcomm. on Health of the H. Comm. on Energy and Commerce, 111th Cong. 3-4 (2010) (statement of Glenn M. Hackbarth, Chairman, Medicare Payment Advisory Comm’n); Bloche, supra note 241, at 475 (“Medicare should go as far as is politically feasible toward closing the chasm between payment for high-tech procedures and other uses of physician time.”).

259 Some scholars believe that Congress's refusal to “split the SGR” has been due to Congressional staffers’ fears that adoption of such proposals would cause infighting between physicians in different fields. See Yoshio Laing, Brian et al., Primary Care's Eroding Earnings: Is Congress Concerned?, 57 J. Fam. Prac. 578, 578-83 (2008)Google Scholar.

260 Patient Protection and Affordable Care Act, Pub. L. No. 111-148, § 3007(1) (2010); see also McClellan, Mark et al., A National Strategy to Put Accountable Care into Practice, 29 Health Aff. 982, 987 (2010)CrossRef Google Scholar (advocating adjustment of misevaluations in the Physician Fee Schedule as a means of tying physician reimbursement to outcomes). The PPACA also funds many types of pilot programs that test various restructured physician payment models, ranging from pay for performance to payment bundling models. See § 10326 (2010) (“Pilot Testing Pay-for-Performance Programs for Certain Medicare Providers”); § 3023 (“National Pilot Program on Payment Bundling”). Because such a wide variety of demonstration plans are funded by the PPACA, experts remain hopeful that at least some of the successful programs can subsequently be generalized in the U.S. healthcare system to achieve cost savings and improved health outcomes. See Atul Gawande, Testing, Testing: The Health- Care Bill Has No Master Plan for Curbing Costs. Is That a Bad Thing?, THE NEW YORKER, Dec. 14, 2009, http://www.newyorker.com/reporting/2009/12/14/091214fa_fact_gawande?currentPage=#ixzz11orQzWdL.

261 § 3134.

262 § 3134(a).

263 Id.

264 Bloche, supra note 241, at 475 (noting further that antitrust law prevents private insurers from colluding to impose cuts simultaneously).

265 Id.; see also Ginsburg & Grossman, supra note 250, at 376, 382.

266 See Medical Education Trust Fund Act of 1999, S. 210, 106th Cong. (1999) (proposing a one and a half percent tax on health insurance premiums, Medicare, and Medicaid that would generate seventeen billion dollars per year to support GME); see also Huang, supra note 185, at 199-202 (proposing a broad base one percent tax on private insurance premiums that would yield six billion dollars per year); Shuren, supra note 187, at 197-200 (proposing a Medical Education Tax Act that would tax private insurers on the premiums paid by their insured payees).

267 See generally § 1301 (defining Qualified Health Plans).

268 Byrnes, supra note 164, at 803.

269 See N.J. MED. SCH., UNIV. MED. & DENTISTRY NEW JERSEY, CURRICULUM OVERVIEW, 2011- 2012, available at http://njms.umdnj.edu/admissions/prospective/documents/curriculum.pdf. UMDNJNJMS added a mandatory two week rotation in preventive medicine and public health in 2008. See id.

270 See, e.g., Richmond, Robyn, Teaching Medical Students About Tobacco, 54 Thorax 70, 73 tbl.4 (1999)CrossRef Google Scholar PubMed (reporting that sixty-two of North American medical schools had no systematic approach to teaching medical students about smoking cessation and prevention, the single most preventable cause of morbidity and mortality in the United States); see also Graber, David R. et al., Academic Deans’ Perceptions of Current and Ideal Curriculum Emphases, 62 J. Dental Educ. 911, 911 (1998)CrossRef Google Scholar PubMed (reporting on a study utilizing a mail-in survey reporting that “health promotion/disease prevention” and “primary care” were two of the three topic areas considered by dental school deans to be most in need of emphasis in their school curricula).

271 See Comments at Prospective Roundtable, supra note 92, at 8 (testimony of Barbara Starfield).

272 Wilkinson, Joanne E. et al., FaMeS: An Innovative Pipeline Program to Foster Student Interest in Family Medicine, 42 Fam. Med. 28, 29 (2010)Google Scholar PubMed.

273 Id. at 31-33 (1.94 times).

274 Booza, Jason C. et al., Incorporating Geographic Information Systems (GIS) into Program Evaluation: Lessons from a Rural Medicine Initiative, 23 J. Am. Board Fam. Med. 59, 59–60 (2010)CrossRef Google Scholar PubMed.

275 Id.

276 See id. at 61-64 (noting that a majority of students were placed in residency programs located in counties where the rural population was forty percent or greater, in a state where only twenty-five percent of patients live in rural areas).

Article contents

The National Residency Exchange: A Proposal to Restore Primary Care in an Age of Microspecialization

Abstract

Access options

References

Save article to Kindle

Save article to Dropbox

Save article to Google Drive

Reply to: Submit a response

Your details

You have entered the maximum number of contributors

Conflicting interests