The United States has been facing a decline in its primary care workforce for several years, and the results of a recent survey of medical residents indicate the trend will likely continue. A study published in the Journal of the American Medical Association found that only 22% of the 51,390 internal medicine (including primary care) residents surveyed plan to pursue a career in general internal medicine. Even more discouraging is the fact that more than half (53%) of residents enrolled in a primary care program reported subspecialty career plans. The results of the survey show that medical students are less likely to pursue a career in primary care, which will only exacerbate the country’s predicted primary care shortage. The American Academy of Family Physicians (AAFP) estimates that the United States faces a shortage of 60,000 primary care physicians by 2020. However, the National Association of Community Health Centers (NACHC) reports that 60 million Americans are already feeling the effects. According to NACHC, one in six Americans lack adequate access to primary care providers. Compensation gap Many believe medical residents are discouraged from a primary care career because of inadequate compensation. According to Medscape’s 2012 Physician Compensation Report, the lowest-earning medical specialties are pediatrics ($156,000), family medicine ($158,000), and internal medicine ($165,000), all of which fall under the primary care umbrella. On the other hand, subspecialties such as cardiology ($314,000) and oncology ($295,000) earn nearly double the average primary care salary. With the growing amount of school debt, some students have started to question whether a primary care career is affordable. In a post written for The Common Sense Family Doctor blog, Kenny Lin, MD, said medical students often ask him if they will be able to repay student loans, support a family, and save for retirement on a primary care salary. In the post, Lin cited analysis published in Academic Medicine, which concluded “a primary care career remains financially viable for medical school graduates with median levels of education debt.” However, the fact remains that primary care physicians earn significantly less than physicians in other specialties due to the fee-for-service (FFS) model. “The current US Healthcare System is broken in the fact that it rewards those specialties who perform procedures,” said Mike Sevilla, MD, family physician, social media enthusiast, and manager of the Family Medicine Rocks blog. “There is a lot of talk from politicians about emphasis on preventative medicine services (like those delivered by primary care physicians), but health policy changes have been slow to emphasize preventative care.” Under the FFS model, specialists are reimbursed each time they perform an expensive procedure. Primary care physicians do not perform such procedures, and are often not compensated adequately for the disease management and counseling services they provide. Narrowing the gap The Affordable Care Act includes several payment reform models that will eventually move the US from a FFS model to one based on pay-for-performance. Sevilla says pay-for-performance models, such as patient centered medical homes and accountable care organizations, are being tested in pilot programs across the country. The programs discourage expensive, unnecessary procedures, and emphasize the value of primary care. “This is what is needed to help fix the broken US health care system,” Sevilla said. In the meantime, CMS made an effort to help rectify the worsening gap between payment to primary care physicians and subspecialists. In the 2013 Medicare Physician Fee Schedule, CMS increased payments to primary care providers by 7%. CMS did so in the form of two codes, which will pay primary care providers for coordinating patient care during the 30 days following a hospital or nursing facility stay. More than money Although money may be part of the reason medical students shy from primary care, Lin said it is not the whole reason. According to Lin, medical residency training does not fully prepare students for practicing in the community and running a practice, which are fundamental tenets of primary care. Residency training is primarily conducted in the hospital setting, which means students become comfortable in that setting. Also, medical training does not educate students on the business side of medicine, leading students to favor the comfort and security that comes with working in a hospital. In fact, 48% of residents surveyed by Merritt Hawkins said they were unprepared to handle the business side of medicine, and 32% said they would prefer to be employed by a hospital. Lin said primary care residency programs that offer training opportunities in the community setting and teach healthcare business may make residents more receptive to a career in the specialty.