Primary care in transition

It is generally agreed that too few physicians have chosen careers in primary care. The advent of managed care as a popular method of health care provision is now affecting primary care physicians in ways that may further discourage enthusiasm for the practice of primary care and have an unintended negative effect on the primary care physician supply. In addition, the early implementation of the resource-based relative value scale by Medicare and some insurance carriers has been less beneficial to primary care physicians than expected and may even have been harmful to general internists. Efforts to improve the position of primary care physicians in relation to payers and among peers are hindered by the fact that, as a group, primary care physicians are less affluent, less influential, and greatly outnumbered by their more specialized colleagues. Consequently, some of the support currently directed toward primary care may be more apparent than real. My proposals, which aim both to protect and to enhance primary care practice, are the creation of separate primary care fee schedules and separate primary care budgets within health plans, changes in consumer protection rules that intrude on primary care practice, and the development of statewide primary care associations for mutual support and greater bargaining power. Some aspects of contracting and gatekeeping require further study.