Advancing Primary Care 

D E C E M B E R 2010

COUNCIL ON GRADUATE MEDICAL EDUCATION 

Twentieth Report 

COUNCIL ON GRADUATE MEDICAL EDUCATION 

Twentieth Report 

Advancing Primary Care
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D E C E M B E R 2010
 
The views expressed in this document are soley those of 

the Council on Graduate Medical Education and do not 

necessarily represent the views of the U.S. Government. 
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TWENTIETH REPORT OF COGME 

Table of Contents 

Council on Graduate Medical Education........................................................................................................ v
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Preface ........................................................................................................................................................3
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Abstract ........................................................................................................................................................3
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Executive Summary .......................................................................................................................................4
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Introduction...................................................................................................................................................9
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Discussion ................................................................................................................................................... 15
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1. The Number of Primary Care Physicians ......................................................................................... 15
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2. Mechanisms of Physician Payment and Practice Transformation for Primary Care ......................... 21
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3. The Premedical and Medical School Environment ........................................................................... 31
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4. Graduate Medical Education ........................................................................................................... 38
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5. The Geographic and Socioeconomic Maldistribution of Physicians................................................. 41
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Bibliography................................................................................................................................................ 47
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List of Figures
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Figure 1: Age Distribution of Patient Care Primary Care Physicians.....................................................9
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Figure 2: Key Challenge Areas............................................................................................................. 12
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Figure 3: Family Medicine vs. Specialty Income and Primary Care Preferences ................................... 16
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Figure 4: NRMP Match Summary 2010 .............................................................................................. 17
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Figure 5: U.S. Medical School Graduating Seniors Opting for Family Medicine.................................. 18
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Figure 6: Magnitude of Primary Care Physician Shortage ................................................................... 19
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Figure 7: Percent of Patients for Whom Specialists Serve as Primary Care Physicians ......................... 21
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Figure 8: Primary Care Median Compensation vs. Specialty Median Compensation........................... 22
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Figure 9: Percentage Change in Year-1 Residency Positions Offered .................................................... 25
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Figure 10: Change in Median Physician Compensation ....................................................................... 26
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Figure 11: Estimated Cost of Increasing Reimbursement..................................................................... 27
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Figure 12: Essential Functions of Primary Care................................................................................... 28
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Figure 13: Primary Care Medical Home .............................................................................................. 29
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Figure 14: Medical Student Indebtedness............................................................................................. 37
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Figure 15: Title VII Funding (in 2008 Dollars)..................................................................................... 43
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TWENTIETH REPORT OF COGME v 

The Council on Graduate Medical Education
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The Council on Graduate Medical Education 

(COGME) was authorized by Congress in 1986 

to provide an ongoing assessment of physician 

workforce trends, training issues, and financing policies 

and to recommend appropriate Federal and private-sector 

efforts to address identified needs. The legislation calls 

for COGME to advise and make recommendations to 

the Secretary of the Department of Health and Human 

Services (DHHS); the Senate Committee on Health, 

Education, Labor, and Pensions; and the House of 

Representatives Committee on Commerce. Since 2002, 

COGME has been extended through annual appropriations. The legislation specifies 17 members for the 

Council. Appointed individuals are to include representatives of practicing primary care physicians, national and 

specialty physician organizations, international medical 

graduates, medical student and house staff associations, 

schools of medicine and osteopathy, public and private 

teaching hospitals, health insurers, business, and labor. 

Federal representation includes the Assistant Secretary 

for Health, DHHS; the Administrator of the Centers for 

Medicare and Medicaid Services, DHHS; and the Chief 

Medical Director of the Veterans Administration. 

CHARGE TO THE COUNCIL 

The charge to COGME is broader than the name 

implies. Title VII of the Public Health Service Act, 

as amended, requires COGME to provide advice and 

recommendations to the Secretary and Congress on the 

following issues: 

1. The supply and distribution of physicians in the 

United States; 

2. Current and future shortages or excesses of physicians in medical and surgical specialties and subspecialties; 

3. Issues relating to international medical school graduates; 

4. Appropriate Federal policies with respect to the matters specified in items 1–3, including policies concerning changes in the financing of undergraduate and 

graduate medical education (GME) programs and 

changes in the types of medical education training 

in GME programs. 

5. Appropriate efforts to be carried out by hospitals, 

schools of medicine, schools of osteopathy, and accrediting bodies with respect to the matters specified 

in items 1–3, including efforts for changes in undergraduate and GME programs; and 

6. Deficiencies in, and needs for improvements in, existing data bases concerning the supply and distribution 

of, and postgraduate training programs for, physicians in the United States and steps that should be 

taken to eliminate those deficiencies; 

7. Encouraging entities providing graduate medical 

education to conduct activities to voluntarily achieve 

the recommendations of the Council as warranted; 

and 

8. Development of performance measures, longitudinal 

evaluations and recommendation of appropriation 

levels for programs under COGME’s charge. 

In addition to providing advice and making recommendations to both the Secretary and Congress, the 

COGME shall also: 

•	� Encourage entities providing graduate medical education to conduct activities to voluntarily achieve the 

recommendations of the Council. 

COGME PUBLICATIONS 

Reports 

Since its establishment, COGME has submitted the 

following reports to the DHHS Secretary and Congress: 

•	� First Report of the Council (1988); 

•	� Second Report: The Financial Status of Teaching 

Hospitals and the Underrepresentation of Minori

ties in Medicine (1990); 

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•	� Third Report: Improving Access to Health Care 

Through Physician Workforce Reform: Directions 

for the 21st Century (1992); 

•	� Fourth Report: Recommendations to Improve Access to Health Care Through Physician Workforce 

Reform (1994); 

•	� Fifth Report: Women and Medicine (1995); 

•	� Sixth Report: Managed Health Care: Implications 

for the Physician Workforce and Medical Education 

(1995); 

•	� Seventh Report: Physician Workforce Funding 

Recommendations for Department of Health and 

Human Service’s Programs (1995); 
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TWENTIETH REPORT OF COGME 

• Eighth Report: Patient Care Physician Supply and 

Requirements: Testing COGME Recommendations 

(1996); 

OTHER COGME PUBLICATIONS 

• Ninth Report: Graduate Medical Education Consortia: Changing the Governance of Graduate 

Medical Education to Achieve Physician Workforce 

Objectives (1997); 

•	� Tenth Report: Physician Distribution and Health 

Care Challenges in Rural and Inner City Areas 

(1998); 

• Eleventh Report: International Medical Graduates, The Physician Workforce and GME Payment 

Reform (1998); 

•	� Twelfth Report: Minorities in Medicine (1998); 

•	� Thirteenth Report: Physician Education for a Changing Health Care Environment (1999); 

•	� Fourteenth Report: COGME Physician Workforce 

Policies: Recent Developments and Remaining Challenges in Meeting National Goals (1999); 

•	� Fifteenth Report: Financing Graduate Medical 

Education in a Changing Health Care Environment 

(2000); 

•	� Sixteenth Report: Physician Workforce Policy Guidelines for the United States, 2000–2020 (2005); 

•	� Seventeenth Report: Minorities in Medicine: An 

Ethnic and Cultural Challenge for Physician Training, an Update (2006); and 

•	� Eighteenth Report: New Paradigms for Physician 

Training for Improving Access to Health Care 

(2007). 

•	� Nineteenth Report: Enhancing Flexibility in Graduate Medical Education (2007) 

•	� Scholar in Residence Report: Reform in Medical 

Education and Medical Education in the Ambulatory Setting (1991); 

•	� Process by which International Medical Graduates 

are Licensed to Practice in the United States (September 1995); 

•	� Proceeding of the GME Financing Stakeholders 

Meeting (April 11, 2001) Bethesda, Maryland; 

•	� Public Response to COGME’s Fifteenth Report 

(September 2001); 

•	� Council on Graduate Medical Education and National Advisory Council on Nurse Education and 

Practice: Collaborative Education to Ensure Patient 

Safety (February 2001); 

•	� Council on Graduate Medical Education: What Is It? 

What Has It Done? Where Is It Going? 2nd edition 

(2001); 

•	� 2002 Summary Report (2002). 

For more information on COGME, visit the Council’s 

Web site at: http://www.cogme.gov or contact: 

Council on Graduate Medical Education
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5600 Fishers Lane, Room 9A-27
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Rockville, MD 20857
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Voice: (301) 443-6190
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Fax: (301) 443-8890 
TWENTIETH REPORT OF COGME vii

Council on Graduate Medical Education 

Chair 

Russell G. Robertson MD 

Professor and Chair, 

Department of Family and Community Medicine 

Feinberg School of Medicine 

Northwestern University 

Feinberg School of Medicine 

Chicago, Illinois 

Vice Chair 

Robert L. Phillips, Jr., MD, MSPH 

Director, 

The Robert Graham Center: Policy Studies in Family 

Medicine and Primary Care 

Washington, D.C. 

Denice Cora-Bramble, MD, MBA 

Senior Vice President, Children’s National Medical 

Center 

Goldberg Center for Community Pediatric Health 

Professor of Pediatrics, George Washington University 

Washington, D.C. 20010 

Joseph Hobbs, MD 

Professor and Chair, Department of Family Medicine 

and 

Senior Associate Dean for Primary Care and 

Community Affairs, School of Medicine 

Medical College of Georgia 

Augusta, Georgia 

Thomas E. Keane, MD 

Director, RWJ Foundation 

Chief, Interventional Radiology 

Genesis Health Care 

2602 Prendergast Place 

Reynoldsburg, Ohio 

Mark A. Kelley, MD 

Executive Vice President, Henry Ford Health System 

CEO, Henry Ford Medical Group

 Detroit, Michigan 

Jerry E. Kruse, MD, MSPH 

Professor and Chair 

Department of Family and Community Medicine 

Southern Illinois University 

School of Medicine 

Springfield, Illinois 

Spencer G. Nabors, MD, MPH, MA 

Postdoctoral Scholar 

Department of Critical Care Medicine 

University of Pittsburgh Medical Center 

Pittsburgh, Pennsylvania 

Kendall Reed, DO, FACOS, FACS 

Dean and Professor of Surgery 

Des Moines University 

College of Osteopathic Medicine 

Des Moines, Iowa 

1* Sheldon M. Retchin, MD, MSPH 

Vice President for Health Sciences 

Virginia Commonwealth University 

Chief Executive Officer 

VCU Health System 

Richmond, Virginia 

Vicki L. Seltzer, MD 

Chairman Emeritus 

Department of Obstetrics and Gynecology 

North Shore University Hospital and Long Island 

Jewish Medical Center 

Old Westbury, New York 

Jason C. Shu, MD, DOM 

OB/GYN Pennsylvania State University 

Montoursville, Pennsylvania 

William L. Thomas, MD, FACP 

Executive Vice President for Medical Affairs and Chief 

Medical Officer 

MedStar Health 

Columbia, Maryland 

Leana S. Wen, MD, MSc 

Harvard Affiliated Emergency Medicine Residency 

Brigham & Women’s Hospital/Massachusetts General 

Hospital 

Boston, Massachusetts 

Statutory Members 

Assistant Secretary for Health 

Department of Health and Human Services 

Washington D.C. 

1  * Dr. Retchin resigned from the COGME on September 30, 2010, to

assume his new role as Vice-Chair of the National Health Care Workforce Commission, created by the Affordable Care Act of 2010.
viii TWENTIETH REPORT OF COGME 

Administrator 

Centers for Medicare and Medicaid Services 

U.S. Department of Health and Human Services 

Undersecretary for Health 

Veterans Health Administration 

U.S. Department of Veterans Affairs 

Designee of the Assistant Secretary for Health 

Former 

Wendy E Braund, MD, MPH, MSEd 

Acting Chief, Public Health Branch 

Division of Public Health and Interdisciplinary 

Education 

Bureau of Health Professions 

Health Resources and Services Administration 

U.S. Department of Health & Human Services 

Current 

J. Nadine Gracia, MD, MSCE 

Chief Medical Officer 

Office of the Assistant Secretary for Health 

U.S. Department of Health and Human Services 

Washington, DC 

Designee of the Centers for Medicare and Medicaid 

Services 

Tzvi M. Hefter 

Director 

Division of Acute Care 

Centers for Medicare and Medicaid Services 

Baltimore, Maryland 

Designee of the Department of Veterans Affairs 

Former 

Carole Pillinger, MD 

VHA Clinical Director of Undergraduate and 

Graduate Medical Education 

Office of Academic Affiliations, Washington, DC 

Columbia, South Carolina 

Current 

Barbara K. Chang, MD, MA 

Director, Medical & Dental Education 

Office of Academic Affiliations 

VHA Central Office, Washington, DC 

Louisville, Kentucky 

COGME Staff 

Jerald M. Katzoff 

Executive Secretary and Designated Federal Official 

Daniel G. Mareck, MD 

Former Director, Division of Medicine and Dentistry 

Kathleen Klink, MD 

Current Director, Division of Medicine and Dentistry 

Shane Rogers 

Public Health Analyst 

Eva M. Stone 

Program Analyst and Committee Management 

Specialist 
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TWENTIETH REPORT OF COGME 

This report is the result of a collaborative effort by the 

members of the Council. The members of the Council’s 

writing committee played a key role in drafting the recommendations and associated supporting material. To 

develop the report, the writing committee created two 

writing groups. 

One writing group focused on the overall context 

for the report and the recommendations related to the 

ideal number of primary care physicians and primary 

care physician reimbursement. Members of this writing 

group included: 

• Dr. Jerry Kruse, Chair 

• Dr. Mark Kelley, Co-Chair 

• Dr. Tom Keane 

• Dr. Carol Pillinger 

• Dr. Russ Robertson 

• Dr. Vicki Seltzer 

• Dr. Bill Thomas 

• Ani Turner1 

• Dr. Leana Wen 

The other writing group focused on the recommendations related to primary care physician education 

(graduate and undergraduate) and primary care physician distribution. This group also focused on issues of 

1  Ms. Turner and Dr. Roehrig are not members of the Council, but

provided technical support to the writing groups as health workforce

researchers with Altarum Institute.

management of educational debt and the role of midlevel providers. Members of this writing group included: 

• Dr. Sheldon Retchin, Chair 

• Dr. Robert Phillips, Co-Chair 

• Dr. Denice Cora-Brambles 

• Dr. Wendy Braund 

• Dr. Joseph Hobbs 

• Dr. Spencer Nabors 

• Dr. Kendall Reed 

• Dr. Russ Robertson 

• Charles Roehrig PhD1 

• Dr. Jason Shu 

• Dr. Winston Liaw2 

The two groups developed working papers to address 

their respective areas of focus. The writing committee, 

led by Dr. Robertson, then worked to develop a consolidated set of draft recommendations based on the work 

of the two groups. After the draft recommendations 

were developed, the committee worked to develop the 

draft report that supported these draft recommendations. 

This work was conducted over a series of conference calls 

and involved many hours of work developing sections 

of the report. 

2  Dr. Liaw is not a member of the Council, but assisted Dr. Phillips

through his role at the Robert Graham Center.

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Preface
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This report has been written in and through a time 

of dramatic change in the health care environment in the United States. The beginnings can 

be traced to November of 2008 and coincident with 

the arrival of a new administration in Washington DC. 

Members were acutely cognizant of the role the Council could play in this process of health reform and so 

worked to emphasize past reports, particularly the 19th, 

Enhancing Flexibility in Graduate Medical Education, 

and expressed a desire to be consonant with the efforts 

that unfolded as the report was being written of which the 

capstone was clearly the new Affordable Care Act. Where 

appropriate, we have referenced the Affordable Care Act 

in our report as evidence of the Council’s direction as 

well as citations from this legislation consistent with our 

recommendations. We also referenced the recent June 

publication of the Medicare Payment Advisory Commission’s report to Congress entitled, “Aligning Incentives in 

Medicare” as evidence of the Council’s work and desire 

to collaborate with another governmental entity where 

there is alignment with specific aspects of the Council’s 

efforts. Last, we note the Secretary of Health and Human Service’s new program, the Affordable Care Act 

Primary Care Residency Expansion (PCRE) Program. 

This is a $168 million, five-year program, aimed at increasing the number of residents trained in a primary care 

specialty (family medicine, general internal and general 

pediatric medicine). The program’s purpose is to increase 

the number of primary care physicians by expanding 

enrollment in primary care residency programs. The 

new residency training positions must be over and above 

the number currently being trained, even if a program 

is already over its Centers for Medicare and Medicaid 

Services (CMS) authorized Graduate Medical Education (GME) cap. 

ABSTRACT 

As a result of a number of factors including compensation, practice environments, and experience in medical 

school, there is a shortage in the number of primary care 

physicians that is accelerating. At the present time, 32 percent of physicians in the U.S. are primary care providers, 

of which 12.7 percent are family physicians, 10.9 percent 

general internists, 6.8 percent general pediatricians, and 

1.6 percent in general practice. In addition, a percentage of obstetricians/gynecologists serve as primary care 

providers, particularly among their younger female adult 

patients. While there are real shortages in general surgery 

and key pediatric and internal medicine subspecialties, 

the shortage in primary care providers, particularly those 

capable of caring for adults with chronic disease, overshadows the deficits in all other specialties. This shortage 

is especially critical in the context of health care reform 

objectives that have the potential of adding 32 million 

newly insured individuals that will only further increase 

the need for primary care physicians. 

The current U.S. primary care physician workforce is 

in jeopardy of accelerated decline because of decreased 

production and accelerated attrition. A review of 

questionnaires administered to all 2008 allopathic and 

osteopathic medical school graduates revealed that only 

17 percent chose any of the primary care specialties as 

their first choice. This decreased medical student interest 

in primary care is caused by multiple factors including the 

high workload and insufficient reimbursement of this field 

of practice relative to the earnings of many specialists. 

These factors, in addition to the “hidden curriculum” in 

many medical schools that actively discourages student 

interest in the adult primary care specialties, the lack of 

strong primary care role models, and dynamic practice 

environments in other specialties often absent onerous 

administrative requirements, contribute to the reluctance 

to enter primary care disciplines. This workforce is also 

in jeopardy because of the substantial reduction in the 

production of primary care physicians from graduate 

medical education. Expansion of subspecialty training 

options, loss of primary care training positions (especially 

in family medicine), and alternate career options (such 

as general internal medicine graduates choosing to work 

as hospitalists) have effectively reduced primary care 

production by one-third over the last decade. Additive 

is the overall aging of the current primary care workforce 

and its anticipated retirement, particularly should the 

economy continue to improve. 

There is one essential caveat that should be addressed. 

While this report’s emphasis is on the overall need for 

primary care physicians, it must be clearly stated that this 

reflects the need to increase the numbers of physicians 

capable of caring for adults and their associated chronic 

disease burden. This does not appear to be the case for 

general pediatrics. In fact, student interest remains high 

and has led to a surplus, relative to other areas of primary 

care, in the supply of general pediatricians. During the 

last decade, there have been increases in the numbers of 

medical students who are choosing general pediatrics. 

With regard to the supply of general pediatricians and 

in the context of this report, the major challenge is their 

geographic maldistribution. For example, in Idaho there 

are 32 general pediatricians per 100,000 children, whereas 

in the District of Columbia the ratio is 186.6 per 100,000. 
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The Council on Graduate Medical Education met 

in April and November 2009 and April 2010 to review 

the current environment and develop recommendations. 

The Council identified four challenges and developed five 

recommendations as presented in this report. 

The challenges are: 

1)	� The practice environment 

2)	� The environment in medical schools 

3)	� The graduate medical education environment 

4)	� The geographic maldistribution of physicians in 

practice 

Recommendations to address these challenges are 

presented in five categories: 

1)	� The number of primary care physicians 

2)	� Mechanisms of physician payment and practice 

transformation for primary care 

3)	� The premedical and medical school environment 

4)	� The graduate medical education environment 

5)	� The geographic and socioeconomic maldistribution 

of physicians 

EXECUTIVE SUMMARY 

There is compelling evidence that health care outcomes and costs in the United States are strongly linked 

to the availability of primary care physicians. For each 

incremental primary care physician (PCP), there is 1.44 

fewer deaths per 10,000 persons. Patients with a regular 

primary care physician have lower overall health care costs 

than those without one. In the U.S., primary care physicians are in short supply, particularly in certain regions 

of the country, as discussed in Section 1 of this report. 

As a result of a number of factors including compensation, practice environments, and experience in medical 

school, there is a shortage in the number of primary care 

physicians, particularly those with the ability to care for 

adults and their associated chronic disease burden. This 

shortage is especially critical now in the context of health 

care reform objectives that will increase the need for primary care physicians. As a result of reform, as many as 

32 million previously uninsured Americans will be eligible 

for coverage. Such an influx of previously uninsured and 

likely underserved individuals will undoubtedly increase 

the demand for primary care services nationwide. 

At the present time, 32 percent of physicians in the 

U.S. are primary care providers, of which 12.7 percent 

are family physicians, 10.9 percent general internists, 

6.8 percent general pediatricians, and 1.6 percent are in 

general practice. In addition, there are a percentage of 

obstetricians/gynecologists that serve as primary care 

TWENTIETH REPORT OF COGME 

providers, particularly among younger female adults. 

The current U.S. primary care physician workforce is 

in jeopardy of accelerated decline because of decreased 

production and accelerated attrition, as described in 

Section 1. Decreased production from graduate medical 

education is a reflection of the choices made by young 

physicians and by teaching hospitals that are associated 

with a growing income disparity between primary care 

physicians and other specialties. Over the last several 

years, a variety of policies have been adopted to reduce 

disparity and the new Affordable Care Act takes steps 

to reduce this disparity. Decreased medical student 

interest in primary care is caused by multiple factors 

including heavy workload, insufficient reimbursement, 

the hidden curriculum in medical school, and a lack of 

strong primary care role models. Declining reimbursement relative to specialties, increasing workloads, and 

associated administrative requirements contribute to 

accelerated attrition. 

Attrition will also be augmented as the primary care 

physician workforce continues to age, currently averaging 47 years old. At the present, there are 242,500 primary care physicians in the U.S. and almost one quarter 

(55,000) are age 56 or older. The likelihood is that many 

of these physicians will retire within the next decade. 

The Challenges 

There is a shortage of primary care physicians in this 

country and that shortage is likely to worsen. The Council 

on Graduate Medical Education (COGME) reviewed 

four aspects of key challenges contributing to the shortage 

and approaches for addressing them. These include the 

practice environment, medical student experience, graduate medical education, and maldistribution of physicians. 

•	� Challenges in the Practice Environment: In the 

practice environment, there are not enough primary 

care providers to serve the growing and aging U.S. 

population. Moreover, on average, compensation 

of primary care providers is less than 55 percent 

of the average compensation of other medical 

specialties. For this reason and others, primary 

care physicians are dissatisfied with their careers as 

compared to other physicians. Many are struggling 

with relatively low reimbursement rates, high overhead costs, and increasing burdens of complex care. 

The responsibility for coordinating all the patient’s 

care also creates significant administrative burdens 

for primary care physicians; they face a number 

of certification and paperwork burdens associated 

with federal initiatives aimed at deterring fraud 

among durable medical equipment suppliers and 

home health agencies. When medical students are 

exposed to this practice environment through contact with primary care faculty members in medical 
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TWENTIETH REPORT OF COGME 

schools and community-based mentors, it has the 

effect of discouraging student interest in becoming 

a primary care physician, specifically among those 

caring for adults. 

•	� Challenges in the Medical School Environment: The 

percentage of U.S. medical graduates choosing family medicine decreased from 14 percent in 2000 to 8 

percent in 2005. These career choices are strongly 

shaped by the medical school experience. In U.S. osteopathic medical schools, graduating seniors’ intent 

to pursue primary care dropped from 34 percent in 

2001 to 29 percent in 2008. 

One reason for this decline in interest levels is exposure to what has been termed the “hidden curriculum.” 

During clinical training, medical students work shoulderto-shoulder with residents, interns, and their supervising 

faculty. This is their first glimpse of the “real world” 

of medical practice where they are exposed to a disproportionate number of specialists. This is because most 

medical schools have, in one form or another, a faculty 

practice plan anchored to a large hospital that attracts 

unusually complex patients not representative of the 

general population. 

•	� Challenges in Graduate Medical Education: Medical 

school deans and university presidents have traditionally been judged on their ability to build large 

medical research enterprises focused on discovery 

and innovation, truly laudable aspirations. Most 

academic medical centers focus on complex care to 

pursue these institutional goals, emphasize basic science and clinical investigation, and provide relatively 

greater rewards to those offering subspecialty care. 

In addition, many large hospitals have developed 

graduate medical education (GME) programs to 

support their complex care and are often more 

highly remunerative programs. The GME programs 

of these large teaching hospitals are effective in recruiting physicians to the medical staff and building 

subspecialty clinical care. This disconnect between 

meeting the needs of the population versus meeting 

the needs of the academic health center was the focus 

of an Institute of Medicine report in 1989 and has 

recently been an area of concern for the Medicare 

Payment Advisory Commission. 

•	� Challenges in the Maldistribution of Physicians: Primary care physician geographic and socioeconomic 

maldistribution in the U.S. is a chronic public policy 

challenge. Despite persistent efforts to address the 

problem through various initiatives, approximately 

50 million Americans live in health professional 

shortage areas (HPSAs). 

RECOMMENDATIONS 

The Council on Graduate Medical Education met in 

April and November of 2009 and April 2010 to examine 

these challenges and develop recommendations. The 

Council’s review of the challenges and their recommendations are presented in this report. The recommendations 

are presented here in five categories. Analyses of these 

recommendations are detailed in the discussion sections 

of this report. The five categories are: the number of 

primary care physicians, mechanisms of physician payment and practice transformation for primary care, the 

premedical and medical school environment, the graduate 

medical education environment, and the geographic and 

socioeconomic maldistribution of physicians. 

The recommendations are summarized below. The 

recommendations are designed to work in a complementary fashion, and in some cases, we suggest that 

implementation should be sequenced to maximize effectiveness. Mechanisms for payment to address compensation disparities should be implemented prior to 

improving capacity in the medical school and graduate 

medical environments. Recommendations for increasing 

the supply of primary care physicians should be implemented in parallel with recommendations for addressing 

maldistribution of physicians. 

Preamble: Policies and programs should be implemented to enhance and support the practice of primary 

care, and to increase the supply of primary care physicians. Payment for physician services is biased in favor 

of hospital-based and procedural services and does not 

provide appropriate incentives to enhance and support 

the practice of primary care, or to increase the supply of 

primary care physicians. Policy changes should be dramatic to remedy these legacy biases and have immediate 

effect. COGME recommends against policies that favor 

slow and incremental change. 

1. The Number of Primary Care Physicians 

Recommendation: Policies supporting physicians providing primary care should be implemented that raise the 

percentage of primary care physicians (general internists, 

general pediatricians, and family physicians) among all 

physicians to at least 40 percent from the current level of 

32 percent, a percentage that is actively declining at the 

present time. The achievement of this goal should be measured by assessing physician specialty once in practice, 

rather than at the start of postgraduate medical training. 

Congress and the Department of Health and Human 

Services should: 

1. Implement policies that raise the percentage of primary care physicians among all physicians to at least 

40 percent. 
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TWENTIETH REPORT OF COGME 

2. Implement policies that increase the supply of physician assistants, nurse practitioners, nurses, and other 

staff positions necessary for coordinated, integrated 

practice in primary care teams. 

3.	� Provide incentives and regulatory reform so that clinicians and staff have the opportunity to “work at the 

top of their degree” regardless of specialty or setting. 

4.	� Encourage and support the roles of other physicians 

who provide comprehensive, longitudinal primary care. 

Rationale: The current U.S. primary care physician 

workforce, critical to effective health care delivery, is in 

jeopardy of serious decline because of decreased production, accelerated attrition, and contraction of effort. 

There is a dramatic shortage of primary care physicians 

for adult care and a maldistribution among primary care 

physicians across the nation. Decreased medical student 

interest in primary care is caused by multiple factors including heavy workload and insufficient reimbursement. 

These same factors are leading to accelerated attrition 

from primary care practice. Additionally, the large cohort 

of physicians born between 1940 and 1960 is nearing 

retirement: in 2005 more than 250,000 active physicians 

were over 55 years old. 

2. Mechanisms of Physician Payment and 

Practice Transformation for Primary Care 

Recommendation: To achieve the desired ratio of 

practicing primary care physicians, the average incomes 

of these physicians must achieve at least 70 percent of 

median incomes of all other physicians, as discussed in 

Section 2 of this report. Investment in primary care office 

practice infrastructure will also be needed to cope with the 

increasing burdens of chronic care and to provide comprehensive, coordinated care. Payment policies should 

be modified to support both of these goals. 

Congress, CMS, and private insurers should: 

1. Address mechanisms to increase payments immediately to primary care physicians and practices. Such 

mechanisms should include: 

•	� Preferential increases in fee-for-service payments to 

primary care services. Institute further measures, 

such as the 2007 Centers for Medicare and Medicaid 

Services (CMS) implementation of the American 

Medical Association (AMA)/Specialty Society RVS 

Update Committee (RUC) recommendation to increase the work relative value unit (RVU) valuation. 

This will correct any inequities in the fee-for-service 

system and will provide higher payments for primary 

care services. The recently passed Affordable Care 

Act provides for a 10 percent bonus in Medicare 

payments for primary care practices that provide at 

least 60 percent of their services in primary care. 

•	� Financial rewards for care coordination in primary 

care practices. Dramatically expand payments for 

care coordination. Congress and CMS should 

expand Medicaid programs and institute Medicare 

programs with payments that appropriately reflect 

the true aggregate costs for care coordination to 

primary care practices that emphasize the four essential functions of primary care. Private insurers 

should institute similar care coordination payments 

to primary care physicians in primary care practices. 

•	� Financial rewards for improvements in performance 

measures. Authorize study of systems of pay-forperformance to ensure simplicity and to make certain that they are based on evidence that measures 

improvement of patients’ symptoms, problems, 

functioning, resiliency, and slow progression of ill 

health. 

2. Reward the Patient-Centered Medical Home (PCMH) 

financially when its physicians meet the four essential 

functions (first contact access, patient-focused care 

over time, comprehensive care, and coordinated care) 

and the three corollary functions (family orientation, 

community orientation, and cultural competency) 

and when measures of process and quality are met 

and improved. The PCMH should be supported 

as the construct for the practice environment that 

achieves optimal care coordination and integration, 

for use of health information technology, for enhanced access, and for appropriate payment. Study 

levels of funding necessary to sustain the PCMH 

model and its impact on costs in settings other than 

physicians’ offices. 

3. Implement payment models that bundle payments 

for full-service accountable care organizations and/ 

or incentivize the development of community health 

care organizations that provide the four essential 

functions of primary care through collaboration of 

primary care physicians, public health, care coordination organizations, and mental health organizations. 

Rationale: The current payment system contributes to 

several key challenges, including disincentives for students 

and providers considering primary care and a fragmented 

health care system wherein different providers provide 

care to a patient with little integration or coordination. 

Addressing these challenges would lead to improved 

outcomes and better containment of costs. 

3. The Premedical and Medical School 

Environment 

Recommendation: Medical schools and academic 

health centers should develop an accountable mission 

statement and measures of social responsibility to improve the health of all Americans. This includes strate-
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TWENTIETH REPORT OF COGME 

gically focusing and changing the processes of medical 

student and resident selection and altering the design of 

educational environments to foster a physician workforce 

of at least 40 percent primary care physicians and a health 

system that meets societal needs, as outlined in Section 3. 

Medical Schools and Academic Health Centers should: 

1. Allocate resources to: 

•	� Increase and/or sustain the involvement of primary 

care physicians through all levels of medical training; 

•	� Support student primary care interest groups; 

•	� Recruit, develop, and support community physician 

faculty members; and 

•	� Require student participation in rural, underserved, 

and/or global health experiences. 

2. Expand medical school class size strategically to 

address the primary care physician deficit and maldistribution issues. 

3. Reform admission processes to increase the number 

of qualified students more likely to choose a primary 

care specialty and to serve medically vulnerable populations. 

4. Recruit and retain underrepresented minority students and faculty members. 

5. Require block and longitudinal experiences of sufficient length that medical students clearly understand 

the essential functions of primary care and the medical home. 

6. Collaborate with local communities and distribute 

resident training accordingly, support reductions in 

physician income disparities, and lead in the development of new models of practice. 

Medical Schools, Academic Health Centers, the 

Association of American Medical Colleges, American 

Association of Colleges of Osteopathic Medicine, the Liaison Committee for Medical Education, the Commission 

on Osteopathic College Accreditation, the Accreditation 

Council for Graduate Medical Education, the American 

Osteopathic Association, Congress, regulatory agencies, 

and licensing agencies should: 

7. Reform the continuum of medical education, from 

premedical training through continuing education, 

to impart general competencies most efficiently and 

promote the choice of careers in primary care. 

Federal and state governments should: 

8. Provide increased incentives for physicians who 

practice primary care or other critical specialties in 

designated health workforce shortage areas. 

9. Substantially enhance funding for scholarships, 

loans, loan repayment, and tuition waiver programs 

to lower financial obligations for students who plan 

and pursue careers in primary care. 

Rationale: Students’ future career choices are strongly 

shaped during medical school. While many students 

express interest in primary care when they first enter 

medical school, this interest may erode by the time they 

choose their graduate medical education specialty in their 

fourth year of training. 

4. Graduate Medical Education 

Recommendation: Graduate Medical Education 

(GME) payment and accreditation policies and a significantly expanded Title VII program should support the 

goal of producing a physician workforce that is at least 40 

percent primary care, as discussed in Section 4. This goal 

should be measured by assessing physician specialty in 

practice rather than at the start of postgraduate medical 

training. Achieving this goal will require a significant increase in current primary care production from residency 

training and major changes in resident physician training 

for the practice environment of the future. 

Congress, the Administration, Department of Health and 

Human Services, and accrediting agencies should: 

1. Change regulations to support more training in outpatient settings and experimentation with practice 

models to prepare residents appropriately for an 

evolving contemporary health care environment. 

2. Strategically increase the number of new primary care 

GME positions and programs to accommodate the 

increased production of medical school graduates 

and respond to the need for a workforce composed 

of at least 40 percent primary care physicians. 

3. Increase training in ambulatory, community, and 

medically underserved sites by: 

•	� Promoting educational collaboration between 

academic programs and Federally Qualified Health 

Centers (FQHCs), rural health clinics (RHCs), and 

the National Health Service Corps (NHSC); 

•	� Implementing new methods of funding to include 

reallocation of existing GME funding, new GME 

funding that is not calculated according to Medicare 

beneficiary bed-days, and substantial expansion of 

Title VII funding specifically for community-based 

training. The Affordable Care Act authorizes 

increased funding for Community Health Centers 

beginning in FY 2011. 

4. Provide financial incentives for GME that: 

•	� Directly provide GME funding to primary care 

residency programs, educational consortia, or non-
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TWENTIETH REPORT OF COGME 

hospital community agencies to provide the proper 

incentives for ambulatory and community-based 

training; 

•	� Explore augmenting payments for primary care residents, including differentially higher salaries and early 

loan repayments, to decrease the negative impact of 

educational debt on primary care specialty choice; 

•	� Fund all primary care residency programs at least at 

the 95th percentile level of funding for all programs 

(using total direct medical education (DME) and 

indirect medical education (IME) payments as a 

basis); and 

•	� Reward teaching hospitals, training programs, and 

community agencies financially on the basis of the 

number of primary care physicians produced, to be 

determined by specialty in practice and not at the 

initiation of training. 

Rationale: Graduate medical education is central 

to development of the workforce. Federal policies are 

needed to redesign GME to meet existing challenges. 

There are opportunities to improve training paradigms 

to respond adequately to the primary care physician 

workforce deficit, which could be further exacerbated by 

elements of health care reform. 

5. The Geographic and Socioeconomic 

Maldistribution of Physicians 

Recommendation: So long as inequities exist, policies 

should support, expand, and allow creative innovation 

in programs that have proven effective in improving the 

geographic distribution of physicians serving medically 

vulnerable populations in all areas of the country, as 

discussed in Section 5. 

Congress and the Administration should: 

1. Ensure funding of the National Health Service 

Corps at the $1.15 billion amount authorized by the 

Affordable Care Act so that the NHSC can recruit 

more primary care physicians, provide greater support of scholarship recipients, create special learning 

opportunities and networks for scholarship recipients 

and early loan repayers, and forge formal affiliations 

with academic institutions and training programs. 

2. Increase the funding for Title VII, section 747, to 

$560 million in Primary Care Medicine and Dentistry 

cluster grants. 

3. Implement programs to increase funding by the 

Agency for Healthcare Research and Quality 

(AHRQ), National Institutes of Health (NIH), and 

private research enterprises for projects that stimulate 

primary care and community-based research and 

emphasize methodologies such as population-based 

ecological and cluster studies, qualitative behavioral 

studies, and comparative effectiveness research. 

4.	� Increase funding for Community Health Centers 

(CHCs) that are committed to training students and 

residents, and increase funding for Area Health Education Centers (AHEC) programs to improve existing 

programs, support new programs, and support innovative funding proposals that promote the practice of 

primary care in medically underserved areas. 

Rationale: Primary care physician maldistribution 

in the U.S. has been a long-standing and persistent challenge in spite of recurrent attempts to ameliorate it with 

targeted physician workforce and health care financing 

policies as well as undergraduate and graduate medical 

education programmatic interventions. 
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TWENTIETH REPORT OF COGME

 Introduction 

There is compelling evidence that health care 

outcomes and costs in the United States are 

strongly linked to the availability of primary care 

physicians [1,2,3,4]. For each incremental primary care 

physician (PCP), there are 1.44 fewer deaths per 10,000 

persons [2]. Patients with a regular primary care physician 

have lower overall health care costs than those without 

one [5,6]. In the United States, primary care physicians 

are in short supply, particularly in certain regions of the 

country [7]. 

The Institute of Medicine’s Definition of Primary Care 

“Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal 

health care needs, developing a sustained partnership 

with patients, and practicing in the context of family 

and community.” 

(Donaldson, Yordy, Lohr, & Vanselow, Committee on the Future 

of Primary Care, Institute of Medicine, p. 31, 1996)[8] 

The supply and distribution of primary care providers is established in the free market largely by hospitals 

that shape the portfolios of their training programs and 

insurers who determine payment for services. As in many 

other sectors where public need is important, the market 

does not always allocate resources in a way that optimizes 

public benefit and costs. As a result of a number of 

Figure 1: Age Distribution of Patient Care Primary Care Physicians 

factors including compensation, practice environments, 

and experience in medical school, there is a shortage in 

the number of primary care physicians. This shortage is 

especially critical now that health care reform legislation 

will provide coverage for as many as 32 million previously 

uninsured Americans. Such an influx of newly insured 

individuals will undoubtedly increase the demand for 

primary care services nationwide. 

Even before the enactment of this legislation, the U.S. 

primary care physician workforce has been in jeopardy. 

Medical student interest in primary care has declined 

because students see primary care physicians dissatisfied 

with their high workload and low income. These factors 

are also contributing to accelerated attrition of physicians from primary care practice [9]. This is important 

as almost one-quarter of primary care physicians (about 

55,000) are “near retirement”age (56 or older) as shown in 

Figure 1. Primary care production from graduate medical 

education also declined over the last decade to less than 

24 percent of all graduating physicians [10]. Declining 

reimbursement, increasing workloads, and associated 

administrative requirements contribute to accelerated 

attrition [9]. 

Physician workforce supply and its balance have been 

controversial over the last two decades. Physician shortages were predicted in the 1970s, while an oversupply 

was envisioned in the 1990s, especially for subspecialty 

physicians. These predictions were largely based on 
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the emergence of HMOs and the concept of managed 

competition. Both relied more heavily on the role of 

primary care and less on subspecialties. These factors 

led to increased medical student interest in primary care, 

which proved to be fleeting. 

As the new millennium began, tight controls on managed care had vanished because of public backlash and 

a more favorable economy. Health care reverted to a 

more traditional fee-for- service reimbursement system. 

Insurance, including Medicare, rewarded physicians 

handsomely for procedures and innovative technologies 

such as advanced imaging. However, reimbursement remained limited for those physicians in primary care and 

or other specialists who performed “cognitive” services 

such as disease management, coordination of care, or 

counseling. In many cases, a complicated office visit is 

paid at a rate that is a fraction of a less time-consuming 

procedure [12]. A procedure performed by a specialist 

may be reimbursed at significantly more than the amount 

paid to a primary care physician who has spent the same 

amount of time with a complicated patient [13]. Because 

of the rising burden of chronic disease, primary care 

physicians’ incomes have been disadvantaged because 

of the current approach to reimbursement. They often 

have the most challenging and complex patients and yet 

receive disproportionately low payments for providing 

services to these patients. 

These facts are not lost on physicians-in-training who 

now show decreased interest in primary care careers. If 

these trends continue, the supply of primary care physicians will erode within the next 10 years, particularly as 

many currently practicing primary care physicians reach 

retirement age. This shortage has profound implications 

for the U.S. economy and the health of its citizens. Addressing this shortage will be critical to implementing key 

provisions of health care reform. 

The solutions to this problem must address several 

causal factors. Poor reimbursement rates for primary 

care physicians are only part of the problem. Physiciansin-training need to see primary care as a rewarding and 

well-organized career choice that offers both a practice 

environment and lifestyle attractive enough to warrant 

30 years of challenging practice. 

There is one essential caveat that should be addressed. 

Because of the rising burden of chronic diseases, as well as 

other factors, primary care physicians’ incomes have not 

kept pace with the increasing costs of their practice and 

have been disadvantaged because of the current approach 

to reimbursement. This does not appear to be the case 

for general pediatrics. In fact, compared to other areas 

of primary care, medical student interest remains high 

in general pediatrics. 

During the last decade, there were increases in the 

numbers of medical students choosing general pediatrics 

TWENTIETH REPORT OF COGME 

[14]. With regard to the supply of general pediatricians 

and in the context of this report, the major challenge is 

the geographic maldistribution of general pediatricians. 

For example, in Idaho there are 32 general pediatricians 

per 100,000 children whereas in the District of Columbia 

the ratio is 186.6 per 100,000 [14]. 

The Historical Evolution of Primary Care 

Health care delivery has changed in the United States 

in the last 50 years. Historically, the vast majority of 

physicians provided both general medical and surgical 

care and were called general practitioners. As surgery 

became more complicated, many of these physicians 

retreated from surgery to focus more on chronic diseases 

such as heart failure, diabetes, and hypertension. In the 

1960s and 1970s, many of the generalists still maintained 

a very active inpatient practice in the hospital. In that 

era, most ill patients were hospitalized, often for diagnostic evaluations or to treat a chronic disease. Patients 

with advanced disease would remain in the hospital until 

they died or recovered. The general practitioner cared 

for both hospitalized patients and maintained an active 

office practice. 

In the 1980s, among the changes that greatly influenced medical practice was Medicare’s development of 

diagnostic related groups (DRGs) to reduce hospital costs. 

The DRG system defined the level of fixed payment for 

every hospital admission, independent of the number of 

days the patient spent in the hospital. Hospitals were 

now motivated to reduce lengths of stay and shift much 

of the care to the ambulatory setting. Thus, ambulatory 

care became one of the fastest growing costs in health 

care delivery [15,16]. 

This shift to ambulatory care profoundly changed 

medical practice. Physicians could no longer admit 

patients for diagnostic evaluation and keep them in the 

hospital for advanced therapies while collecting fees for 

the performance of said services. Instead, these patients 

were cared for in the ambulatory setting except when 

acutely ill. This placed tremendous pressure on physicians. When most sick patients were hospitalized, their 

care was provided under controlled circumstances. The 

physicians were supported by hospitals’ substantial infrastructure of nurses and consultants. With DRGs, the 

situation was transformed: many chronically ill patients 

remained in the ambulatory care setting and depended 

solely on the services of the primary care physician and 

a small office staff. 

When Medicare developed DRGs to reduce hospital 

costs, a significant amount of care that traditionally occurred in the hospital was displaced to the office practice 

of the primary care physician. This failed to increase 

payments to physicians to help them care for these more 

complex ambulatory patients. In effect, the cost of 
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TWENTIETH REPORT OF COGME 

chronic care was shifted from the hospital to the primary 

care physician – with no offsetting payment. This resulted 

in a disconnection between hospital and ambulatory 

care, making the delivery of care to these patients more 

challenging. While patients are admitted to the hospital briefly for acute problems, such as congestive heart 

failure, the fragmentation of care resulting from shorter 

hospitalizations often results in readmission and further 

exacerbation of their chronic disease. In addition, the 

management of contributing factors, such as dietary 

indiscretion and poor medication adherence, is left to the 

primary care physician, who may not be able to afford 

the infrastructure to manage these complex issues [17]. 

The primary care physician is also responsible for 

providing preventive services. These include screening 

for cancer, diabetes, cholesterol, and hypertension and 

the initial management of patients who are found to 

have these common conditions. None of these services 

is simple to organize and execute. The development and 

use of registries to track preventive services, education 

and compliance are substantial and time-consuming 

issues [18]. 

This heavy burden of preventive services and the management of chronic conditions are not well reimbursed 

relative to services provided in other medical specialties. 

Furthermore, under Medicare fee-for-service payment, 

the primary care physician can only collect for these 

services when the patient is seen face-to-face. This payment system discourages more efficient consultations that 

could be provided via telehealth methods, over the phone, 

and through e-mail. In order for the doctor to receive 

reimbursement, patients must report to the office for 

routine follow-up and therefore must comingle with other 

patients who have unstable (and perhaps contagious) 

medical conditions. This situation will only worsen as the 

American population ages, thus increasing the burden of 

chronic disease. This demographic shift, which has been 

inexorable in the past two decades, has placed steadily 

increasing pressure on adult primary care practice [19]. 

It is useful to compare the evolution of adult and 

pediatric primary care to see how the issues differ. In 

pediatrics, the patient population turns over constantly 

as children grow into adulthood. Subspecialty physicians 

usually treat patients with pediatric chronic diseases, although the use of specialists varies according to the age of 

the patient as well as medical and surgical conditions [20]. 

In contrast, the adult generalist is in exactly the opposite 

situation. That physician may attract young patients early 

in his or her practice, but these patients age over time and 

begin to develop the predictable problems with chronic 

disease. Therefore, the more successful the physician, 

the more unstable the patient population may become. 

For such complex patients, there has traditionally been 

no extra reimbursement other than the pay-as-you-go 

fee-for-service model. Care coordination often goes unattended because there is no incentive in the reimbursement 

system for this time commitment. Unless this problem 

is corrected, Medicare beneficiaries will have increasing 

difficulty finding primary physicians to serve their needs. 

The Growth of Subspecialty Physicians 

Subspecialty practices, particularly in the medical 

subspecialties, emerged in the 1970s. The first were in 

organ-specific areas such as cardiology, gastroenterology, 

and pulmonary diseases. Advanced technology such 

as cardiac catheterization, ultrasound, and fiber optic 

instrumentation transformed these cognitive specialties 

into specialties with complex procedures. Insurers viewed 

these procedures as very similar to surgical operations 

and reimbursed both the professional and technical fees 

accordingly. The result is that therapeutic and diagnostic 

procedures are well rewarded in most forms of insurance 

payment. 

This has fractured the specialty of internal medicine, 

which had previously been dominated by primary care physicians called general internists. Now the vast majority of 

physicians entering internal medicine training are attracted 

to medical subspecialties, many of which are procedural 

in their orientation, such as cardiology, gastroenterology, 

and pulmonary [21]. The salaries of such subspecialists 

are double or even triple that of even the most lucrative of 

general internal medicine practices [22]. The lifestyle of 

the medical subspecialist is also attractive, particularly for 

those who perform procedures. Most patients with chronic 

disease are returned to the primary care physician after 

procedures are performed and the acute crisis has been 

resolved. Subspecialists have greater economic incentives 

to perform procedures rather than to manage complex 

care, and there is evidence that many of these procedures 

are unnecessary [23]. There is also evidence that some 

primary care physicians are beginning to follow this same 

path by introducing more lucrative procedures into their 

office to increase reimbursements. This leaves less time for 

the cognitive primary care services. 

The Challenges 

The Council reviewed four areas of key challenges 

contributing to the primary care shortage and approaches 

for addressing them. These include the practice environment, medical student experience, graduate medical education, and maldistribution of physicians. These factors 

are closely linked and failure to address each will jeopardize access to primary care for decades to come. Unless 

the practice environment and income improve, it is highly 

unlikely that physicians will consider primary care as a 

viable career option. This perception will be reinforced 

in the medical school environment unless primary care 

assumes a more important role in both undergraduate 

and postgraduate medical education. 
12 TWENTIETH REPORT OF COGME 

Figure 2: Key Challenge Areas 

Challenges in the Practice Environment 

The mean compensation of primary care providers 

is less than 55 percent of the mean compensation of 

other medical specialties. For this reason and others, 

primary care physicians are dissatisfied with their careers 

compared to other physicians [24]. Many are struggling 

with relatively low reimbursement, high overhead costs, 

and increasing burdens of complex care. Sometimes, the 

dissatisfaction is apparent among primary care faculty 

members and community preceptors, which can send 

negative messages to students. A significant portion of 

a primary care physician’s time (approximately 20 hours 

/ week) is dedicated to preventive services. In most cases, 

these services are not well compensated [18]. In addition, physicians have time for only brief visits with their 

patients, many of which have chronic disease and are 

aged. However, the primary care physician often cannot 

afford the time or the office staff to meet these challenges. 

This leads to physician and patient dissatisfaction and 

to poorly coordinated care [25]. This may be the reason 

that many general internists leave active clinical practice 

within 10 years of earning their board certification [26]. 

The American Board of Internal Medicine and the 

American College of Physicians (ACP) recently found 

that 17 percent of general internists certified in the early 

to mid-1990s have since left internal medicine. This raises 

the possibility of significant mid-career attrition from 

primary care even before retirement age [27]. 

Many primary care physicians become professionally 

isolated. They have very little time to go to the hospital 

to interact with other colleagues. This constraint has led 

to eroding relations between hospitals and physicians 

[28,29]. When patients develop problems too complex for 

the office, they are sent to the hospital and, if admitted, 

often treated by a “hospitalist” physician assigned to the 

patient. Once that patient’s condition stabilizes, he or 

she is discharged, often while still in a fragile state. The 

primary care physician has little time and few resources to 

focus on this potentially unstable patient, who previously 

would have remained hospitalized for a longer period of 

time. This may be a key reason why hospital readmissions 

are so common for patients with chronic diseases [30]. 

Compensation and lifestyle issues affect not only 

satisfaction and retention of practicing physicians, but 

also affect student interest in primary care practice. The 

Association of American Medical Colleges (AAMC) 

found that a variety of factors contribute to making a 

specialty choice, with influences of mentors in the field, 

lifestyle and options for fellowship training ranking as 

having the strongest influences [31]. Salary and family 

expectations also played significant roles in the decision 

making process. The Macy Foundation supported study 

recently reported a mean lifetime income differential 

between specialty and primary care physicians of $3.5 

million. The foundation found that this differential had 

a significant negative impact on the choice of primary 

care careers by medical students [32]. 

Among primary care physicians, career dissatisfaction focuses on two issues—low income compared to 

other physicians and heavy workload driven by the administrative burdens of practice. For the practice to be 

professionally rewarding and attractive, both problems 

must be solved quickly. 
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TWENTIETH REPORT OF COGME 

Challenges in the Medical School Environment 

The percentage of those U.S. medical graduates 

choosing family medicine decreased from 14 percent in 

2000 to 8 percent in 2005 [33]. These career choices are 

strongly shaped by the medical school experience. While 

many students express interest in pursuing careers in 

primary care when they first enter medical school, this 

interest may erode by the time they choose their graduate medical education specialty in the fourth year [34]. 

In U.S. osteopathic medical schools, graduating seniors’ 

intent to pursue primary care dropped from 34 percent 

in 2001 to 29 percent in 2008 [35]. 

One reason for this decline in interest levels is exposure to what has been termed the “hidden curriculum” 

[36,37,38]. During clinical training, impressionable medical students work shoulder-to-shoulder with residents, 

interns, and their supervising faculty. This is their first 

glimpse of the “real world” of medical practice and they 

are fed a steady diet of subspecialization. This is because 

most medical schools have, in one form or another, a 

faculty practice plan anchored to a large hospital that 

attracts acutely ill patients. 

Furthermore, students receive relatively less exposure 

to ambulatory practice compared to their inpatient experience. Ambulatory practice is tightly managed and requires 

a high level of productivity. Placing students in this setting 

disrupts this productivity and requires financial support to 

offset this cost. The result is that most medical students 

have heavy exposure to serious acute subspecialty inpatient 

care and very little exposure to ambulatory care, where 

most of American medicine is practiced. The opportunity for exposure to role models in primary care practice 

is very limited. 

The exceptions to this rule are medical schools that 

emphasize primary care education. Most often, these are 

publicly funded schools whose mission is to train physicians for their community, region, or state. However, in 

the aggregate, a minority of medical students trained in 

this country has any significant exposure to primary care 

practice unlike medical students trained in osteopathic 

medical settings whose primary mission is geared towards 

the production of primary care physicians. The primary 

care physicians in the academic medical center are often 

not full time clinicians, and students usually are not given 

the opportunity to “live and breathe” a primary care practice on an around-the-clock basis. To address these challenges, strategies should be developed to expand student 

opportunities during the premedical and medical school 

phases of training. 

Challenges in Graduate Medical Education 

Medical school deans and university presidents have 

traditionally been judged on their ability to build large 

medical research enterprises focused on discovery and 

innovation. Most academic medical centers focus on 

technology-intensive care to pursue these institutional 

goals, emphasize basic science and clinical investigation, 

and provide relatively greater rewards to subspecialty care 

[39]. In most schools, the family medicine department, 

dedicated to primary care, is dwarfed in size and prestige 

by the department of internal medicine, which is often 

the largest research department in the entire university. 

In addition, many large hospitals have developed GME 

programs to support their complex care programs. The 

GME programs of these large teaching hospitals are effective for the recruitment of physicians to the medical staff 

and for building subspecialty clinical care. This disconnect between meeting the needs of the population versus 

meeting the needs of the academic health center was the 

focus of an Institute of Medicine report in 1989 and has 

recently been an area of concern for the Medicare Payment 

Advisory Commission. 

Although Medicare capped its funded GME slots in 

1997, accredited GME positions have grown 6.3 percent 

from 2003-2006, virtually all of which are self-funded by 

the hospitals. Despite this increase, a rise in subspecialty 

rates led to fewer physicians pursuing generalist careers 

[10,40]. Like student choices, this build-out of residency 

training positions is highly correlated with specialty income 

[41]. Teaching hospitals invest in lucrative services in order 

to support their bottom line and residents and fellows are 

an inexpensive way to support those services. Increasing 

options for subspecialization has both direct and indirect 

effects on primary care production, first by closing primary 

care positions to be used for subspecialty training, and 

second by giving would-be primary care physicians options 

to subspecialize. The net effect is a substantial reduction 

in primary care production from GME, now at about 29 

percent or less compared to 32 percent from 2003 to 2008 

[42]. In bending GME to service their financial bottom 

line, the needs of the population are not best served. 

All GME payments from the Centers for Medicare 

& Medicaid Services (CMS) are awarded to hospitals. 

Therefore, at many levels, GME payments have been used 

to foster the clinical enterprises of the teaching hospitals, 

which are largely devoted to technology-intensive subspecialty care. There is little incentive in GME payments for 

education in primary care or in community-based ambulatory settings that are often more expensive to operate. 

Strategies should be implemented to improve GME and 

to modify incentives so that they foster interest in primary 

care education and careers. 

Challenges in the Maldistribution of Physicians 

Primary care physician maldistribution in the U.S. 

is a chronic public policy challenge. Despite persistent 

efforts to address the problem through various initiatives, 
 

 

 

 

 

 

 

 

 

approximately 50 million Americans live in health professional shortage areas (HPSAs) [43]. While the overall 

numbers of physicians per capita has increased, there 

remain significant shortages in many rural and inner city 

areas where many minority and/or low-income individuals reside. While 20 percent of the U.S. population lives 

in a rural area, only 9 percent of the nation’s physicians 

serve that population [43]. Effective approaches for addressing the geographic and socioeconomic maldistribution of physicians should be developed and implemented. 

Recommendations 

The Council on Graduate Medical Education met in 

November 2009 and April 2010 to examine these challenges and develop recommendations. The Council’s 

review of the challenges and their recommendations 

are presented in this report. The recommendations are 

presented in five categories: the number of primary care 

physicians; mechanisms of physician payment and practice transformations for primary care; the premedical and 

medical school environment; the graduate medical education environment; and the geographic and socioeconomic 

maldistribution of physicians. 

The recommendations are designed work in a complementary fashion and in some cases implementation 

should be sequenced to maximize effectiveness. Mechanisms for payment to address compensation disparities 

should be implemented prior to improving capacity in 

the medical school and graduate medical environments. 

Recommendations for increasing supply of primary care 

physicians should be implemented in parallel with recommendations for addressing maldistribution of physicians 

so that mitigating shortages in some areas does not hinder 

improvements in other areas. 
TWENTIETH REPORT OF COGME 15 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 Discussion
�

Preamble: Policies and programs should be implemented to enhance and support the practice of primary 

care, and to increase the supply of primary care physicians. Payment for physician services is biased in favor 

of hospital-based and procedural services and does not 

provide appropriate incentives to enhance and support 

the practice of primary care, or to increase the supply of 

primary care physicians. Policy changes should be dramatic to remedy these legacy biases and have immediate 

effect. COGME recommends against policies that favor 

slow and incremental change. 

1. THE NUMBER OF PRIMARY CARE 

PHYSICIANS 

Recommendation: Policies supporting physicians providing primary care should be implemented that raise the 

percentage of primary care physicians (general internists, 

general pediatricians, and family physicians) among all 

physicians to at least 40 percent from the current level of 

32 percent, a percentage that is actively declining at the 

present time. The achievement of this goal should be measured by assessing physician specialty once in practice, 

rather than at the start of postgraduate medical training. 

Congress and the Department of Health and Human 

Services should: 

1.	�Implement policies that raise the percentage of 

primary care physicians among all physicians to at 

least 40 percent. 

2. Implement policies that increase the supply of physician assistants, nurse practitioners, nurses, and other 

staff positions necessary for coordinated, integrated 

practice in primary care teams. 

3.	�Provide incentives and regulatory reform so that clinicians and staff have the opportunity to “work at the 

top of their degree” regardless of specialty or setting. 

4.	�Encourage and support the roles of other physicians 

who provide comprehensive, longitudinal primary care. 

Rationale: The current U.S. primary care physician 

workforce, critical to effective health care delivery, is in 

jeopardy of serious decline because of decreased production, accelerated attrition, and contraction of effort. 

There is a dramatic shortage of primary care physicians 

for adult care and a maldistribution among primary care 

physicians across the nation. Decreased medical student 

interest in primary care is caused by multiple factors including heavy workload and insufficient reimbursement. 

These same factors are leading to accelerated attrition 

from primary care practice. 

Problem / Opportunity for Improvement 

Situation 

There is a dramatic shortage of primary care physicians for adults and a maldistribution of all primary care 

physicians. The large cohort of physicians born between 

1940 and 1960 is nearing retirement: in 2005, more than 

250,000 active physicians were over 55 years old [44]. 

There is significant evidence that optimal health care 

outcomes and optimal health system efficiency are demonstrated when at least 40-50 percent of the physician workforce is composed of primary care physicians (PCPs) [45]. 

For example, a recent Government Accountability Office 

(GAO) report concluded that over-reliance on specialty 

services results in a less efficient health care system [46]. 

The report also concluded that preventive care, 

care coordination for the chronically ill, and continuity of care can achieve cost savings and improve health 

outcomes [46]. Baicker and Chandra found that established surrogate markers for health care outcomes in 

the U.S. are improved at considerably lower expense 

in states that have a high supply of primary care 

physicians [1]. In addition, socioeconomic and racial 

disparities in health care outcomes are dramatically 

reduced when there is an appropriately sized primary 

care workforce [3]. 

However, the proportion of primary care physicians 

is currently 32 percent (as compared to the entire physician workforce) and is declining. In 1961, half of U.S. 

physicians were generalist physicians and most were 

general practitioners. Since then, the percentage of PCPs 

has declined [47,48]. In the late 1970s, 10 years after the 

birth of family medicine as a specialty, the percentage of 

primary care physicians in the U.S. stabilized at about 36 

percent of the total physician workforce. The percentage 

of U.S. physicians in primary care remained at 36 percent 

until 1985 but has since fallen to 32 percent in 2007, a 

relative decline of 11 percent [42]. Moreover, aggregate 

figures do not reflect the fact that there are substantially 

fewer primary care physicians per 100,000 people in rural 

areas as compared to urban areas [46]. 

Current medical student specialty preferences indicate 

that the percentage of physicians who practice primary 

care could potentially decline significantly over the next 

ten years unless there is immediate active intervention. 

As shown in the figure below, there has been a downward 

trend in preferences for primary care, correlated to the 

decline in the relative income of family medicine when 

compared with specialties. It should be noted that other 
16 TWENTIETH REPORT OF COGME 

Figure 3: Family Medicine vs. Specialty Income and Primary Care Preferences 

Source: Altarum Institute, 2010 [42] 

Note: FM Preferences is defined as the percentage of U.S. MDs expressing a preference for primary care as a specialty choice in the AAMC Graduation survey. 

factors including expectations of the practice environment and lifestyle also play a significant role in specialty 

choice. Hauer and colleagues found, for example, that 

students are discouraged by the challenges of caring for 

the types of patients seen in internal medicine [49]. In 

a survey of 1,177 fourth-year medical students at eleven 

medical schools, the authors found that students had 

serious reservations about the quality of life and rewards 

of internal medicine compared with other specialties. 

Students reported they were dissuaded from choosing 

to work in internal medicine by their experiences with 

elderly and chronically ill patients [49]. 

Objectives 

To address the problem described above, policymakers should work to implement policies that increase the 

supply of the primary care workforce to the optimal level. 

In addition, policies should be implemented that increase 

the supply of and better prepare the non-physician primary care workforce for primary care practice. 

Analysis 

1. Implement policies that raise the percentage of primary care physicians among all physicians to at least 

40 percent. 

For physicians who began residency training in 

2008, Altarum Institute estimates that 28.7 percent will 

ultimately wind up practicing in primary care due to 

constraints on sought after specialty residency training 

positions [42]. For future cohorts, Altarum projects that 

the percent of new physicians practicing in primary care 

will continue to trend downward toward 17 percent if 

non-primary care and subspecialty positions continue 

to grow at historical rates. Altarum Institute estimates 

reflect an internal medicine subspecialization rate of 

64 percent, consistent with resident tracking data from 

the American Board of Internal Medicine. These figures count all physicians practicing in general internal 

medicine as primary care, including those practicing as 

hospitalist physicians, and so may overstate the percent 

providing traditional primary care. 
TWENTIETH REPORT OF COGME 17 

Salsberg preliminarily reported that of all residents in training, the percentage that would potentially practice 

primary care decreased from 2002 to 2007 [10]. Other estimates indicate 91 percent of the physicians who complete 

family medicine residencies will likely practice comprehensive, longitudinal care; 44 percent of residents completing 

pediatric residencies will likely practice general pediatrics [50]; and 10-20 percent of residents who graduate from internal medicine residencies will likely practice general internal medicine with a substantial comprehensive longitudinal 

outpatient practice [21,51]. Using these estimates, as shown in the figure below, only 16-18 percent of medical students 

who matched into National Resident Matching Program (NRMP) residencies in 2010 are likely to practice primary care. 

These figures do not include physicians in residency programs outside of the NRMP, such as those from programs accredited by the American Osteopathic Association, which would likely slightly increase the proportion in primary care. 

Today osteopathic physicians, also known as DOs, constitute 7 percent of all U.S. physicians and are responsible 

for 16 percent of patient visits in communities with populations of fewer than 2,500 [52]. Recent surveys of graduating 

osteopathic medical school seniors indicated that 17 percent planned to pursue a career in family medicine; 3 percent 

in general internal medicine; 2.7 percent in general pediatrics; and 5.4 percent in obstetrics/gynecology (ob/gyn) and 

related subspecialties [52]. 

Figure 4: NRMP Match Summary 2010 

NATIONAL RESIDENT MATCHING PROGRAM MATCH SUMMARY 2010 

Primary Care Specialty 

Positions Filled In the 

Match 

Proportion of Residents 

Likely to Practice 

Primary Care 

Number of Residents Likely 

to Practice Primary Care 

Family Medicine 2,384 0.91 2,169 

Internal Medicine 4,947 0.10 - 0.20 495 – 989 

Pediatrics 2,383 0.44 1,049 

Medicine – Pediatrics 355 0.50 178 

Total Residents Likely to Practice Primary Care 3,891 - 4,385 

Total Positions Matched 24,378

 Percent in Primary Care 16% - 18% 

Source: National Resident Matching Program, 2010 [53]; Freed, et al., 2009 [50]; Alliance for Academic Internal Medicine, 2009 

[51]; Garibaldi, Popkave, & Bylsma, 2009 [21]. 

According to data from the American Academy of 

Family Physicians, the percentage of seniors graduating from U.S. medical schools and choosing residency 

spots in family medicine has declined from 62 percent 

in 1999 to 45 percent in 2010 [47]. Medical student interest in primary care and the number and proportion 

of primary care physicians must be increased radically 

if health care outcomes and equity are to improve and 

health care costs are to be controlled. 

Estimates of physician supply and primary care physician supply may vary by source. The American Medical 

Association’s publication “Physician Characteristics and 

Distribution, 2008 Edition” reports a total physician 

workforce of 884,000, of which 272,000 (31 percent) are 

primary care physicians [54]. This is consistent with estimates prepared for the Council by Altarum Institute [42]. 
18 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TWENTIETH REPORT OF COGME 

Figure 5: U.S. Medical School Graduating Seniors Opting for Family Medicine 

Source: American Academy of Family Physicians, 2009 [47]. 

The shortage in geriatricians has also been exacerbated as measured by decreasing numbers of physicians 

sitting for the geriatric board exams and applying for 

geriatric fellowships. Physicians caring for an aged 

population face the most acutely ill patients and depend 

primarily on Medicare reimbursement for services rendered. Outside of academic settings where there may be 

some degree of cross subsidization, it is simply unfeasible 

to make ends meet when only caring for the elderly. 

The shortage of primary care physicians would 

become even more significant if health care reforms 

extended coverage to some or all U.S. residents who are 

currently uninsured. In a scenario where 35 percent of 

those currently not covered gained insurance coverage, 

84,000 primary care physicians would be required [55]. 

Other estimates have also shown a significant shortage 

of primary care physicians at present and a significant 

shortage that will grow for decades unless drastic action 

is taken immediately. Colwill and colleagues predict a 

deficit of 44,000 adult primary care physicians by 2025 

[56]. Subsequent analysis by Colwill and the American 

Academy of Family Physicians notes that “a more-rapidthan-expected decline in the production of general internists suggest that shortages of adult care generalists will 

be even worse than predicted, and that family physicians 

will be relied upon to close the bulk of that gap” [47]. 

Analysis by FocalPoint, based in part on data from 

a recent AAMC study suggests there is a shortage of 

63,000-139,000 primary care physicians. An additional 

63,000 primary care physicians would be required in 

the U.S. physician workforce to raise the proportion of 

primary care physicians to 40 percent of all physicians, 

and 138,000 primary care physicians would need to be 

added to reach 45 percent. This estimate could be refined 

by considering that some primary care is delivered by 

health care professionals other than family physicians, 

general internists, and general pediatricians. Remarkably 

few people declare other specialties or providers as their 

usual source of care, in fact just three percent of adults 

and less than one percent of children [57]. Many women 

consult an ob/gyn for their gynecologic care and some 

consider that they are the source of their primary health 

care. Women who cited the ob/gyn as their usual source 

of care were mostly young women. As the shortage of 

primary care physicians increases, the expected demand 

for ob/gyns and expected shortfalls in this field also needs 

to be considered. Moreover, 11.9 percent of primary care 

visits in the U.S. in 2006 were attended solely by a nurse 

practitioner (NP) or physician assistant (PA) [58]. 
TWENTIETH REPORT OF COGME 19 

Figure 6: Magnitude of Primary Care Physician Shortage 

Source: AAMC 2009 State Physician Workforce Databook [7], FocalPoint 2010 [59]. 

History informs us that immediate action is needed. 

A 1989 Institute of Medicine (IOM) report, which addressed the need for radical change in graduate medical 

education financing to improve the nation’s primary 

care supply, recommended incremental changes rather 

than immediate action to achieve its recommendations 

[60]. Incremental change did not lead to the outcomes 

desired by the IOM, and the problems persist today at an 

even greater magnitude. A policy of incremental change 

will likely lead to failure again. Drastic and immediate 

systemic changes are needed to increase the number of 

primary care physicians per capita and the percentage 

of primary care physicians among all physicians into the 

range that will optimize health care outcomes, equity, 

and costs. 

Several steps are required to increase the number of 

practicing primary care physicians. The first step is to 

make primary care more attractive by improving compensation and providing support to restructure practices. 

The second step is to modify medical school education to 

promote student interest in primary care. The third step 

is to re-design graduate medical education by policies that 

reward institutions to increase their GME commitment 

to well organized primary care. 

2. Implement policies that increase the supply of physician assistants, nurse practitioners, nurses, and other 

staff positions necessary for coordinated, integrated 

practice in primary care teams. 

As the demand for primary care and coordinated, 

integrated systems of practice increase, so will the demand 

for non-physician clinicians (NPCs). Such clinicians will 

play a vital role in the provision and coordination of care 

in primary care delivered in the context of the PatientCentered Medical Home. 

There has been rapid growth in the number of physician assistants (PAs) but the profession is trending 

towards specialty care. Physician assistants and nurse 

practitioners (NPs) comprise the largest groups of NPCs 

who will participate in coordinated systems of primary 

care. In 2007, there were approximately 80,000 PAs 

eligible to practice in the U.S. [61]. There are currently 

approximately 125,000 NPs practicing in the U.S. [62]. 

Unfortunately, the percentage of new graduates of 

PA and NP programs who serve in primary care practices 

is dwindling. While the majority (68.8 percent) of PAs 

practiced in primary care settings in 1974 [63], only 37 

percent of PAs reported one of the primary care disciplines as their primary specialty in 2008 [61]. 

Several studies support the effectiveness of collaborative practice, in which physicians and other providers work to coordinate patient care together under the 

direction of the physician in a common setting. As our 

health system shifts toward preventive and chronic care, 

efficiency in provision of services will become increasingly 

critical. An analysis of actual and recommended time 

for patient care typically provided by family physicians 

concluded that a single physician supervising two fulltime PAs or NPs could provide all services recommended 

by the U.S. Preventive Services Task Force to a panel 

of 2,500 patients, which is a typical case load in family 

medicine [64]. Increasing physician productivity through 

collaborative practice with NPCs would help to mitigate 

the future projected shortage of primary care physicians. 

Patient satisfaction is high in a variety of systems providing collaborative care, including a large managed care 

organization [65], an academic medical practice [66], and 

the Veterans Health Administration [67]. Use of nonphysician providers in collaborative primary care practice 

has also demonstrated cost savings: an analysis of a large 

managed care organization revealed lower practitioner 

labor costs per visit in the practices utilizing more PAs/ 

NPs in care delivery [68]. 
20 TWENTIETH REPORT OF COGME 

3. Provide incentives and regulatory reform so that all 

clinicians and staff “work at the top of their degree” 

regardless of specialty or setting. 

Implementing reforms for establishing scope of practice for clinicians commensurate with their degrees has 

been a strategy for trying to manage health care costs. 

In the late 1990s, many states passed laws expanding the 

scopes of practice for non-physician clinicians [69]. Incentives such as reimbursement reform to expand the rates of 

reimbursement of non-clinician services can complement 

the regulatory reforms [70]. In addition to helping to 

manage the costs of care delivery, such reforms can help 

improve access for underserved populations [71]. Moreover, because some primary and preventive care is actually 

provided by specialists, many of these services could be 

managed in primary care settings, improving coordination 

of care and lessening demand on specialists, so that each 

profession optimizes its areas of expertise [72]. There 

same authors report that there is also strong evidence 

that specialists unnecessarily prolong their consultative 

relationships with patients as opposed to returning them 

to their primary care physician for continued care [72]. 

4. Encourage and support the roles of other physicians 

who provide comprehensive, longitudinal primary care. 

Another way to increase the effective number of 

primary care providers is for more non-primary care physicians to provide comprehensive, longitudinal primary 

care in addition to their specialty offerings. Physicians 

outside of family medicine, general pediatrics, and general internal medicine sometimes provide primary care 

services to their patients. For example, in a nationally 

representative study, which had an overall response rate 

of 63.4 percent, leaders of 373 single-specialty cardiology, 

endocrinology, and pulmonology practices were surveyed 

to assess the extent to which specialists also serve as 

primary care physicians for their patients. Eighty one 

percent of practices reported that their physicians serve 

as primary care physicians for 10 percent or less of their 

patients, 12.5 percent serve as primary care physicians 

for more than 20 percent of their patients, and only 2.7 

percent said they do so for more than 50 percent of their 

patients, as shown in the figure below [73]. Few patients 

name a non-primary care physician as their usual source 

of care, but it would be helpful to understand which 

specialties are more likely to fulfill this function in order 

to more accurately assess primary care access and supply 

and enhance the efficiency with which it is provided by 

specialists. People with non-primary care physicians serving in this role have significantly higher costs than those 

who have a primary care physician [57]. This is likely 

because such physicians do not function primarily as a 

usual source of comprehensive, longitudinal care. Thus, 

a key aspect of this provision is that the specialist must 

provide the full spectrum of primary care inclusive of 

the management of office-based chronic care, age related 

screening, and be reasonably accessible for the provision 

of acute care. Studies of the effectiveness of systems of 

care to improve outcomes and lower costs have used the 

Institute of Medicine definition of primary care, and 

include only family physicians, general internists, and 

pediatricians as primary care physicians in the analyses. 

It is unknown whether the population-based benefits of 

primary care extend to practices in which the delivery of 

primary care services is not the main focus. The effect 

of primary care delivered by non-primary care physicians 

may lessen the efficiency of the whole system. Further 

study of this issue is needed. 
Percentage of Patients for Whom Physicians in a Specialist Practice Report Serving as Primary Care Physicians.* 

Percentage of Patients 

for Whom Specialists 

Serve as Primary Care 

Physicians 

Percentage of Practices, by Specialty 

Cardiology 

(N=207) 

Endocrinology 

(N=58) 

Pulmonology 

(N=108) 

Total 

(N=373) 

0 48.1 40.4 42.0 45.7 

1-5 19.6 18.0 28.0 21.5 

6-10 18.1 7.7 7.1 14.0 

11-20 5.6 4.6 8.3 6.2 

21-35 2.2 6.8 7.5 4.1 

36-50 5.0 10.9 5.0 5.7 

51-66 0 0 1.5 0.4 

67-90 0.2 8.0 0.0 0.9 

91-100 1.3 3.6 0.7 1.4 

TWENTIETH REPORT OF COGME 21

Benefits of Adopting this Recommendation 

• A physician workforce made up of a high percentage 

of primary care providers will bring about improved 

health care outcomes, improved access, and lower 

costs for health care. 

2. MECHANISMS OF PHYSICIAN PAYMENT 

AND PRACTICE TRANSFORMATION FOR 

PRIMARY CARE 

Recommendation: To achieve the desired ratio of 

practicing primary care physicians, the average incomes 

of these physicians must achieve at least 70 percent of 

median incomes of all other physicians. Investment in 

primary care office practice infrastructure will also be 

needed to cope with the increasing burdens of chronic 

care and to provide comprehensive, coordinated care. 

Payment policies should be modified to support both of 

these goals. 

Congress, CMS, Medicaid, and private insurers should: 

system and will provide higher payments for primary 

care services. The recently passed the Affordable 

Care Act provides for a 10 percent bonus in Medicare 

payments for primary care practices that provide at 

least 60 percent of their services in primary care. 

• Financial rewards for care coordination in primary 

care practices. Dramatically expand payments for 

care coordination. Congress and CMS should 

expand Medicaid programs and institute Medicare 

programs with payments that appropriately reflect 

the true aggregate costs for care coordination to 

primary care practices that emphasize the four essential functions of primary care. Private insurers 

should institute similar care coordination payments 

to primary care physicians in primary care practices. 

• Financial rewards for improvements in performance 

measures. Authorize study of systems of pay-for-performance to ensure simplicity and to make certain that 

they are based on evidence that measures improvement of patients’ symptoms, problems, functioning, 

1. Address mechanisms to increase payments immedi- resiliency, and slow progression of ill health. 

ately to primary care physicians and practices. Such 

mechanisms should include: 2. Reward the Patient-Centered Medical Home (PCMH) 

financially when its physicians meet the four essential 

functions (first contact access, patient-focused care 

over time, comprehensive care, and coordinated care); 

the three corollary functions (family orientation, community orientation, and cultural competency); and 

when measures of process and quality are met and 

improved. The PCMH should be supported as the 

construct for the practice environment that achieves 

optimal care coordination and integration, for use of 

• Preferential increases in fee-for-service payments to 

primary care services. Institute further measures, 

such as the 2007 Centers for Medicare and Medicaid 

Services (CMS) implementation of the American 

Medical Association (AMA)/Specialty Society RVS 

Update Committee (RUC) recommendation to increase the work relative value unit (RVU) valuation. 

This will correct any inequities in the fee-for-service 

Figure 7: Percent of Patients for Whom Specialists Serve as Primary Care Physicians 

* N denotes the number of practices in each category. Percentages are weighted to be nationally reprentative 

Source: Casalino, Rittenhouse, Gillies & Shortell, 2010 [73]. 
22 

 

TWENTIETH REPORT OF COGME 

health information technology, for enhanced access, 

and for appropriate payment. Study levels of funding 

necessary to sustain the PCMH model and its impact 

on costs in settings other than physicians’ offices. 

3. Implement payment models that bundle payments 

for full-service accountable care organizations and/ 

or incentivize the development of community health 

care organizations that provide the four essential 

functions of primary care through collaboration of 

primary care physicians, public health, care coordination organizations, and mental health organizations. 

Rationale: The current payment system contributes to 

several key challenges, including disincentives for students 

and providers considering primary care and a fragmented 

health care system wherein different providers offer care 

to a patient with little integration or coordination. Addressing these challenges would lead to improved health 

care outcomes and better containment of costs. 

Problem / Opportunity for Improvement 

Situation 

The first challenge in improving mechanisms of 

physician payment is the disparity in income between 

physicians in primary care and those in medical specialties. Since the late 1990s, there has been a steady decline 

in PCP income relative to specialty income; by 2004, 

median PCP income was only 50 percent of median 

specialty physician income [42]. The figure below shows 

the gap in average compensation between primary care 

physicians and specialist physicians in 2008 [74]. This gap 

has grown significantly over the last two decades despite 

Congressional intent to reduce it through the Medicare 

Resource-Based Relative Value System [57]. 

Figure 8: Primary Care Median Compensation vs. Specialty 

Median Compensation 

Source: Medical Group Management Association, 2009 [74] 

In a comprehensive literature review and examination 

of factors related to the choice of family medicine, Senf 

and colleagues found that students rejecting primary 

care as a career choice were concerned with low income, 

prestige, and breadth of knowledge required [75]. In a 

study investigating the perceptions of physician remuneration and how these perceptions affect career selection, Morra and colleagues found that the vast majority 

of medical students who were surveyed agreed with the 

statement that family physicians are paid too little [76]. 

Furthermore, the importance of payment as a factor in 

their choice of medical specialty increased with higher 

debt and advancing training. Students see careers in 

primary care as a poor choice for paying back the debt 

they have incurred during medical training, while specialized careers are considered a more cost effective way to 

repay student debt. Morra and colleagues concluded that 

financial considerations might be an important driver 

in the declining interest in family medicine. In 2008, 

Ebell showed that there is an extremely high correlation 

between specialty income and student residency choice; 

this had not changed since his prior study in 1989 [77]. 

The Graham Center found growth in the specialty income 

gap to be the strongest factor in predicting student and 

resident eventual specialty in practice, and that choosing primary care over other specialties reduced career 

earning potential by $3.5 million [57]. Findings from the 

Altarum Institute also corroborate the need to increase 

primary care income in order to promote student interest 

in primary care practice [42]. 

In an article entitled “Easing the Shortage in Adult 

Primary Care-Is it all about Money?” Steinbrook contends that compared with office-based generalists, those 

who enter medical specialty fields can expect more control 

over their lives, a greater variety of professional experiences, sufficient funds to pay off student debts, and higher 

incomes over the long-term—a $3.5 million gap return 

on investment over the course of a career for primary 

care versus specialty physicians [78]. The author suggests 

that increasing numbers of medical schools, students, and 

residency positions will have limited effects if students 

shun primary care careers. The discrepancies in income 

that make it difficult to entice students to enter primary 

care can be mitigated to some extent by targeted federal 

programs that support loan repayments for those working 

for the underserved, and implement related strategies. 

Goroll and colleagues also attribute the crisis in the 

supply of primary care physicians in part to a dysfunctional payment system and present a model that replaces 

encounter-based reimbursement with payment for comprehensive care [79]. This model includes support for new 

systems and teams needed to deliver coordinated care. 

The model is also needs-risk-adjusted and performancebased. The model increases payment for PCPs in return 

for achieving societal health goals such as improved 
23 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TWENTIETH REPORT OF COGME 

access, quality, safety, and efficiency, which in turn can 

offset the costs of the investment. 

Outside of the U.S., examples demonstrate that reducing the disparity in income can increase the number 

of physicians choosing primary care. The most recent 

data regarding the effectiveness of practice reform and 

increased reimbursement to primary care physicians upon 

student preference comes from Ontario, Canada. In 

response to a drastic decline in student interest in family 

medicine (the only primary care specialty in Canada), 

the mechanism of payment for primary care services was 

reformed (with a resultant increase in family physician 

income of 50-60 percent and a relative family physician 

income to over 80 percent of specialty income) and practice structure organized into a better coordinated model 

(the Family Health Team). 

In Canada from 1998 to 2004, there was a 25 percent 

decline in the number of medical students who made family medicine their first choice of careers. At that time, a 

plan was implemented to reform the physician payment 

system to provide extra incentives for income to Canadian family physicians. By 2006, the median income of 

Canadian family physicians had risen to $212,000 per 

year or 87 percent of the median annual specialty income 

of $245,000 [80]. Since 2006, physicians’ incomes have 

continued to rise, and median family physician income 

in medical home practices in Ontario reached $250,000 

in 2009 [81]. Medical student choice for family medicine 

as a career in Canada has increased by 27 percent since 

2004, to levels higher than those of 1998 [81]. In 2009, 

39 percent of medical students in Ontario chose family 

medicine as a career (a relative increase of 62 percent) 

[81]. Nearly 4 million Canadians lack a family physician 

and half of that number report problems accessing health 

care. This has led policymakers to implement interdisciplinary teams, new organizational structures, governance 

and reimbursement models, after-hour care requirements, 

electronic health records, and pay-for-performance initiatives [82]. Use of new systems including a blended capitation model (the Family Health Network) and an enhanced 

fee-for-service blended model (the Family Health Group) 

were found to rapidly attract primary care physicians at 

a time when selection of primary care practice by medical residents was at an all-time low, reimbursements for 

primary care providers was a fraction of that paid to specialists, and there was a dramatic increase in the number 

of underserved communities [83]. 

In a recent and comprehensive report titled “The 

Future of Medical Education in Canada: A Collective 

Vision for MD Education,” the authors examined how 

medical education can best respond to the evolving needs 

of that country, and included ten recommendations: address individual and community needs; enhance admissions processes; build on the scientific basis of medicine; 

promote prevention and public health; address the hidden 

curriculum; diversify learning contexts; value generalism; 

advance inter- and intra-professional practice; adopt 

a competency-based and flexible approach; and foster 

medical leadership. To accomplish this, the report advocates realignment of accreditation standards, building 

capacity for change, increasing national collaboration, 

improving the use of technology, and enhancing faculty 

development. The active process that follows consists of 

data gathering, consultation, and formulation of recommendations and next steps. This review and revamping 

of graduate medical education was considered essential 

to assess current and future societal needs and identify 

changes needed to align them [84]. 

In the U.K., planning for a bonus payment system 

for general practitioners (now known there as family 

physicians) begun in 1999 and was fully implemented 

in 2004. Incomes for family physicians in the U.K. have 

risen swiftly to the point that the gap between the median 

incomes of primary care physicians and non-primary care 

physicians in the U.K. has vanished. This rise in income 

occurred when bonus payments added about 30 percent 

to British family physician incomes [85]. The anticipated 

rise in income in Great Britain for family physicians had 

a great impact on medical student choice. In 1996, 15 

percent of medical students in Great Britain chose careers 

in family medicine. By 2004, there had been a steady rise 

in preference for family medicine, resulting in a consistent 30-35 percent family medicine preference from 2004 

through 2006 among U.K. medical students [86]. 

Williams advocates a National Payment System in 

the U.K. where all payers would comply with standard 

payment methods and reporting standards [87]. While 

the amounts of the payments would vary, the methods 

for payer and provider types would remain consistent. 

Specific payment methods would be mandated to align 

incentives across providers. The author suggests that, 

“Pay for performance, best practice pricing, price discounting, alignment of incentives, the medical home, 

payment by episodes, and provider performance 

reports are a set of payment reforms that can result 

in lower costs, better coordination of care, improved 

quality of care, and increased patient/family involvement. While individual payers can implement some 

or all of these reforms, the overall effectiveness of the 

incentives to cost control is linked to the consistency 

of incentives across all payers” 

(Williams, 2010 p.59-60) [87]. 

The second challenge, introduced above, is the fragmentation of U.S. health care. This fragmentation can 

result in poor communication, increased medical errors, 

and reduced access to care. There is growing evidence 

that effective inter-professional practice models such as 
24 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

the PCMH model can lead to improved patient outcomes 

and cost containment through more effective utilization 

of resources [88,89,90]. Under the PCMH model, a 

patient receives care from a team that provides comprehensive and coordinated care for the large majority of 

that individual’s health care needs. 

Over many decades, the fee-for-service system in 

the U.S. has created market distortions that have led to 

an inequity in physician reimbursement and a perverse 

incentive to provide more medical care and more procedures/imaging, regardless of whether those are in the best 

interest of the patient or the population. To facilitate 

adoption of the PCMH model, payment system reform 

is needed. Such reform should maintain the disparate 

provider infrastructure but change the payment system 

to provide financial incentives for more coordinated and 

efficient delivery of care [91]. Efficiency in practice styles 

can be promoted through an efficiency adjustment to PCP 

fee levels and modifications in Medicare’s payment system 

that aligns incentives to desired objectives. McGuire 

suggests the pairing of risk and quality adjusted fee-forservice payments to primary care physicians to improve 

the efficiency of their care, with an active beneficiary 

choice of primary care physicians with an enrollment fee, 

would provide an incentive and the financing for service 

elements not covered by procedure-based fees [92]. 

Objectives 

COGME supports policies that will narrow the gap 

between primary care physician income and specialty 

care physician income. Primary care physician income 

TWENTIETH REPORT OF COGME 

should be increased to a minimum threshold of at least 

70 percent of the median income of non-primary care 

specialties. Increased payments to primary care physicians and to primary care practices must properly incent 

the type of care that improves the efficacy, efficiency, and 

equity of the system. Increased payments are needed immediately to lead to the development of practices that are 

attractive to health care professionals, medical students 

and patients. 

Analysis 

1. Address mechanisms to increase payments immediately to primary care physicians and practices. 

In the late 1990s, median PCP income rose to 60-65 

percent of median subspecialty income. More than onethird of medical students expressed interest in primary 

care careers at a time when median PCP income reached 

its highest levels as compared to median subspecialty 

income; this was also at a time of great anticipation 

among medical students that pervasive implementation 

of managed care would lead to an even greater increase 

in PCP income and the narrowing of the relative income 

gap compared to non-primary care physicians. However, 

since 1995, compensation of primary care physicians has 

grown much more slowly than that of most specialties. As 

shown in Figure 10, the only physician incomes that have 

not kept pace with the general rate of inflation are those 

of family medicine, general internal medicine, general ob/ 

gyn, and general pediatrics. There have also been declines 

in the number of U.S. medical school graduates who have 

chosen careers in these four respective specialties [83,93]. 
25 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TWENTIETH REPORT OF COGME 

Figure 9: Percentage Change in Year-1 Residency Positions Offered 

Source: Weida, Phillips, & Bazemore, 2010 [41] 

Note: Percentage change in number of year-1 residency programs (PY1) offered from 1998 to 2008 vs. 2007 income by specialty. Percentages in parentheses are percentage growth in specialty income adjusted for inflation between 1998 and 2007. 

Altarum Institute noted that in order for medical student interest in primary care to reach the current one-third 

proportion of practicing physicians, current preferences 

for primary care would need to double. To achieve that, 

Altarum Institute concluded that a significant increase 

in primary care income relative to non-primary care, 

combined appropriately with other primary care enhancements, would be required [42]. Altarum Institute 

also concluded that increasing the primary care supply 

above its historic one-third share would require dramatic 

and sustained health system reform. Such reform would 

include major reforms in health care delivery models and 

reimbursement to emphasize and reward the practice of 

primary care [42]. 

Sandy and colleagues have also recently put forward 

recommendations for physician payment reforms in the 

“New Charter for Primary Care” [12]. These recommendations support increases in primary care physician reimbursement and suggest underlying mechanisms by which 

such an increase can be achieved. They recommend: 

•	� Health care reimbursement must be rebalanced commensurate to the individual and population health 

valuecreatedbypatientengagement,carecoordination, 

and comprehensive personalized longitudinal care, as 

opposed to the current system, which rewards technical 

procedural volume. Congressional action was recommended to recalibrate the Resource-Based Relative 

Value Scale (RBRVS) fee structure for Medicare and 

Medicaid and for adoption by private insurers. 

•	� The Medicare Sustainable Growth Rate (SGR) formula should be split into two pools: one for primary 

care (non-consultative services and consultative 

cognitive services) and the other for procedural and 

imaging services. 

•	� Gain sharing approaches should be developed that 

reward both primary care and specialty physicians 

for quality improvement and reduced inappropriate 

variation. 

•	� The U.S. should develop a blended payment system 

that provides proper incentives to improve health 

care outcomes and to maximize efficiency. This 

system should place less emphasis on fees-for-service 

and more emphasis on care coordination and payfor-performance. 
26 

 

 

 

 

 

 

 

 

TWENTIETH REPORT OF COGME 

Figure 10: Change in Median Physician Compensation 

Source: Medical Group Management Association (MGMA) 2005 Data [93], National Residency Matching Program (NRMP, 2010) match data 

[53], Bodenheimer, Grumbach, & Berenson, 2009 [25], 

An objective of such reforms should be to increase 

reimbursement to primary care physicians to reduce 

disparity in compensation between primary care and 

non-primary care physicians, and to provide sufficient 

payment for other important aspects of primary care, 

such as care coordination. Altarum Institute reported 

that current best estimates of the impact of income 

on physician specialty choice imply that an increase in 

primary care incomes of about 80 percent would lead to 

a doubling of interest in primary care, to 40 percent of 

medical students [94]. This finding is corroborated by the 

findings from Canada discussed earlier, which showed a 

substantial increase in student interest in primary care 

when primary care incomes reached 83 percent of specialty incomes. Primary care incomes that are at least 

70 percent of specialty incomes are needed to stimulate 

a change in medical student interest toward primary care 

careers. Medical student choice of primary care careers 

nears optimal levels when primary care incomes are 80-

85 percent of non-primary care incomes. Increases in 

reimbursement policy should reflect payments needed to 

achieve these levels of primary care physician income and 

to provide appropriate practice transformation and care 

coordination. Estimates of incremental near-term cost 

are set out in the chart below. The percentage from Medicare/Medicaid is an estimate based on family physicians, 

pediatrics, and internal medicine. Such increases in the 

short-term could also be tempered by policies that shift 

reimbursement, until the cost-saving benefits are realized. 
27 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TWENTIETH REPORT OF COGME 

Figure 11: Estimated Cost of Increasing Reimbursement 

Source: AAMC, 2009[95]; Lasser, Woolhandler & Himmelstein, 2008[22]; FocalPoint, 2010a [55] 

Congress, CMS, Medicaid, and private insurers 

should institute further measures, such as the 2007 Centers for Medicare & Medicaid Services (CMS) relative 

value unit (RVU) revaluation that will correct the inequities in the fee-for-service system and will provide higher 

payments for primary care services. 

A significant change in the Medicare fee-for-service 

system was made on April 1, 2007, when greater value 

was assigned to evaluation and management services 

typically performed by primary care physicians relative to 

procedural and imaging procedures usually performed by 

non-primary care physicians. This change was intended 

to produce a 37 percent increase in Medicare reimbursement for primary care visits, but the net increase was 

only 5 percent [96]. Institution of more aggressive RVU 

revaluations would correct the inequities in the fee-forservice system. 

Congress, CMS, Medicaid, and private insurers 

should dramatically expand payments for care coordination. Congress and CMS should expand Medicaid 

programs and institute Medicare programs with appropriately high payments for care coordination to primary 

care practices that emphasize the four essential functions 

of primary care. Private insurers should institute similar 

care coordination payments to primary care physicians 

in primary care practices. 

Care coordination payments are payments made directly to a primary care practice for coordinating the care 

of individual patients. The payments are usually made 

on a per-member-per-month basis and are in addition to 

payments for fee-for-service and pay-for-performance. 

Payments may be stratified by demographic characteristics such as age and gender, and by level of intensity of 

care necessary based on the presence of chronic illness 

in individual patients. In many regions of the United 

States and in other nations, care coordination payments 

have been successful in improving outcomes; in lowering 

costs for the health care systems; in improving income for 

primary care physicians; and in providing greater integration of public health care coordination, mental health, 

and primary care activities. 

An example of this is the system that has developed 

in North Carolina: Community Care of North Carolina 

[97]. CCNC provides care coordination payments to 

primary care practices and to Public Health Departments 

for care coordination for Medicaid patients in the state 

of North Carolina. This integrated system achieved 

significant savings for the state Medicaid budget and 

dramatically decreased emergency room utilization and 

hospitalizations for asthma for patients who were part of 

the program. For CCNC, the PCMH was defined as a 

primary care practice that agreed to accept patients who 

chose that practice for their care. It illustrates the simplicity and power of a health care system that emphasizes 

primary care and public health simultaneously. Among 

the benefits provided by the program are a 34 percent 

reduction in hospitalization rates among asthmatic children and an 8 percent reduction in emergency department 

visits. The state saved an estimated $5.4 million over a 

3-year period on care for enrollees who were either asthmatic or diabetic [98]. 

Congress, CMS, and private insurers should authorize study of systems of pay-for-performance to ensure 

simplicity and to make certain that they are based on evidence that measures improvement of patients’ symptoms, 

problems, functioning, resiliency, and slow progression 

of ill-health. The development of pay-for-performance 

systems in the U.S. is still in its infancy. Medicare uses the 

Physician Quality Reporting Initiative (PQRI) system but 

this represents only a 1-2 percent bonus in Medicare payments to practices. Other pay-for-performance systems, 

such as the one developed by the National Committee 

on Quality Assurance to determine care coordination 

payments to Patient-Centered Medical Homes, are quite 

complicated and technical. 
28 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The U.K. has developed a pay-for-performance 

system that was intended to increase family physicians’ 

income by up to 25 percent depending upon their performance with respect to quality indicators relating to 

the clinical care of ten chronic diseases [99]. This payfor-performance system did indeed result in increases 

in family physician income in the U.K. of 25 percent or 

more. It has not been without problems and has been 

criticized because of exclusion of a large number of 

patients by exception reporting. In the long run, inappropriate indicators for pay-for-performance can lead 

to the removal of patients from a practice for unhealthy 

behavior or for failure to achieve targeted treatment goals. 

It can undermine cultural competence by de-emphasizing 

the biopsychosocial model and the health beliefs of individual patients. These systems have the potential to be 

complicated and burdensome for primary care practice 

and should measure performance that has a significant 

positive effect on health care outcomes and cost. 

Significant study should be given to systems of payfor-performance. The systems should emphasize process 

rather than outcome and should be simple. They should 

be based on evidence that encourages voluntary continuous quality improvement programs and participation in 

voluntary recognition reporting processes by primary 

care practices. Studies should measure improvement of 

patient’s symptoms, problems, functioning and resiliency, 

and the late progression of ill health. 

2. Reward the Patient-Centered Medical Home (PCMH) 

financially when its physicians meet the four essential 

functions (first contact access, patient-focused care 

over time, comprehensive care, and coordinated care) 

and the three corollary functions (family orientation, 

community orientation, and cultural competence) of 

primary care, and when measures of process and qualFigure 12: Essential Functions of Primary Care 

TWENTIETH REPORT OF COGME 

ity are met and improved. Support the PCMH as the 

construct for the practice environment that achieves 

optimal care coordination and integration, for use of 

health information technology, for enhanced access, 

and for appropriate payment. Study levels of funding 

necessary to sustain the PCMH model and their impact on costs in settings other than physicians’ offices. 

Medical care has evolved into three silos. The first 

is the primary care office, which is, at best, chaotic. The 

second is the hospital where inpatient care is provided by 

hospitalists because the primary care physicians have no 

time to supervise the care of their hospitalized patients and 

very few of their patients are there for any length of time. 

The third silo is subspecialty medicine, where care is often 

of a more episodic and technical nature rather than longterm comprehensive care management. These silos need 

to be dismantled and blended into organized systems that 

manage the patient across the continuum of care and align 

all providers with common incentives [100,101]. 

The PCMH can be an effective practice framework 

for achieving optimal care coordination and integration, 

use of health information technology, enhanced access, 

and appropriate payment [81]. Several definitions of the 

PCMH home have emerged. The American Academy of 

Pediatrics first advanced the concept of a primary care 

medical home model as a central location for archiving 

a child’s medical records and as an accessible, continuous, comprehensive, family-centered, coordinated, and 

compassionate approach offering culturally effective care 

[102]. The American Academy of Family Physicians 

(AAFP), the American Academy of Pediatrics (AAP), the 

American College of Physicians (ACP), and the American 

Osteopathic Association (AOA), endorsed the principles 

of a PCMH model in a joint statement issued in February 

2007 [103]. These principles are described in Figure 13. 
TWENTIETH REPORT OF COGME 29 

Figure 13: Primary Care Medical Home

In 2004 and 2005, the evidence-based characteristics 

of the PCMH were defined by the aggregation of data 

from large population-based studies [2,104]. These studies defined characteristics of primary care practice that 

improve outcomes and lower costs through the use of 

systems of comprehensive, longitudinal care provided 

by personal primary care physicians. 

Four essential functions of primary care can lead 

to improved health care outcomes. These four essential 

functions lead to corollary functions that are also associated with improved outcomes and efficiency. The 

PCMH combines the traditional elements of primary 

care practice with visionary elements for the use of health 

information technology, systems of enhanced access, and 

appropriate physician payment. Results of a PCMH 

demonstration project undertaken at Group Health from 

2006-2007 demonstrated that PCMH enrollees reported 

higher ratings than controls on 6 of 7 patient experience 

scales, 10 percent of PCMH staff reported burnout at 12 

months compared to 30 percent of controls, and PCMH 

enrollees used fewer emergency services and more e-mail, 

phone, and specialist visits. There were no significant cost 

differences at the conclusion of the study [105]. 

The construct of the PCMH will be most useful when 

it promotes the development of a pervasive network of 

practices that provide comprehensive, longitudinal care 

by a personal primary care physician. PCMHs will be 

most successful when they are defined simply and lead 

to practice settings where patients wish to attend and 

where physicians, health care professionals, and staff 

wish to practice. 
30 TWENTIETH REPORT OF COGME 

The payment mechanisms discussed above would 

facilitate the necessary increase in staff-to-physician 

ratio to optimize integration of care and to significantly 

increase primary care physician reimbursement. These 

elements will attract the physicians and other health care 

professionals necessary to develop a pervasive network 

of PCMHs. These practices should exhibit enhanced 

systems of access, which include non-traditional methods 

of communication with patients and the development of 

virtual consult systems. Insurance coverage should be 

developed so that no out-of-pocket expenses are required 

of the patient for services delivered by the primary care 

physician in the context of the PCMH. 

Medical students and resident physicians should have 

a significant increase in the amount of time for which they 

train in the context of the PCMH with a primary care 

physician. COGME suggests reallocation of resources 

in medical schools to both longitudinal and block experiences for medical students in primary care practices. The 

block experiences should be of sufficient length that the 

medical student clearly understands the essential functions of primary care and the PCMH. 

The practices should be developed to achieve a “joy of 

practice.” They should attract health care professionals, 

medical students, and patients. 

3. Implement payment models that bundle payments for 

full-service accountable care organizations, and/or 

incentivize the development of community health care 

organizations that provide the four essential functions 

of primary care through collaboration of primary care 

physicians, public health, care coordination organizations, and mental health organizations. 

The Accountable Care Organization (ACO) model 

features a group of aligned primary care physicians and 

subspecialists who take responsibility for outcomes and 

economics of a population of patients [106]. In some 

states, the Medicare Physician Group Practice Demonstration Program offers such an opportunity. Examples 

include the Henry Ford Medical Group and Geisinger 

Health System, which have shown cost savings as well as 

high quality outcomes [107]. 

There are several benefits of such integration and 

coordination of care. About 70-80 percent of primary 

care involves services such as the maintenance of stable 

patients, provision of preventive services, or management 

of records. There is also a significant amount of unpaid 

work performed by primary care physicians, such as 

review and interpretation of lab results, corresponding 

with patients, consultation with other medical professionals and other necessary activities [108]. Some of 

these services can be performed by health professionals 

other than physicians, thus increasing the opportunity for 

face-to-face patient-physician interaction, and allowing 

physicians to focus on more acutely ill patients. This is 

very similar to what happens in hospitals, where doctors, 

nurses, and other professionals work as a team. With 

an organized ambulatory system, the outpatient team 

monitors and manages routine care but brings unstable 

or acutely ill patients to the physician for earlier intervention. If the patient is hospitalized, the ambulatory 

system interacts intimately with the inpatient service so 

the continuity of care is uninterrupted. 

Models such as this work better when the payment 

system is aligned to the practice model. Under the current payment system, physicians are paid separately 

from hospitals and physicians are often not optimally 

organized among themselves. To make primary care 

attractive as a career requires more than just increasing 

primary care physician payments – that step alone will 

still leave the primary care physicians isolated from other 

providers and disconnected from the hospital and public 

health entities. Instead, payment systems should be developed to align incentives. Payments could be bundled to 

include services by primary care providers, subspecialty 

physicians, and hospitals. This scenario could provide 

payment for certain conditions or episodes of care, for 

certain disease populations, or under a full or limited risk 

capitation [109]. Another scenario would provide different payment mechanisms for primary care and specialty 

services. The primary care services would be aligned with 

community health services through blended payments and 

would include financial incentives to integrate primary 

care medicine, community mental health services, public 

health, and community care coordination for patients 

with the most complex health problems [110]. In this 

scenario, medical specialty services would be aligned 

with hospital systems through a different mechanism of 

bundled payments. 

These models are derivatives of the decade-old fullrisk capitation model. That model is not widely used 

today because most capitations were not adjusted for 

risk and were managed by private insurance companies. 

In contrast, most group practices have found the practice 

philosophy of Medicare Advantage to be a promising 

model. The risk associated with a panel of patients can 

be assessed in order to make the payment stream more 

predictable. This allows systems of care to configure 

services to allocate resources appropriately. Bundled 

payment facilitates the shift of resources to primary care 

physicians because they are expert at managing multiple 

chronic diseases. This places the primary care physician 

at center stage in managing the patient’s continuum of 

care. This leadership role, coupled with improved earning potential, would make primary care a much more 

attractive career to prospective physicians. 

Currently, there is little economic connection between 

physicians and the hospitals, primary care, and subspecialists. Likewise, there are few economic connections 

between primary care physicians and public health, 
31 

 

 

 

 

 

 

 

 

Medical schools and academic 

health centers should develop an accountable mission 

statement and measures of social responsibility to improve the health of all Americans. This includes strategically focusing and changing the processes of medical 

student and resident selection and altering the design of 

educational environments to foster a physician workforce 

of at least 40 percent primary care physicians and a health 

system that meets societal needs. 

 

 

 

 

 

 

 

 

 

 

 

 

TWENTIETH REPORT OF COGME 

mental health, and care coordination organizations in the 

community. The Council believes that optimal outcomes 

result when: 

•	� Physicians are economically linked and the incentives 

are aligned; 

•	� Health information technology (IT) is used to facilitate communication and effective partnerships 

exist with hospitals or public health or community 

organizations; 

•	� There is a focus on quality metrics and best practices; 

and 

•	� Compensation is based on quality and value, both 

for individual patients and for entire populations. 

Benefits of Adopting this Recommendation 

•	� Innovative models of care that address inequities in 

compensation between primary care providers and 

medical specialists will remove disincentives to enter 

primary care. 

•	� The four essential functions of the Patient-Centered 

Medical Home (first contact access, patient-focused 

care over time, comprehensive care, and coordinated 

care) combined with integrated systems of care and 

highly functioning information technology work in 

concert to improve outcomes and lower costs. 

•	� Reforming payment mechanisms to facilitate improved practice models will improve outcomes while 

simultaneously controlling costs. Thus, the crisis in 

the future supply of primary care providers is likely 

to be mitigated. 

3. THE PREMEDICAL AND MEDICAL SCHOOL 

ENVIRONMENT 

Recommendation: 

Medical Schools and Academic Health Centers should: 

1. Allocate resources to: 

•	� Increase and/or sustain the involvement of primary 

care physicians through all levels of medical training; 

•	� Support student primary care interest groups; 

•	� Recruit, develop, and support community physician 

faculty members; and 

•	� Require student participation in rural, underserved, 

and/or global health experiences. 

2. Expand medical school class size strategically to 

address the primary care physician deficit and maldistribution issues. 

3. Reform admission processes to increase the number 

of qualified students more likely to choose a primary 

care specialty and to serve medically vulnerable populations such as the elderly and those with physical and 

functional disabilities. 

4. Recruit and retain underrepresented minority students and faculty members. 

5. Require block and longitudinal experiences of sufficient length that medical students clearly understand 

the essential functions of primary care and the medical home. 

6. Collaborate with local communities and distribute 

resident training accordingly, support reductions in 

physician income disparities, and lead in the development of new models of practice. 

Medical Schools, Academic Health Centers, the Association of American Medical Colleges, American 

Association of Colleges of Osteopathic Medicine, the 

Accreditation Council for Graduate Medical Education, the American Osteopathic Association, Congress, 

regulatory agencies, and licensing agencies should: 

7. Reform the continuum of medical education, from 

premedical training through continuing education, 

to impart general competencies most efficiently and 

promote the choice of careers in primary care. 

Federal and State governments should: 

8. Provide increased incentives for physicians who 

practice primary care or other critical specialties in 

designated shortage areas. 

9. Substantially enhance funding for scholarships, 

loans, loan repayment, and tuition waiver programs 

to lower financial obligations for students who plan 

and pursue careers in primary care. 

Rationale: Students’ future career choices are strongly 

shaped during medical school. While many students 

express interest in primary care when they first enter 

medical school, this interest may erode by the time they 

choose their graduate medical education specialty in their 

fourth year of training. 

Problem / Opportunity for Improvement 

Situation 

As discussed in the introduction of this report, students’ future career choices are strongly shaped during 

medical school. While many students express interest in 
32 

primary care when they first enter medical school, this 

interest may erode by the time they choose their graduate medical education specialty in their fourth year of 

training. Influences on students’ choices include future 

earning power, lifestyle associated with the specialty, and 

training and role models [111]. In addition, in medical 

school, students receive significant exposure to subspecialization and inpatient experiences but less exposure to 

ambulatory practice. While there are some exceptions, a 

minority of medical students trained in this country has 

significant exposure to primary care practice. 

There had been little growth in the number of Liaison 

Committee of Medical Education (LCME) accredited 

medical schools or number of medical students in these 

schools in the 40 years before 2002. Since 2002, the 

LCME has accredited five new schools and there are five 

more applicant schools. In addition, 90 percent of the 

125 pre-existing LCME accredited schools of medicine 

plan to increase medical student enrollment [111]. In 

2002, there was a baseline of 16,488 annual admissions to 

LCME medical schools; by 2009, the number of medical 

students enrolled had increased by 11.6 percent to 18,393. 

By 2013, an overall increase of 21 percent is projected (for 

approximately 19,900 medical students enrolled annually). The net increase in annual enrollment of medical 

students at LCME schools from 2002 to 2013 is expected 

to be less than 3,500 [111]. 

The American Association of Colleges of Osteopathic Medicine (AACOM) also predicts an increase in 

the number of schools of osteopathic medicine and in 

osteopathic medical students. From 2002 to 2009 there 

was a 62.2 percent increase in annual enrollment, from 

3,079 to 4,994. The AACOM projects a further increase 

to 6,122 osteopathic medical students enrolled in 2013, for 

an overall increase of 3,043 or 99 percent [52]. Together, 

the increase in the number of medical students admitted 

to LCME schools and osteopathic schools each year will 

reach almost 6,000 compared to the 2002 baseline, for an 

increase of 30 percent [111]. 

These new medical school graduates will join a workforce with significant shortages in various disciplines. 

When supply and demand are considered in light of 

population-based health care outcomes and societal need, 

the shortages are most dire in family medicine, general 

internal medicine, general pediatrics, general surgery, 

and psychiatry [111]. As the population ages, according 

to data from the Geriatrics Workforce Policies Studies 

Center of the American Geriatrics Society, the current 

shortage of geriatricians is 8,600 and the projected future 

shortage is 23,447 by 2030 [112]. The additional medical students may provide some relief to the significant 

primary care physician shortage in the United States. 

Canadian medical schools have faced similar problems recently. In 1998, the Canadian Residency Matching 

TWENTIETH REPORT OF COGME 

Service (CaRMS) reported that 32 percent of Canadian 

medical students had chosen family medicine as their career choice. By 2004, this percentage fell to 24.5 percent. 

Public officials and primary care physicians considered 

this a national emergency and plans were implemented 

to reverse the trend. The plans were successful and the 

CaRMS reports that 32.5 percent of Canadian medical 

students chose family medicine residencies in 2009. Most 

primary care physicians in Canada are family physicians 

and there is a relatively low contribution of general internal medicine and general pediatrics to primary care. 

The Canadian plan focused on two major areas: the 

cultivation of student interest in family medicine in the 

first two years of medical school and increasing family 

physician income relative to specialty income. The plan 

to enhance student interest focused on reallocation of 

funds to increase the amount of teaching time for family 

physicians in Year 1 and Year 2 of medical school and 

through the implementation of a robust system of family medicine interest groups [113]. The family medicine 

groups in Canada also placed much greater emphasis on 

family medicine leadership training and leadership awards 

for medical students and residents. 

Objectives 

Although the current deficit in the production of 

primary care physicians is caused by many factors not 

directly related to the medical education process, medical 

schools must play a central role in improving preparation 

and production of students for entry into primary care 

specialties to meet the nation’s health care needs. Current and planned increments in medical school class size 

are not likely to increase the number of students entering primary care specialties as long as medical school 

admissions and undergraduate and graduate training 

paradigms remain unchanged. This is especially true 

given the overwhelming impact that external factors (e.g., 

reimbursement) have on ultimate specialty choice. 

Medical schools have an implied societal contract to 

produce physician resources in response to society’s health 

care needs. Balancing students’ eventual specialty choices 

with our nation’s health care needs is difficult when most 

influencing factors occur outside the academic arena. 

These external influencing factors should not dissuade 

medical schools from implementing a re-examination 

of their admission processes, especially in the setting of 

class size expansion, to explore mechanisms to admit a 

greater number of qualified students who would more 

likely choose a primary care specialty. Finding these 

students may require identification of regional or medical 

school-specific attributes that potentially predict primary 

care specialty choice, since current evidence suggests that 

many locally successful programs may not have universal 

applicability. Success in meeting these objectives should 
33 

 

 

TWENTIETH REPORT OF COGME 

not be based on the number of students entering primary 

care. Instead it should be based on placement of graduates five years after medical school to determine which 

are still in primary care, either in practice or in training. 

Medical schools and academic health centers should 

develop accountable mission statements and measures of 

social responsibility to improve the health of all. This 

includes strategically focusing and changing the processes 

of medical student and resident selection and altering the 

design of educational environments to foster a physician 

workforce of at least 40 percent primary care physicians 

and a health system that meets societal needs. 

In tandem with reconfiguration of the premedical 

pipeline and medical curriculum, efforts should be aimed 

at reforming medical education to increase its primary 

care orientation. As suggested by Ramsey and Miller, 

academic health centers should develop a single mission 

for academic medicine to support the goal of social responsibility to improve the health of all [114]. Medical 

schools and academic institutions should be encouraged to support implementation of health care reform 

to improve health care outcomes. They should adjust 

their missions to help produce graduates who will place 

appropriate focus on health care needs of their communities. For example, medical schools can assume leadership 

roles in advocacy for appropriate distribution of residency 

physicians and professional reimbursement. They can 

advocate for primary care, both within medicine (e.g., 

revision of LCME regulations to require a department 

of family medicine), and outside (e.g., advocate for medical home and other concepts essential in primary care). 

Medical schools should re-evaluate their educational 

processes and environments to ensure that they promote the choice of specialties needed to meet physician 

workforce needs and actively work to remove activities 

and experiences that disincentivize these choices. The 

implementation of early clinical experiences in holistic 

and continuous care, wellness, prevention, and chronic 

disease management provides students with insight into 

the care of the whole patient, family, and community – 

essential elements of primary care. 

Analysis 

1. Allocate resources to: 

•	� Increase and sustain the involvement of primary care 

physicians throughout training; 

•	� Support student primary care interest groups; 

•	� Recruit, develop, and support community physician 

faculty members; and 

•	� Require student participation in rural, underserved, 

and/or global health experiences. 

Improving exposure to primary care throughout 

medical school can help increase the number of students 

who choose primary care after graduation. When interested students are recruited to careers in medicine, the 

next step is for the medical school curricula to maintain 

and enhance their drive to service and desire to practice 

primary care. Redesign is needed in both the formal 

and informal curricula. Medical schools should review 

their educational processes and environments to ensure 

that they incent the choice of specialties needed to meet 

physician workforce needs and actively work to remove 

activities and experiences that create disincentives for 

these choices. 

Enhancing the formal curriculum includes the incorporation of more outpatient experiences and ensuring 

that a required part of clinical training takes place in 

community-oriented health clinics, such as Rural Health 

Clinics (RHCs) and Community Health Centers (CHCs). 

Lessons can be learned, from osteopathic schools and 

existing primary care tracks in allopathic schools, about 

the optimal distribution of outpatient and inpatient 

experiences. Training residents in underserved settings 

such as CHCs is a contemporary approach to promoting primary care practice in shortage areas. CHCs are 

federally funded primary care clinics that care for patients 

who are uninsured or underinsured. A study comparing 

residents trained in CHCs versus non-CHCs showed 

that CHC-trained family physicians were almost twice as 

likely as their non-CHC trained counterparts to work in 

underserved settings after concluding their training [115]. 

Such an expanded track dedicated to service formed 

the core concept of COGME’s Eighteenth Report’s proposal of the United States Public Health Medical Schools 

(USPHMC), a proposal for a new system of public health 

and community health-oriented medical education. The 

USPHMC would consist of a national system of schools 

that specifically addresses the shortage, maldistribution, 

and lack of diversity in the physician workforce by targeting the societal concerns of health disparities, public 

health issues, and emergency preparedness. Tuition for 

medical school would be waived in lieu of subsequent service [116]. The 100th anniversary of the Flexner Report is 

an ideal opportunity to add momentum to the USPHMC 

concept and to push for reexamination of issues such as 

the integration of public health, financing of education, 

and recruitment and retention in primary care. 

In addition to reform efforts for the formal curriculum, there is also a need for change in the informal 

curriculum. Primary care interest groups have existed for 

decades as an outlet and informal gathering setting for 

medical students; participation in these groups has been 

shown to increase interest in primary care careers. Curricular additions on topics such as health systems reform 

further enhance student interest in systems improvement 

and instill interest in primary care practice and leader-
34 

 

 

 

 

 

ship. Recent studies have demonstrated that global health 

experiences also stimulate interest in primary care. More 

investigations should be done into the effect of pilot projects in the informal curriculum and programs should be 

implemented based on this evidence. 

2. Expand medical school class size strategically to 

address the primary care physician deficit and maldistribution issues. 

While there are significant external influencing factors 

impacting student specialty choice, changes in admission 

processes can increase the numbers of and improve the 

placement of primary care providers. For example, in setting class-size expansion, mechanisms should be explored 

for admitting a greater number of qualified students 

who would more likely choose a primary care specialty. 

Finding these students may require identification of 

regional- or medical school-specific attributes that are 

more likely to yield students that will select primary care 

specialty choice. Successes at many local programs may 

be difficult to replicate more broadly. To support this, 

there also should be strategic investment in early pipeline 

student programs, such as summer educational enrichment experiences in undergraduate and high schools to 

increase non-traditional student interest in medicine with 

specific emphasis on primary care. 

In addition, it is important to support development 

of faculty who will teach primary care and serve as mentors. Mentoring is an approach that has long been used 

in many organizations to attract and retain employees. 

Faculty members who are satisfied in their careers make 

better role models for students considering careers in 

primary care. 

3.	� Reform admission processes to increase the number of 

qualified students more likely to choose a primary care 

specialty and to serve medically vulnerable populations. 

Research shows that certain factors are correlated 

with students’ inclination to choose primary care [117]. 

Among these factors are being a member of the minority 

population, having worked previously in an underserved 

setting, and growing up in a similar area (rural and urban 

underserved areas). More aggressive efforts should be 

taken to recruit such individuals. 

As discussed earlier, coming from a rural background 

is one of the factors correlated with the choice of entering family medicine [75]. “Pathways programs” have 

been provided in rural settings to facilitate admission to 

medical school for rural premedical students by carefully 

selecting student graduates who show significant interest in rural medicine and proficiency in undergraduate 

coursework. A 4-week summer program at a medical 

school in Louisville provides opportunities for students 

to shadow physicians practicing in rural settings, participate in tutorials in the sciences, learn concepts of 

TWENTIETH REPORT OF COGME 

community assessment, and apply for early assurance 

admission to medical school [118]. However, as the 

number of schools planning and implementing such 

programs increases, attention to attrition becomes more 

important. In a review of previously published studies 

these same authors conclude that attrition is a result of 

maturation that naturally occurs with resultant change 

of career plans; those seeking medicine for non-service 

(intellectual challenge) reasons drop out earlier, as other 

careers materialize; physicians offer input that patient 

gratitude is not forthcoming and paperwork is excessive; 

and pre-med advisors paint a picture of medical school 

and practice that is too demanding [118]. 

4. Recruit and retain underrepresented minority students 

and faculty members. 

The nation’s health professions have not kept pace 

with the changes in demographics. There is evidence 

that the disparity between the proportion of minorities 

in health professions and those in the general populations contributes to disparities in health care outcomes 

that persist for minorities. Organizations such as the 

Sullivan Commission have outlined proposals to recruit 

more minorities to a career in medicine [119]. 

While there were 4,167 Caucasian resident physicians 

in ACGME-accredited and GME programs on duty in 

the area of family medicine, there were only 598 AfricanAmerican, 60 American Indian/Alaska Native, and 819 

Hispanic-origin physicians in that field. These same 

numbers for internal medicine were 8,673 Caucasian, 

1,219 African-American, 47 American Indians/Alaska 

Natives, and 1,824 of Hispanic origin [120]. Thus, despite the fact that underrepresented minorities tend to 

select primary care disciplines, only 15 percent of family 

medicine residents and 14 percent of internal medicine 

residents are underrepresented minorities. 

In an effort to promote interest in and prepare disadvantaged students for medical careers, the Stanford 

Medical Youth Sciences Program provides academic 

enrichment in medical sciences to high school students 

from very low-income backgrounds and underrepresented 

minority groups [121]. The 5-week summer residential 

program offers classroom instruction, courses in anatomy, 

hospital field placements, research projects, and advising 

on college admissions. Direct exposure to science, mentoring, preparation for college admissions, and guidance 

in long-term careers has been effective in increasing the 

number of underrepresented students in the health care 

professions. Murray-Garcia and Garcia describe medical 

school pipeline strategies focusing on underrepresented 

minority students in kindergarten through 12th grade, 

which aim to make these students more qualified as 

medical applicants [122]. Programs employ interventions 

such as role modeling, motivation, academic enrichment, 

research apprenticeships, and academic partnerships be-
35 

 

 

 

 

 

 

TWENTIETH REPORT OF COGME 

tween public school districts and medical schools. The 

authors claim that issues of culture and identity must also 

be addressed for these programs to be effective. A preliminary evaluation suggested that the program increased 

matches in family medicine at a time when matching in 

that discipline was declining nationally. 

The Affordable Care Act reauthorizes funding, effective FY2011, for several programs under the Centers of 

Excellence and Health Care Professionals Training for 

Diversity sections, including revisions of the formulas 

used for funding allocations. 

5.	� Require block and longitudinal experiences of sufficient 

length that medical students clearly understand the essential functions of primary care and the medical home. 

As discussed in the preceding section, block experiences should be of sufficient length that the medical 

student gains experience to understand the essential 

functions of primary care and the medical home. GME 

funding should be reformed in such a way that both 

government and non-government payers are involved. 

Additionally, GME funding should be redirected to 

support community Teaching Health Centers training 

primary care physicians. 

6. Collaborate with local communities and distribute 

resident training accordingly, support reductions in 

physician income disparities, and lead in the development of new models of practice. 

Residents whose training includes exposure to community settings are more likely to practice in such settings. 

Collaborating with local communities can help reduce 

some of the barriers to effective community–based training. Such barriers can include higher costs, limited space, 

and limited availability of instructors. By collaborating 

with local communities to address these barriers, more 

residents will be exposed to community settings. Such 

residents are more likely to practice primary care. 

The Affordable Care Act authorizes increased funding for Community Health Centers effective beginning 

FY 2011 (The Affordable Care Act, Sect. 5313). This new 

authority awards grants through the Centers for Disease 

Control and Prevention (CDC) to support community 

health workers that promote positive health behaviors 

in medically underserved communities. 

7. Reform the continuum of medical education, from 

premedical training through continuing education, 

to impart general competencies most efficiently and 

promote the choice of careers in primary care. 

Increasing the effectiveness of medical school primary 

care experiences in academic health centers where there 

is a dominance of non-primary care specialties poses a 

unique but not insurmountable challenge. Primary care 

clerkships in family medicine, general internal medicine, 

and pediatrics should create additional contemporary ambulatory teaching venues through academic/community 

partnerships with private practices, CHCs, and residency 

programs in rural and urban settings to increase student 

exposure, understanding, and appreciation of community-based primary care. To accomplish the needed 

expansion in primary care experiences for most medical 

schools would require the recruitment, development, and 

support of community physician faculty networks capable 

of providing the curricular components of required 

clinical courses in a diversity of contemporary clinical 

settings and locales. The Affordable Care Act authorized 

funding for development of Teaching Health Centers and 

allocated funding to support training in existing centers. 

A program aimed at fostering student interest in 

family medicine targets entering first-year students and 

incorporates curricular, extracurricular, summer, and 

career planning components [123]. The Family Medicine Student Track (FaMeS) pipeline program at Boston 

University Medical School includes components such as 

placements with family physicians in the student’s first or 

second year, preference given to family medicine sites in 

clerkship match and summer externships, and workshops 

focusing on a variety of careers in family medicine. 

Potential innovations for the transformation of the 

medical education curriculum need to focus more on 

public health, systems reform, and primary care. An 

example is a concept that was recently developed by the 

Lake Erie College of Osteopathic Medicine (LECOM). 

LECOM is starting a 3-year medical school curriculum 

called the Primary Care Scholars Pathway (PCSP). PCSP 

selects students who commit to primary care careers and 

channels them through a tailored 3-year curriculum, 

rather than 4-year curriculum, with the expectation that 

the students will enter residency training in family medicine, general internal medicine, or general pediatrics. The 

curriculum emphasizes primary care clinical experiences 

beginning in the first year, integration with community 

service, and mentorship. In lieu of tuition, the students 

commit to at least 5 years of primary care practice following residency training [123]. 

The success of the 3-year primary care track in 

LECOM will provide instructive lessons as efforts are 

made to incentivize primary care career tracks. Not 

only will it provide more information on the benefits of 

specialized, primary care tracks in undergraduate medical 

education, but it will also inform the current discussions 

on ideal length of training. Workforce researchers have 

argued for years that one way to quickly increase the 

supply of physicians is to reduce the number of years of 

training. Already medical schools such as Duke University require 3 years of formal education; even more 

“traditional” allopathic schools have relatively flexible 

fourth years. The fourth year of medical school is designed to be a time for medical students to explore other 
36 

 

 

 

interests and take elective courses. It could be argued, 

though, that for students planning to enter a career in 

primary care, the fourth year of academic instruction 

could be waived. The shortening of medical education 

can help relieve workforce constraints and serve as an 

incentive for students to enter primary career in cases 

where medical education debt is a serious detractor from 

entering the profession. 

Schwartz and colleagues advocate directing training 

grant funds to schools with track records of producing 

primary care medicine graduates, development or expansion of primary care fast track programs where students 

are ensured preferential admission to generalist residency 

programs in underserved areas, increased investment in 

primary care research, and increased funding for faculty 

development and fellowship training in primary care 

[124]. Further, medical schools should consider the 

reallocation of intrinsic resources to support course development and implementation that responds to defined 

physician workforce needs. 

In summary, the medical schools’ emphasis on the 

whole patient, continuous and comprehensive care, and 

chronic disease management should be one of the themes 

embedded in and ongoing throughout the curriculum to 

provide students with insights into the care of the whole 

patient, family, and community – essential elements of 

primary care. These educational experiences should occur early and be reinforced and built upon through the 

optimal mix of inpatient and outpatient experiences. 

Students should have ample opportunities to be exposed 

to population- and practice-based research that emphasizes the translation of new knowledge into community 

practice. In addition, medical schools should explore 

increased rural health and global medicine education 

activities since there is evidence suggesting that students 

selecting these course activities are more likely to enter 

primary care specialties. 

8. Provide increased incentives for physicians who 

practice primary care or other critical specialties in 

designated shortage areas. 

As noted in the introduction, there is a severe and 

worsening shortage of primary care providers, in the 

U.S., particularly in rural and other underserved areas 

[7]. The existing shortage of primary care physicians 

and other health care professionals has been exacerbated 

by a decline in student interest in entering primary care 

disciplines in recent years. As indicated previously, there 

are numerous reasons for this including relatively low 

compensation compared to subspecialists, heavy workload, and lifestyle issues such as professional isolation. 

With the aging population, health care reform, and the 

implementation of new models of health care delivery, the 

need for primary care physicians has sharply increased. 

Consequently, more powerful incentives are needed to 

TWENTIETH REPORT OF COGME 

encourage medical students to enter primary care and 

to practice in designated shortage areas. These include 

strategies such as implementing admission processes that 

favor applicants with an expressed interest in primary 

care, ongoing and expanded support for NHSC programs 

that offer substantial scholarships and loan repayments 

or forgiveness to those who work in underserved locales, 

payment mechanisms that result in more equitable compensation, efforts to address lifestyle issues such as professional isolation through new technologies, and emphasis 

on rural training tracks and rotations that better prepare 

trainees for rural and underserved practice. 

The Affordable Care Act authorizes increased funding for the NHSC scholarship and loan repayment 

program, allows part-time service and teaching time to 

qualify toward the NHSC service requirement, and increases the annual NHSC loan repayment amount from 

$35,000 to $50,000 effective beginning in FY 2011. It also 

reauthorizes and increases funding for multiple Title VII 

health professions and diversity programs, and public 

health and physician training under Title VII effective 

beginning FY 2011. 

Several states are also focusing on medical workforce 

needs. New Jersey, for example, has established a new 

Center for Medical and Health Workforce Planning to 

guide the allocation of its resources based on needs. Idaho 

has established collaborative relationships with medical 

schools and GME programs in Washington and Utah 

to support its future physician workforce needs. Similar 

initiatives exist in other states. 

9. Substantially enhance funding for scholarships, loans, 

loan repayment, and tuition waiver programs to lower 

financial obligations for students who plan and choose 

careers in primary care. 

As discussed earlier, increasing educational debt has a 

negative impact on primary care specialty choice. Medical 

students fund a large proportion of the cost of their medical education through educational loans. The median 

indebtedness of medical school students graduating in 

2006 was expected to be $120,000 for students in public 

medical schools and $160,000 for students attending 

private medical schools. Approximately 29 percent of all 

medical students will graduate with debts of $200,000 or 

more [95]. Osteopathic physicians graduated with similar 

mean debts of $134,000 for public schools and $154,000 

for private schools in 2006 [125]. Given the disparities in 

physician income and high debt burdens at graduation, 

jobs in specialty fields are more attractive to new physicians. Financial incentives such as loan repayment can 

help to decrease the impact of debt. 

The Affordable Care Act includes loan repayment tax 

exclusions. Certain state-funded student loan repayment 

programs that are intended to increase the availability 

of health care services in shortage or underserved areas, 
37 

 

 

 

 

 

 

 

TWENTIETH REPORT OF COGME 

Figure 14: Medical Student Indebtedness 

Source: Association of American Medical Colleges, 2004 [126] 

along with the payments from NHSC loan repayment 

programs, are excluded from federal income taxation. In 

addition, the Health Care and Education Reconciliation 

Act amends the Income-Based Repayment Program to 

cap student loan payments for new borrowers after July 

1, 2014 to 10 percent of adjusted income (rather than 15 

percent) and would allow remaining debt to be forgiven 

after 20 years of payments (rather than 25 years). 

More resourceful loan repayment programs should 

be created at both state and federal levels to decrease the 

potential financial disincentives facing medical students 

who choose primary care specialties. Students’ escalating educational debt, when combined with the prospect 

of a specialty choice with lower potential income, makes 

primary care specialty choices less attractive. Because it 

is difficult to predict the evolving interests of students 

in medical schools, loan repayment programs should be 

targeted to post-medical school periods such as the primary care residency and the immediate practice period 

post-residency to incentivize primary care residency 

choice. The United States Public Health Service Core 

Expansion could help to address the primary care physician needs of vulnerable patient populations, especially 

since these programs are experiencing over-subscription. 

Debt relief provided by service obligations also increases 

the likelihood that students will eventually choose a primary care specialty. Other debt relief measures such as 

community-based sponsorships, tax credits, reductions in 

the amount of time in training, and higher primary care 

GME salary base warrant exploration. Expansion of 

educational debt relief programs could play an important 

role in securing an appropriate primary care physician 

workforce even if these efforts only sustain interest and/ 

or target special populations where physician recruitment 

faces substantial challenges. 

Benefits of Adopting this Recommendation 

•	� The premedical and medical school environment 

has a strong influence on the specialties that medical students eventually enter and thus has a mission 

to provide the types of opportunities that generate 

commitment to primary care and preparation for 

this type of practice. 

•	� Primary care can be revitalized and interest in this discipline rekindled by enhancing the medical education 

pipeline, redesigning the medical school curriculum, 

and reforming the medical education environment. 

•	� Policies aimed at debt management will stem the 

decline in entry into primary care practices resulting from the lower reimbursement for primary care 

compared to other specialties. 

•	� Incentives for entering primary care practices in underserved areas will address critical health workforce 

needs across the nation. 
38 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TWENTIETH REPORT OF COGME 

4. GRADUATE MEDICAL EDUCATION 

Recommendation: GME payment and accreditation 

policies and a significantly expanded Title VII program 

should support the goal of producing a physician workforce that is at least 40 percent primary care. This goal 

should be measured by assessing physician specialty 

once in practice rather than at the start of postgraduate 

medical training. Achieving this goal will require a significant increase in current primary care production from 

residency training and major changes in resident physician training for the practice environment of the future. 

Congress, the Administration, Department of Health and 

Human Services, accrediting agencies, and private insurers should: 

1. Change regulations to support more training in 

outpatient settings and innovation in practice models 

to prepare residents appropriately for an evolving 

contemporary health care environment. The Affordable Care Act authorizes more flexibility for GME 

programs to count training in outpatient settings 

and didactic and scholarly activities towards GME 

payments. 

2. Strategically increase the number of new primary 

care GME positions and programs to accommodate 

the increased production of medical school graduates and respond to the need for a workforce composed of at least 40 percent primary care physicians. 

3. Increase training in ambulatory, community, and 

medically underserved sites by: 

•	� Promoting educational collaboration between 

academic programs and Federally Qualified Health 

Centers (FQHCs), rural health clinics (RHCs), and 

the National Health Service Corps (NHSC); 

•	� Implementing new methods of funding to include 

reallocation of existing GME funding, new GME 

funding that is not calculated according to Medicare 

beneficiary bed-days, and substantial expansion of 

Title VII funding specifically for community-based 

training. The Affordable Care Act authorizes 

increased funding for Community Health Centers 

beginning in FY 2011. 

4. Provide financial incentives for GME that: 

•	� Directly provide GME funding to primary care 

residency programs, educational consortia, or nonhospital community agencies to provide the proper 

incentives for ambulatory and community-based 

training; 

•	� Explore augmenting payments for primary care residents, including differentially higher salaries and early 

loan repayments, to decrease the negative impact of 

educational debt on primary care specialty choice; 

•	� Fund all primary care residency programs at least at 

the 95th percentile level of funding for all programs 

nationally (using total direct medical education 

[DME] and indirect medical education [IME] payments as a basis); and 

•	� Reward teaching hospitals, training programs, and 

community agencies financially on the basis of the 

number of primary care physicians produced, to be 

determined by specialty in practice and not at the 

initiation of training. 

Rationale: Graduate medical education is central 

to development of the workforce. Federal policies are 

needed to redesign GME to meet existing challenges. 

There are opportunities to improve training paradigms 

to respond adequately to the primary care physician 

workforce deficit, which could be further exacerbated by 

elements of health care reform. 

Problem / Opportunity for Improvement 

Situation 

The specialty mix of physicians coming through the 

GME pipeline is not aligned with the requirements of 

maintaining an efficient, high-quality, health care system. 

Primary care physicians are essential to a well-functioning 

delivery system, yet in recent years there has been a trend 

toward increased specialization [127]. To respond to this 

and the current small increase in medical school class size 

requires an increase in the size of existing primary care 

GME programs and the development of new programs. 

These GME programs could be sponsored by traditional 

institutions, such as hospitals and other clinical settings 

where patient care, administrative, and potential faculty 

resources are appropriate to provide substantial components of GME. Educational partnerships with these 

community-based clinical venues to promote increased 

primary care GME training require incentives to hospitals 

and non-traditional sponsors as well as removing regulatory disincentives. 

Many large hospitals have developed GME programs 

to support their complex care programs. The GME 

programs of these large teaching hospitals are effective 

in recruiting physicians to the medical staff and building 

subspecialty clinical care; however, increasing subspecialization rates have resulted in fewer physicians entering 

generalist careers [10]. Moreover, a broad-based trend 

toward fewer work hours among physicians based on 

an analysis of U.S. Census Bureau data from 1976-2008 

and their relationship to physician fees may also alter 

the physician workforce landscape, with implications for 

health care reform implementation [128]. 

The pattern of GME growth reveals that most new 

GME positions are subspecialty fellowships. Although 

Medicare capped its funded GME slots in 1997, at a time 
39 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TWENTIETH REPORT OF COGME 

when an oversupply of physicians was being projected 

[40], the accredited GME positions grew 6.3 percent 

from 2003 to 2006, virtually all of which are self-funded 

by the hospitals. Of these new positions, less than half 

are subspecialty training and fellowships [10,40]. These 

fellows can assist attending physicians, cover inpatient 

services independently, and serve as future medical staff 

recruits for complex care. Primary care trainees fulfill 

none of these criteria. 

All GME payments from CMS are awarded to hospitals. Therefore, at many levels, GME payments have been 

used to foster the clinical enterprises of the teaching hospitals, which are largely devoted to complex subspecialty 

care. There is little to no incentive in GME payments for 

education in primary care or in community-based ambulatory settings. Unless the incentives are changed, GME 

payments will do little to promote interest in primary care 

education and careers. 

GME positions in the U.S. have increased at a steady 

rate despite the GME cap placed by the Balanced Budget 

Act of 1997, although from 2002 to 2007, the number 

of U.S. physicians in primary care specialties decreased 

by 2,641 [10]. It is likely that GME positions will continue to expand to accommodate the new medical school 

graduates, and, 

“If positions expand to accommodate growth in new 

graduates as well as the usual complement of IMGs 

who enter GME for the first time each year (now about 

7,000), the size of the underlying cohort will increase 

from about 27,000 in 2008 to 31,000 in 2015 and up to 

34,000 in 2020” 

(Altarum Institute, 2010, p. 6)[42]. 

Objectives 

To achieve the changes required to increase the quantity 

and quality of GME in response to the needs of the 

physician workforce requires substantial resource 

investments. 

•	� Title VII investments are needed to promote primary 

care GME training initiatives to enhance the quality 

and number of physicians produced. 

•	� Since there is a strong need for expansion of the 

primary care physician workforce, it is essential to 

provide GME payment incentives for hospitals and 

other primary care GME sponsors to develop and 

maintain these programs. Programmatic incentives 

to expand and improve existing GME programs 

would likewise ensure greater primary care physician 

production. 

•	� Resources should be identified to create incentives 

for the involvement of non-academic educational 

collaborations with community clinical venues necessary to provide the resources to produce a larger 

number of highly qualified primary care physicians. 

•	� Removing inadvertent restrictions to primary care 

educational reforms contained in ACGME rules and 

regulations should be addressed to facilitate novel 

program development, experimentation, implementation, collaboration, and evaluation. 

Analysis 

1. Change regulations to support more training in outpatient settings and experimentation with practice 

models to prepare residents appropriately for an evolving contemporary health care environment. 

Traditional medical school training has favored the 

production of specialists, with an emphasis on provision 

of inpatient training in the academic medical center setting. Increasingly, ambulatory care training has been 

provided and clerkships established with primary care 

mentors at community-based sites, such as Community 

Health Centers in rural locations. Training in these venues 

can expose and prepare trainees for the realities of primary care practice in rural and underserved settings. This 

both equips and encourages trainees to practice in these 

arenas once they complete their education and training. 

With the widespread implementation of innovative 

models of health care delivery to provide cost effective 

quality care to our expanding and aging population, 

residents will need to learn the repertoire of skills sets 

required for practice in these modalities. A reformed 

delivery system will require health care professionals 

trained to provide coordinated care across institutional 

boundaries. This kind of training is not routinely provided in residency programs today [127]. Such training 

should include, for example, the key components of the 

Patient-Centered Medical Home (first contact access, 

patient-focused care over time, comprehensive care, and 

coordinated care) and its corollary functions (family 

orientation, community orientation and cultural competency) and working collaboratively with interdisciplinary 

teams to provide integrated and coordinated care. As the 

health care environment and its delivery systems continue 

to change, so must the training that is provided to future 

physicians to reflect new payment mechanisms, health 

care settings and models of care. 

2. Strategically increase the number of new primary 

care GME positions and programs to accommodate 

the increased production of medical school graduates 

and respond to the need for a workforce composed of 

at least 40 percent primary care physicians. 

Current GME caps should remain in place while 

permitting increments in the number of primary care 

GME positions to respond to the increased physician 

workforce demands for primary care physicians. COG-
40 

 

ME’s intrinsic reports, “Modeling the Specialty Mix of 

New Physicians Policy: Implications for Primary Care, 

2009” and “Modeling the Primary Care/ Specialists Mix 

of New Physicians, 2009,” suggest that across the board 

increments in GME specialty caps would disproportionately increase the number of available non-primary care 

positions. The unintended result could be a net decline 

in filled primary care positions, especially in cases where 

applicants had a primary care specialty as their second 

or third choice. Failure to increase primary care GME 

positions in the context of increases in medical school 

graduates will result in decreased access of International Medical Graduates (IMGs) to U.S. GME training programs. The net effect would be larger financial 

investments in the medical education continuum, which 

would produce the same number of physicians, albeit 

with a larger percentage of U.S. graduates. To realize 

a net increase in physician production with emphasis 

on primary care requires a continuing involvement of 

a steady number of IMGs in the U.S. GME programs, 

with strategic increases in GME positions for specialty 

training in areas that represent critical deficiencies in the 

composition of the nation’s current and projected physician workforce (e.g., primary care). 

COGME’s Nineteenth Report, “Enhancing Flexibility in Graduate Medical Education”, recommended alignment of GME with future health care needs by increased 

funding of GME positions as well as strengthening the 

curricula and structures of GME programs [129]. 

Under the recently funded Primary Care Residency 

Expansion (PCRE) Program, the number of primary 

care physicians is anticipated to increase by expanding 

enrollment in primary care residency programs, beyond 

CMS authorized GME caps. This is a $168 million, 

five-year program, aimed at increasing the number of 

residents trained in a primary care specialty (family 

medicine, general internal and general pediatric medicine). The program’s purpose is to increase the number 

of primary care physicians by expanding enrollment in 

primary care residency programs. The new residency 

training positions must be over and above the number 

currently being trained, even if a program is already over 

its Centers for Medicare and Medicaid Services (CMS) 

authorized GME cap. 

3.	� Increase training in ambulatory, community, and 

medically underserved sites. 

Among students in the GME pipeline, too few are 

drawn from rural areas and inner cities, which may mean a 

reduced propensity to practice in these often underserved 

areas. Studies show that residents tend to select practice 

locations that are similar to where they grew up and where 

they trained [127]. There have been calls for Congress 

to broaden the definition of educational training venues 

beyond the inpatient setting to better prepare physicians 

TWENTIETH REPORT OF COGME 

for community-based primary care practice [40]. Educational access to these needed community clinical venues 

could be facilitated by changes in GME funding policies 

and regulations that currently disincentivize training 

in non-hospital ambulatory settings. Promoting educational collaboration with Federally Qualified Health 

Centers (FQHCs) and rural health clinics (RHCs), and 

the National Health Service Corps (NHSC) represents 

important potential resources to support primary care 

GME activities sponsored by hospitals. The Affordable 

Care Act authorized funding for development of Teaching Health Centers and allocated funding to fund training in existing centers. There are examples of CHCs that 

have the internal infrastructure for primary care GME 

sponsorship if associated with appropriate partners (e.g., 

hospitals) and if CMS rules defining GME sponsorships 

were changed. Other clinical venues that could support 

elements of expanded GME could include private practices, HMOs, and private health systems not currently 

engaged in GME. These new venues must be prepared to 

foster the development of new models of contemporary 

primary care delivery. For instance, training in PatientCentered Medical Homes can help prepare residents for 

the realities of actual contemporary practice. 

Primary care clerkships in family medicine, general 

internal medicine, and pediatrics should create additional 

relevant ambulatory teaching venues through academic/ 

community partnerships with private practices, CHCs, 

and residency programs in rural and urban settings to 

increase student exposure, understanding, and appreciation of community-based primary care. To accomplish 

the needed expansion in primary care experiences for 

most medical schools would require the recruitment, development, and support of community physician faculty 

networks capable of providing the curricular components 

of required clinical courses in a diversity of clinical settings and locales. 

4. Provide financial incentives for GME. 

The single most important way Medicare can influence the mix of physicians being produced by the 

GME system is to reform how it pays for services [127]. 

Significant change in the method of GME funding is 

needed. Currently both DME funding and IME funding for medical education are provided by Medicare 

and some Medicaid programs and are paid directly to 

teaching hospitals. The Medicare Payment Advisory 

Commission (MedPAC) has noted that there is not a 

significant incentive to train physicians in outpatient and 

community settings and in settings which tend to serve 

medically vulnerable populations; furthermore, there are 

not appropriate incentives for primary care training, and 

the current system of GME funding does not ensure the 

training of physician leaders who will play an active role 

in health system reform. Thus, Congress should revise 

the way GME is funded to support the production of an 
41 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TWENTIETH REPORT OF COGME 

appropriate primary care workforce. As discussed above, 

success in producing primary care providers should not be 

based on the number of students entering primary care. 

Instead it should be based on placement of graduates five 

years after medical school to determine which are still in 

primary care, either in practice or in training. Support 

paid directly to primary care residency programs and 

non-hospital community agencies would provide financial 

incentives for ambulatory and community-based training. 

While the Medicare Modernization Act in 2003 authorized redistribution of Medicare GME funding for 

residency positions outside of teaching hospitals, with 

priority given to rural hospitals, residency programs had 

to be already established to receive this redistribution, 

and furthermore, many programs that benefited from this 

change were already above their cap [10]. 

Legislation was introduced to Congress to modify 

the existing gap in policy but the scope of this policy was 

limited to only 24 states and the formula and rules for 

creation of new residency positions were complex [40]. 

This legislation failed to receive support from teaching 

hospitals since they would not benefit from this shift in 

policy. Positions added to teaching hospitals after the 

Medicare cap was imposed increased the number of 

subspecialty fellowships, yet increasing the number of 

first postgraduate year positions does not necessarily 

increase the number that enroll in primary care programs 

[40]. While the AAMC has advocated free determination by medical students and physicians concerning the 

areas of medicine they wish to pursue and the decisions 

made by GME programs and teaching hospitals about 

specialties of residency training positions, a 2008 report 

by the Association of Academic Health Centers calls for 

major reforms that recognize broader societal concerns as 

well as an integrated and comprehensive national health 

workforce policy [40]. 

With growing recognition of the decreasing number 

of students pursuing careers in primary care, groups such 

as MedPAC have supported efforts to tie future federal 

support of GME to training in particular specialties and 

consideration of approaches that would use Medicare 

GME and indirect medical education subsidies to promote primary care, including allocating shares to nurse 

practitioners and physician assistants [40]. 

HRSA recently announced the Expansion of Physician Assistant Training Program (EPAT) under the 

authority of the Affordable Care Act. The program’s 

purpose is to increase student enrollment in primary 

care PA programs and graduates planning to practice 

primary care specialties. Funding from this program will 

fund approximately forty primary care physician assistant 

training programs [130]. 

Benefits of Adopting this Recommendation 

•	� Increasing the number of new primary care GME positionsandprogramswillincreasetheproportionof medical school graduates entering primary care practices. 

•	� Implementing strategies known to promote and 

reward primary care and service in underserved 

settings—such as providing training sites in community and medically underserved areas, fostering 

medical partnerships between academic programs 

and community-oriented health care facilities, 

eliminating restrictive regulations, reallocating GME 

funding to primary care residencies, providing financial incentives for the production of primary care 

physicians, and changing ACGME regulations to 

support ambulatory care training—should serve as 

significant incentives for medical student graduates 

to choose to enter primary care practices. 

5. THE GEOGRAPHIC AND SOCIOECONOMIC 

MALDISTRIBUTION OF PHYSICIANS 

Recommendation: So long as inequities exist, policies 

should support, expand, and allow creative innovation 

in programs that have proven effective in improving the 

geographic distribution of physicians serving medically 

vulnerable populations in all areas of the country. 

Congress and the Administration should: 

1. Ensure funding of the National Health Service 

Corps at the $1.15 billion amount authorized by the 

Affordable Care Act so that the NHSC can recruit 

more primary care physicians, provide greater support of scholarship recipients, create special learning 

opportunities and networks for scholarship recipients 

and early loan repayers, and forge formal affiliations 

with academic institutions and training programs. 

2. Increase the funding for Title VII, section 747, to 

$560 million in Primary Care Medicine and Dentistry 

cluster grants. 

3. Implement programs to increase funding by the 

Agency for Health Care Research and Quality 

(AHRQ), National Institutes of Health (NIH), and 

private research enterprises for projects that stimulate 

primary care and community-based research and 

emphasize methodologies such as population-based 

ecological and cluster studies, qualitative behavioral 

studies, and comparative effectiveness research. 

4.	� Increase funding for Community Health Centers 

(CHCs) that are committed to training students and 

residents, and increase funding for Area Health Education Centers (AHEC) programs to improve existing 

programs, support new programs, and support innovative funding proposals that promote the practice of 

primary care in medically underserved areas. 
42 

 

 

 

 

 

 

 

 

 

 

 

TWENTIETH REPORT OF COGME 

Rationale: Primary care physician maldistribution 

in the U.S. has been a long-standing and persistent challenge in spite of recurrent attempts to ameliorate it with 

targeted physician workforce and health care financing 

policies as well as undergraduate and graduate medical 

education programmatic interventions. 

The Affordable Care Act authorizes re-distribution 

of 65 percent of current unused GME residency slots to 

qualifying hospitals to address physician shortages, especially in rural and other underserved areas. A hospital 

that qualifies for an increase in residency positions would 

have to maintain its base level of primary care residents 

and ensure that at least 75 percent of the additional positions are in primary care or general surgery residencies. 

Problem / Opportunity for Improvement 

Situation 

Primary care physician maldistribution in the U.S. 

has been a long-standing and persistent challenge, in 

spite of recurrent attempts to ameliorate it with targeted 

physician workforce and health care financing policies as 

well as undergraduate and graduate medical education 

programmatic interventions. The NHSC estimates that 

50 million Americans live in health professional shortage 

areas (HPSAs). This problem, impacting both rural and 

urban underserved areas, can be attributed to multiple 

factors including inadequate reimbursement rates for primary care services, medical school debt load, geographic 

isolation, lifestyle preferences, and lower rates of health 

insurance coverage in rural and inner city areas [83,132]. 

Objectives 

Addressing the geographic and socioeconomic maldistribution of the primary care workforce will require 

providing incentives for clinicians to practice in underserved areas, educating more students who are more likely 

to practice in underserved areas, conducting research that 

will facilitate community-based practice, and providing 

support for Community Health Centers. 

Analysis 

1.	� Ensure funding of the National Health Service Corps 

at the $1.15 billion amount authorized by the Affordable Care Act so that the NHSC can recruit more 

primary care physicians, provide greater support of 

scholarship recipients, create special learning opportunities and networks for scholarship recipients and 

early loan repayers, and forge formal affiliations with 

academic institutions and training programs. 

The maldistribution of physicians related to geographic areas and medically vulnerable populations 

should be addressed by providing incentives for physician 

practice, medical student education, and graduate medical 

education training in sites located in CHCs, rural health 

centers, and primary health care shortage areas. The 

NHSC has been successful in providing such incentives. 

Key stakeholders of the NHSC, including the Office 

of Management and Budget (OMB) and the GAO have 

concluded that NHSC placements have improved service 

levels and have resulted in retention of many providers 

in underserved areas. Medical students with NHSC 

scholarships are much more likely to become primary 

care physicians, to practice in underserved areas, and to 

practice in a Community Health Center [133,134,135,]. 

Many interventions at the local, regional, and national levels have yielded positive results, but the ultimate patient outcomes of these interventions may not be palpable 

in communities with an inadequate number of primary 

care physicians. Saxon and Johns recently reported on 

the success of the NHSC and made recommendations 

for expansion [136]. Currently more than 3,800 NHSC 

clinicians practice in rural and urban communities serving 

about 4 million individuals. However, approximately 50 

million Americans live in communities with a shortage 

of health professionals. 

With increased funding, the NHSC could play a much 

greater role in shaping the health system of the future and 

meeting the health needs of the population in the United 

States. For example additional funding could be used to: 

•	� Develop closer links to academic medicine for 

medical student training and for graduate medical 

education residency and fellowship training. The 

requirements for NHSC participation and scholarships should be changed to maximize these opportunities and to inhibit barriers between academic and 

community settings. Time spent teaching medical 

students and residents should count toward service 

time, and efforts should be made to include full-time 

faculty members for NHSC scholarships. 

•	� Make clinical innovations in practice that will attract 

both providers and patients. The NHSC should 

implement the elements of the Patient-Centered 

Medical Home. 

•	� Give higher scholarship stipends and student loan 

repayments, including full student loan forgiveness 

programs that will make it easier for medical students 

who will enter primary care and general surgery 

residencies to then make a significant commitment 

to national service[136]. 
43 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TWENTIETH REPORT OF COGME 

2. Increase the funding for Title VII, section 747, to 

$560 million in Primary Care Medicine and Dentistry 

cluster grants. 

Title VII, section 747 has led to improvements in 

primary care education, workforce capacity building, and 

faculty development. It has helped to identify and disseminate best practices to programs, accrediting bodies, 

and other stakeholders. Title VII, section 747 is the only 

HHS program aimed directly at training primary care 

physicians. These section 747 grants have permitted the 

development of innovative programs that are generalized 

to the larger educational experiences of medical students 

and residents. They spur the development of curricula 

in community-oriented primary care and provide clinical 

training sites where physicians learn to serve vulnerable 

populations. More importantly, these grants are the 

foundation for programs that train academic leaders of 

the future who are more likely to instill in their students 

an understanding of the importance of Patient-Centered 

Medical Homes and a sense of obligation to serve communities and populations. 

Researchers and key stakeholders have recognized the 

contributions of the Title VII programs. For example: 

•	� In 2002, the Robert Graham Center for Policy Studies reported in a study that students who attended 

medical schools that received Title VII, section 747 

funding were more likely to practice primary care in 

a rural area or in a HPSA [137]. 

•	� Krist found that Title VII of the Health Professions 

Education Assistance Act is the only federal program 

that has increased the production of primary care 

physicians who serve medically vulnerable populations [138]. 

Figure 15: Title VII Funding (in 2008 Dollars) 

•	� Reynolds and Rittenhouse and colleagues concluded 

that Title VII, section 747 funding has played a 

significant role in developing the primary care workforce by providing funds for primary care education, 

faculty development, and the creation of innovative 

primary care curricula and models of care [133,139]. 

•	� Davis and colleagues and Newton and Arndt found 

that Title VII, section 747 contracts awarded to 

national primary care organizations have led to 

increased innovation in ambulatory care education 

[140,141]. 

•	� The Congressional Research Service found a deleterious effect on services to the medically vulnerable 

when Title VII funds were lost [142]. 

•	� Rittenhouse and colleagues, in an examination of 

the impact of Title VII training programs on staffing 

of Community Health Centers, found an association between physicians attending Title VII-funded 

medical schools and practicing in CHCs and/or 

participating in the NHSC [133]. 

•	� The Institute of Medicine characterized the Title 

VII programs as an “undervalued asset” [143]. 

Yet, over the past 4 decades, there have significant 

cuts in funding for the Title VII programs. Funding is 

currently less than a fifth of what it was, in real terms, 

in the early 1970s. These reductions in funding have 

significantly undermined the ability of the program to 

continue to make contributions to the nation’s primary 

care workforce development. 

Source: Kolsky, 2009 [144] 
44 

In order to address the significant challenges associated with the emerging primary care physician shortage, 

increased funding is needed to expand and enhance 

primary care training programs. 

 

 

 

 

 

 

TWENTIETH REPORT OF COGME 

3. Implement programs to increase funding by AHRQ, 

NIH, and private research enterprises for projects that 

stimulate primary care and community-based research 

and emphasize methodologies such as populationbased ecological and cluster studies, qualitative behavioral studies, and comparative effectiveness research. 

Outcome-based measures using methodologies such 

as population-based ecological and cluster studies provide an alternative to traditional methods of assessing 

physician supply adequacy and practice models. Such 

research could evaluate the comparative effectiveness of 

alternative approaches on different populations based 

on assumptions about population characteristics, size of 

health care workforce and infrastructure [42]. 

Research is currently lacking related to the most 

common, acute, chronic, and co-morbid conditions, 

which primary care physicians address on a daily basis. 

Primary care physicians are in the best position to design 

and implement research focused on the common clinical 

questions confronted in practice. Funding should be 

increased both for the training of primary care researchers and for this type of clinical research. Such training is 

necessary to impart critical research skills to the primary 

care workforce and to contribute to the body of knowledge necessary to put primary care on a similar footing 

with other specialties that have established research infrastructures. AHRQ supports research to improve health 

care quality, reduce costs, advance patient safety, decrease 

medical errors, and broaden access to essential services. 

There is a need for solid research that can be generalized and expanded. Using methodologies such as population-based ecological and cluster studies, qualitative 

behavioral studies, and comparative effectiveness research 

should be encouraged. AHRQ is in a perfect position to 

support the type of research most commonly conducted 

by primary care physicians and strongly needed in this 

country to optimize health outcomes. 

AHRQ has played an important role in improving the 

quality, safety, efficiency, and effectiveness of health care in 

the U.S. Through its research programs, it supports health 

care IT, facilitates development of an evidence base for 

best practices, and promotes collaboration and dissemination. Research in these areas is leading to significant 

improvements in health care outcomes. For example, a 

study funded by AHRQ’s DEcIDE (Developing Evidence 

to Inform Decisions about Effectiveness) research network 

reported that heart disease patients ages 65 and older who 

receive stents coated with medicine to prevent blockages are 

more likely to survive and less likely to suffer a heart attack 

than patients fitted with stents not coated with medication. 

The findings provide important new evidence for decisionmaking by heart disease patients and their physicians [145]. 

AHRQ recently initiated a study as part of its efforts to 

eliminate hospital-acquired infections that currently result 

in at least 30,000 deaths and excess costs of over $9 billion 

per year. Results of this study can be disseminated; the 

result is substantial improvement in outcomes and cost 

savings through the health care system. Additional funding 

for AHRQ would provide additional resources in research 

priority areas such as measures of value, cost, and efficiency; methods, modeling, and data sources for tracking 

value and impact; impact of consumer incentives; impact 

of regulatory changes; impact of Medicare, Medicaid, and 

the State Children’s Health Insurance Program (SCHIP); 

and impact of publishing reporting strategies. 

4. Increase funding for Community Health Centers 

(CHCs) that are committed to training students and 

residents, and increase funding for Area Health Education Centers (AHEC) programs to improve existing 

programs, support new programs, and support innovative funding proposals that promote the practice of 

primary care in medically underserved areas. 

Increasing the effectiveness of medical school primary 

care experiences in community settings and academic 

health centers can increase the percentage of students 

who choose careers in primary care. Since physicians 

are more likely to practice in settings to which they have 

been exposed as students, increasing students’ exposure 

to community-based settings increases the chance they 

will ultimately practice in such settings. In addition, using Community Health Centers as sites of ambulatory 

medical education increases the probability that students 

trained there will select primary care as their specialty. 

However, high costs at community-based sites including those associated with travel costs and space 

constraints create challenges for community-based 

training, compared to inpatient hospital-based training. 

Increased funding can offset those higher costs and create more opportunities for student exposure to enhance 

understanding and appreciation of community-based 

primary care. Such funding could be used for the recruitment, development, and support of community physician 

faculty networks capable of providing the curricular 

components of required clinical courses in a diversity of 

contemporary clinical settings and locales. 

Current federal cash match guidelines for AHECs 

are restrictive and do not contain specific allowances 

for medical schools or academic health centers to create 

innovative student support programs that foster entry 

into medical school or other health care programs. Since 

most AHECs are located in rural or underserved areas,f 

lexibility in these guidelines could significantly incentivize medical schools to work with these communities to 

attract their students into primary care. 
45 

 

 

 

TWENTIETH REPORT OF COGME 

Benefits of Adopting this Recommendation •	� The NHSC can provide greater support of scholar

-

ship recipients, improving learning opportunities 

that will make them more likely and better prepared 

to practice as primary care providers. 

•	� Increased funding Title VII, section 747 funding will 

lead to increased capacity for training of primary 

care physicians and will enhance students’ exposure 

to underserved areas, which helps increase the pro-

portion of graduating students entering primary care 

and serving in underserved areas. 

•	� Better research of effectiveness and dissemination 

of best practices will improve health care outcomes 

and help to contain costs. 

TWENTIETH REPORT OF COGME 47 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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