array of measures to improve the health workforce’s competency in geriatrics (IOM, 2008).

For many years, health care experts have called for an increase in primary care practitioners. These generalist physicians—general internists, family practitioners, obstetrician-gynecologists, and pediatricians—provide holistic, patient-centered care that should be patients’ “first line of defense” in preventing and treating many illnesses. Instead, our health care system, unlike systems in many other nations, is skewed toward much more costly specialist care. As important as it is to control costs, another reason to change this pattern is even more potent: it is harmful to patients. People living in geographic areas served by larger numbers of primary care providers have better health outcomes (Starfield et al., 2005b). Conversely, research shows a “weak link” between the number of physicians per capita and health outcomes, except for studies of the supply of primary care physicians. Further, “health systems with primary care as the foundation of care provide the best outcomes at the lowest costs” (Goodman and Grumbach, 2008).

Ironically, several Centers for Medicare and Medicaid Services’ (CMS’s) policies discourage physicians-in-training from pursuing primary care careers. First, Medicare is the largest source of funding for graduate medical education (physicians’ residency programs) (HRSA, 2007). Medicare rules limit support for residencies that take place in “nontraditional” and ambulatory sites, where generalists tend to train and practice; instead, the rules favor hospital-based residencies where specialists traditionally receive their training. The result, according to the Council on Graduate Medical Education, is that “current training models are not preparing physicians for the demands of future practice.”

Once primary and specialist physicians complete their residencies—generally with substantial educational debt—Medicare payments are much higher for specialists, which means that those who choose a generalist career will have a much greater financial struggle (Tu and O’Malley, 2007). A variety of strategies have been employed in an attempt to encourage young physicians to choose generalist careers with little long-term success. More effective strategies, involving CMS’s reimbursement system, should be attempted (Colwill et al., 2008). This is an example of how different parts of HHS could be brought into greater alignment.

Advanced practice nurses (clinical nurse specialists, nurse practitioners, nurse midwives, and nurse anesthetists) and physician assistants can fill part of the gap in primary care access, and the country had



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