A lack of consensus on who counts as a primary care physician can affect reimbursement and workforce pipelines, and as demand for healthcare grows, the debate over what specialties fall under primary care is growing.
The traditional definition of primary care includes family medicine, general internal medicine and pediatrics — fields centered on prevention, continuity, coordination and treating common conditions. Primary care physicians are often the go-to trusted source for patients, as well.
In practice, however, patients and physicians often expand that definition to include OB-GYNs, oncologists and even subspecialists, especially in underserved areas.
“There’s a lot of gray,” Rob Fields, MD, executive vice president and chief clinical officer of Beth Israel Lahey Health in Cambridge, Mass., told Becker’s. “Take a pulmonologist or an infectious disease doctor or a rheumatologist, and all of those obviously had internal medicine training before they went into fellowship. And I think this is more common in smaller communities where someone may double duty. They may not get enough volume in rheumatology to only do rheumatology, so they do primary care.”
The ambiguity influences how medical students choose their career paths, how health systems design care teams and how insurers determine reimbursement.
A narrow definition
In 2024, Hackensack Meridian School of Medicine in Nutley, N.J., launched the Primary Care Scholars Program. The program offers tuition forgiveness to students who commit to primary care, complete residency at Hackensack Meridian and work there full time as a primary care physician for the same number of years their medical school was funded.
Targeting four specialties — pediatrics, family medicine, general internal medicine and geriatrics — helps address workforce gaps. It also raises the question about other specialties, such as obstetric-gynecologists.
“A lot of women get their primary care from their gynecologist,” said Jeffrey Boscamp, MD, dean and president of the medical school. “They have that continuity, and they would see you over time but they’re more likely, I think, to refer you for what are fairly common medical problems, whether it be obesity, hypertension, hypercholesterolemia — the things that are most commonly seen in adults, and certainly, they’re not seeing kids.”
Location and role matter
Expectations can vary by market. While serving as chief population health officer at New York City-based Mount Sinai Health System, Dr. Fields observed more self-referrals from patients than he did in North Carolina, where he co-founded a primary care practice focused on Latino health.
Advanced practice providers, such as nurse practitioners, add another layer of complexity to defining primary care providers. Some states grant them autonomy to deliver some primary care services, while others require collaborative agreements with physicians.
A financial mismatch
The definition of primary care has significant implications for reimbursement. Specialties typically considered primary care — including internal medicine and family medicine — are among the lowest-paid in medicine.
“Generally, in our system, you get more money if you do something, right? You don’t get a lot of money for thinking,” Dr. Boscamp said. “So cardiologists that are doing echoes [echocardiograms] or interventional cardiology in general, they get a lot. All the surgical specialties, even dermatology, have procedures, but the average primary care person is sitting and talking to you and spending a fair amount of time. Nobody pays for thinking — for what we call cognitive specialties.”
