Solving the nation's primary care shortage

The supply of primary care physicians needed to bolster the move toward quality-driven reimbursement models is becoming increasingly stretched. And as the emphasis on prevention and chronic disease management increases, more strain will come. 

By 2025, the country will require as many as 35,600 more primary care doctors, and as many as 94,700 physicians overall, to meet the increasing demand of a growing and aging population, according to data released by the Association of American Medical Colleges (AAMC) earlier this year.

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The projected shortage might have a benefit for primary care doctors, with salaries already on the upswing. But it’s still uncertain to what extent, if any, team-based care and the training of other clinicians will offset the burden for physicians faced with overflowing waiting rooms. 

Moreover, the shortage will occur just as accountable care organizations, readmission penalties and other changes in practice design and reimbursement place a premium on better care coordination and other steps to keep patients out of the hospital, says Clese Erikson, deputy director of the George Washington Health Workforce Research Center in Washington, DC. 

“There’s been a lot of effort to study the impacts on quality and costs,” she says. “But very little explicitly looking at the demand for physician services.”

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To ease the pressures on physicians, health systems and large practices are taking steps such as hiring more non-physician practitioners and emphasizing broader, team-based care, say Erikson and other researchers studying issues related to physician supply and demand. Improvements in technology, they hope, also will play a role. But whether those efforts will expand the number of patients each doctor’s practice can treat is still unclear.

Meanwhile, the projected shortage must be tackled on several fronts, starting with increased federal funding for residency slots, says Janis Orlowski, MD, chief healthcare officer at the AAMC. To meet the looming primary care demand, the reality and the perception of the career path also will need a makeover, says Orlowski, citing feedback from medical students that it’s not “a fulfilling” work life.

“What they see is primary care doctors, who in order to make a good living and/or pushed by other productive measures, are not spending time and attention in providing care to a patient,” she says. 

Boosting the supply 

While some of the projected demand for both primary care doctors and subspecialists can be traced to expanded coverage under the Affordable Care Act, the main drivers are the nation’s aging demographic profile, along with anticipated retirements by physicians, according to the AAMC. 

Within the next decade, the number of adults age 65 and older will increase by 41% compared with 5% for the population under age 18. The doctors needed to treat them also are aging. By 2025, slightly more than one-third of doctors currently working will be 65 or older, according to the AAMC. 

But the number of federally-funded residency training slots has been frozen since the late 1990s and thus has not kept pace with those trends, Orlowski says. And while Congress has proposed legislation to boost the number of residency slots by 15,000 over five years, more physician residents does not necessarily translate to more primary care providers, research indicates. 

Next: "Perhaps the solution is to start even earlier"

Just one out of five residents graduating  from internal medicine programs reports that he or she will pursue a career in general medicine rather than a subspecialty, according to a 2012 study published in the Journal of the American Medical Association. Denise Dupras, MD, a study coauthor and general internist at the Mayo Clinic in Rochester, Minnesota, notes that residency programs with designated primary care tracks fared better. 

“But even in the primary care track, only 40% of those folks reported staying in a general internal medicine career,” she says. “So simply increasing the number of those programs may not be the solution.”

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General internists and hospitalists are in the greatest demand, along with family physicians and psychiatrists, says Travis Singleton, a senior vice president at Merritt Hawkins, a healthcare recruiting and consulting firm based in Dallas. One challenge is that hospitalists are sometimes poached from the existing pool of internists, winnowing their numbers further. 

In addition, some general internists are diverted to hospital medicine during their training, Dupras says. “There is a group of people who may have in the past done internal medicine because they enjoy the breadth of medicine, the challenge of making the diagnosis,” she says. But, she adds, “They don’t particularly want that piece of the continuity of care or the follow-up of care.”

The good news is that increasing demand-for reasons ranging from demographic changes to population health needs-is boosting primary care salaries, according to a Merritt Hawkins analysis. 

Starting salaries for general internists increased 14% in 2016 and averaged $237,000 compared with $207,000 the prior year. The 2016 offers for general internists ranged from $195,000 to $320,000, based on recruiting searches conducted from April 2015 through March 2016. (Hospitalists were not included in that group.) Family physician pay was up by 13%, averaging $225,000 versus $198,000 in 2015. Most subspecialists still earn far more, however. 

But Dupras argues that pay is only one piece of the career decision equation. Research hasn’t yet sorted out what attracts and keeps doctors in primary care, she says. But the hospital-based rotations that tend to dominate academic training can sometimes exert a “hidden curriculum,” sending subtle messages that “somehow primary care isn’t as prestigious or as valued.”

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Perhaps the solution is to start even earlier in the training process, Dupras says. If researchers could determine what types of traits and interests primary care doctors are more likely to exhibit, then medical schools could search for those among applicants.

Promoting primary care

Increasing the number of primary care residency programs and where they are located  might ease the shortage, says Paul O’Rourke, MD, a general internist and assistant professor at Johns Hopkins University School of Medicine in Baltimore, Maryland.

O’Rourke, who recently completed an analysis of national matching program data, argues that there is a pent-up interest in primary care. For each slot in a primary care internal medicine program, there were six applications compared with 1.7 for non-primary care slots. 

O’Rourke and his colleagues reported that residency matching data in a related study, published recently in the The American Journal of Medicine. It showed that nearly 61% of the 104 internal medicine primary care programs were located in the northeast, compared with 10.9% in the southeast and 9.4% in the midwest. The researchers also found that the geographical regions with the lowest ratio of primary care physicians to population had few or no programs.

Next: One key uncertainty remains

Already, signs of regional shortages are emerging. In seven states, the supply of primary care doctors relative to population is less than 85% of the national rate, according to an analysis by America’s Health Insurance Plans published in July. In a Merritt Hawkins survey of more than 20,000 physicians, 81% reported working at capacity or being overextended.  

The trend of hospitals and health systems employing physicians can amplify turnover problems, Singleton says. “When you were private, you built the building, you bought the equipment,” he says. But employed doctors, he says, may not be as emotionally and financially tied to their practices, making them more vulnerable to being lured away. 

One key uncertainty: how will shifting reimbursement models drive the need for more primary care doctors? 

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It’s still unknown, Erikson says, how adding care managers, social workers and other non-physicians will impact the number of  patients a practice can treat. There’s some reason for caution. When one health system piloted a patient-centered medical home and team-based care at one of its clinics, the physicians involved ended up reducing their patient panels from 2,300 to roughly 1,800. 

Extenders to the rescue?

Erikson is optimistic that some of the work doctors currently handle can be assumed by other team members over time. “Right now, there’s a real cultural barrier in some practices with being comfortable in trusting your team members to take on greater and greater roles,” she says. 

Additional help for primary care could come from nurse practitioners and physician assistants. From 2003 to 2014, the number of newly certified physician assistants increased 75%, from 4,337 to nearly 7,600, according to data published last year in a Health Affairs blog post. The growth in nurse practitioners was even stronger, from 6,611 new graduates in 2003 to 18,484 in 2014. But other data show about half of physician assistants and nurse practitioners ultimately practice in primary care rather than a subspecialty field. 

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Brian Ring, chief operating officer at Henry Community Health in New Castle, Indiana, says hiring nurse practitioners has significantly improved patients’ access to care in the county’s system, which includes a 49-bed hospital and an outpatient primary care practice, among other services.

“There is a difficulty in recruiting physicians,” he says. “But we have a responsibility to care for our community and meet their expectations on access.”  

To help fill the anticipated primary care shortage, internists themselves bear a responsibility “to do more advocating for why our profession is something that medical students would enjoy,” O’Rourke says. 

O’Rourke adds that it’s likely easier for primary care physicians to develop a healthy work-life balance than it is for doctors opting for even more time-consuming specialties. 

Dupras was initially intrigued by the subspecialties of oncology and pulmonology. She changed her mind after working in Mayo’s outpatient clinic as a resident, where she was assigned a panel of patients with whom she developed a relationship. 

“What are the things that make working hard worth it? For me, it was ... the relationship that I was able to forge with these patients,” Dupras says.