Interest in primary care up, but shortage still looms

Although more medical students are turning to primary care professions again, the marketplace is still expected to face a worsening shortage of primary care physicians (PCPs) in the coming years.

According to this year’s National Resident Matching Program, graduating medical students increasingly appear to be interested in careers in primary care. The percentage of students choosing residencies in family medicine was up 39% in 2013 from 2012, and increases also were seen in those choosing internal medicine–primary care. (See “Interest in primary care,” below.) This year’s intern/resident registration program for osteopathic physicians also saw an increased interest in primary care.

Whether the trend will bolster the numbers of PCPs long term is undetermined. High levels of student debt and lower salaries compared with other  medical specialties have been cited as major obstacles to recruiting physicians to long-term careers in primary care.

American Academy of Family Physicians (AAFP) President Jeffrey J. Cain, MD, FAAFP, remains hopeful. “Reforms in our healthcare system-such as team-based care that brings the expertise of the physician, nurses, nurse practitioners, physician assistants, and the whole array of health professionals together to meet the patient’s individual needs-will do much to meet demand. But that demand is growing, and we need to increase the number of PCPs and all the other health professionals who comprise the team,” he says.

The demand is indeed growing, according to the Association of American Medical Colleges (AAMC). With up to 30 million people newly gaining insurance coverage starting in 2014 and 10,000 Americans turning 65 every day for the next 2 decades, the nation faces a shortage of more than 91,000 physicians by 2020, split evenly between primary and specialty care, the AAMC predicts.

“Physician shortages are occurring because demand is increasing but the supply is not increasing at the same pace, as a result of the cap Congress has imposed on Medicare support for residency training,” says the AAMC’s Tannaz Rasouli, MPH, director of government relations. “In the 2013 match, a significant number of highly qualified U.S. medical school graduates did not match to residency training positions, and nearly all positions were filled. So, it will not be possible to address shortages of both primary and specialty care physicians unless Congress lifts the cap on Medicare support for residencies.”

Cynthia Ambres, MD, MS, partner, Global Healthcare Center of Excellence at KPMG, believes that the primary care field had been decreasing in attractiveness in recent years due to low satisfaction and poor reimbursement “as well as a sense that the PCP was becoming nothing more than the ‘triage officer’ for specialists,” she says. But as the shift to accountable care and payment for value over volume and procedures takes hold,  Ambres adds, “the focus is on the PCP as the true coordinator of quality care and even cost containment.”

The Affordable Care Act (ACA) puts more focus on the delivery of quality care rather than the quantity of medical services doctors provide, according to Richard Snyder, MD, chief medical officer at Independence Blue Cross (IBC), the leading health insurer in Philadelphia, Pennsylvania.

“This in itself is a very important shift, affecting not just how doctors are paid, but also how they practice medicine,” he says. “Similarly, the growth of patient-centered care, where doctors practice in a team environment and can offer more personalized care, is also a key reason more doctors are seeking primary care careers. There is definitely momentum, but lots more progress needs to be made to meet the growing demand for PCPs. One way to do this is through more medical education about the importance of primary care.  That’s why here at IBC we’re so passionate about our partnerships with residency training programs in the Philadelphia region that are training the doctors of tomorrow to practice patient-centered care. It’s a trend we’d like to see catch fire more broadly.”

Shortages will not be offset easily, according to Ambres. “[Midlevel providers], such as physician assistants, nurse practitioners, med techs, and others, are becoming more and more important to leverage the skill set of the PCP optimally,” she says. “Modalities such as online care, allowing PCPs to access specialists to assist in patient care, as well as consult patients directly, are invaluable as we look to ensure timely access to care.”

How ACO, PCMH models might influence PCP demand

The accountable care organization (ACO) and Patient-Centered Medical Home (PCMH) models solidify the importance of PCPs in the way they provide health services, according to Cain.

“The PCMH is based on team-based, comprehensive primary medical care, and the ACO relies on the PCMH to coordinate the full array of the patient’s care-from the community setting to inpatient care to post-hospitalization care-to ensure that patient gets the right care from the right health professional at the right time, to reduce re-hospitalization, and to prevent illness or complications from existing conditions,” he says.

“Both ACOs and PCMHs will greatly increase the demand for PCPs, thereby increasing the need to ensure that more future physicians go into the practice of primary care,” American Osteopathic Association (AOA) President Ray E. Stowers, DO, says.

The success of the ACO will depend on PCPs and their ability, with the aid of technology and appropriate payment models, to coordinate care for patients, according to Ambres.

“PCMHs are good models of care delivery that are already showing the potential for cost reductions based on an evidence-based team approach that reduces duplication and variation, increases provider efficiency, and focuses on wellness, prevention, and patient engagement,” she says. “This model is extremely attractive to physicians in primary care and to medical students choosing specialties.”

ACOs include the full spectrum of patient care-PCPs, surgeons, other physician specialists, nursing homes, and hospital care. “Advanced coordination of care is the foundation of ACOs. However, the majority of them utilize PCPs as the core,” Stowers says. “The hope is that ACOs will meet what has been called ‘the triple aim,’ which is to improve the health of the population, improve the individual patient experience, and reduce the total cost of care.”

ACOs are designed to do this by:

• making physicians accountable for the care of their patients;

• providing incentives to encourage preventive care; and

• saving money though reducing unnecessary hospitalizations, tests, and procedures.

The PCMH model also encompasses coordinated care. Recognizing the importance of the PCMH to the future of healthcare delivery, the AOA was a founding member of the Patient-Centered Primary Care Collaborative, which is dedicated to advancing an effective and efficient health system built on a strong foundation of primary care and use of the PCMH model, according to Stowers.

IBC’s Snyder says he believes that the interest in the PCMH model has never been stronger.

“This is particularly important as healthcare is more complex and people with chronic illnesses are getting care from many different doctors in different settings,” he says. “Patient-centered care increases both physician and patient satisfaction by providing a team approach to healthcare, with a family doctor and support staff that knows all of your care and can best advocate for all your needs.

“Changes in how doctors are rewarded for providing quality care are also attracting more doctors to primary care. We have created a unique financial incentive to help PCPs make the investments necessary to deliver more patient-centered care.”

More than one-third of the PCPs in IBC’s network practice in a medical home, which Snyder says is the highest concentration of medical homes in the nation. “We see PCPs in general and PCMHs in specific as foundational to the development of successful ACOs that align incentives and better coordinate the care of populations across all providers and facilities,” he says.

It is too early to know the short- or long-term effect these emerging efforts will have on future workforce needs, believes the AAMC’s Rasouli. “These changes will take years to come to fruition, and in the interim, it would be irresponsible to ignore the nation’s growing healthcare needs. As demonstrated in Massachusetts, expanding insurance coverage leads to an initial increase in utilization of both primary and subspecialty care.

“Delivery system innovations that improve efficiency, integrate care, and expand use of healthcare teams may help relieve some of the burden on both patients and overwhelmed providers but will not obviate the need to train more doctors in both primary and specialty care,” she adds.

NHSC and Title VII: Part of the solution?

The National Health Services Corp. (NHSC) awards scholarships and student loan repayment to individuals enrolled or accepted into certain health profession degree programs, including osteopathic and allopathic students, who agree to serve in NHSC-approved sites in high-need urban, rural, and frontier communities across the nation upon graduation and completion of their training. Title VII of the Public Health Services Act (Title VII) provides scholarships and loan repayment to minority students and students who agree to work in medically underserved areas for 3 years.

These programs are vital to the growth of primary medical care, and, in the case of the NHSC, to providing care in underserved areas, according to Cain. “Research consistently shows that students attending medical schools receiving Title VII grants for departments of family medicine are more likely to go into primary care and to serve in underserved areas,” he says. “NHSC is equally vital to growing the primary care physician workforce and helping ensure that people in underserved areas get the care they need.”

Despite this year’s increase in medical students choosing primary care, anecdotal evidence shows that students are still apprehensive of becoming PCPs due to high levels of student loan debt coupled with lower payments for the medical services that PCPs provide.

Both the NHSC and Title VII address this dilemma, according to the AOA’s Stowers.

“Physicians who participate in these programs also are more likely than other medical school graduates to continue practicing in medically underserved communities. Unfortunately, these programs are temporary,” Stowers says. “Congress should seek to extend, expand, or make them permanent. The AOA supports efforts to maintain and expand each of those programs to encourage medical students to train and practice in primary care, as well as in rural and medically underserved areas.”

What Rasouli calls “relatively modest” federal investment in the NHSC and the Title VII programs yields tremendous dividends in shaping the healthcare workforce. Chronic underfunding of these programs, however, undermines the efforts to mitigate such challenges facing the workforce, she says.

“Funding for Title VII is 35% less than it was a decade ago, while funding for the NHSC expires in the next few years, leaving questions about how Congress will maintain the program after fiscal year 2015,” Rasouli says. “And as critical as both programs are to shaping the workforce, efforts to substantially increase the number of physicians will require legislation to lift the cap on Medicare support for residency training.”

Ambres, who was a recipient of a NHSC grant that assisted her with funding part of her medical school education, says it made a great difference in her life. “It took some financial pressure off, while allowing me to experience the tremendous gratification received from giving service to the poor and underserved populations of New York City in return for this assistance,” she says. “PCPs do not historically see compensation equal to their specialist colleagues and often have much more difficulty repaying very high debts when they are just beginning their practices.”

Legislation in the works could be the answer

“Congress recognizes the need to build the PCP workforce, and several bills have been introduced with the goal of increasing the number of students who go into primary care specialties,” Cain says.

For example, legislation has been introduced that will increase the cap on residency training positions. “If we can reserve a certain percentage or number for primary care training, this will help increase the number of PCPs,” he says.

The AAFP is reviewing these bills to determine whether they will help meet the nation’s need for PCPs.

In addition, the AAFP has supported the Primary Care Workforce Access Improvement Act, introduced by Reps. Cathy McMorris-Rodgers (R-Washington), and Mike Thompson (D-California).

“This bill would establish a pilot that would look at providing direct graduate medical education funding to community-based residency programs-an approach that would provide more support to community-based primary care residency training,” Cain says. “Also, we’ll be watching the appropriations process in upcoming weeks and months to see if Congress continues to support Title VII and the NHSC.”

Legislation introduced in both the House and the Senate aims to increase the number of Medicare-supported graduate medical education residency positions. Both the bipartisan H.R. 1201 Training Tomorrow’s Doctors Today Act and H.R. 1180, the Resident Physician Shortage Reduction Act of 2013, would begin to alleviate the doctor shortage facing the nation by allowing medical schools and teaching hospitals to train between 3,000 and 4,000 more physicians a year, according to Rasouli.

“Timely enactment of this legislation will be critical to averting the physician shortage crisis and minimizing the time patients must wait to book an appointment with primary and specialty care physicians,” she says.

The AOA endorses the H.R. 487 Primary Care Workforce Access Improvement Act of 2013 and recently endorsed the Training Tomorrow’s Doctors Today Act and H.R. 1180, the Resident Physician Shortage Reduction Act of 2013, and S. 577, the Resident Physician Shortage Reduction Act of 2013.

The American Medical Association also supports H.R. 1180, the Resident Physician Shortage Reduction Act of 2013, and S. 577, the Resident Physician Shortage Reduction Act of 2013.

“Since the enactment of the Balanced Budget Act of 1997, teaching hospitals have been prohibited from increasing the number of resident physicians trained in their institutions,” Stowers explains. “Communities experiencing rapid growth in population are beginning to outgrow the number of physicians practicing there. Hospitals that are currently training residents over their cap, residing in states with new medical schools, and those emphasizing training in community-based settings, stand to benefit from passage of this legislation.

“Furthermore, measures that are part of the ACA, including the Primary Care Incentive Payment Program, which offers bonus payments for primary care services to physicians who treat Medicare patients, and another that increases Medicaid payment levels to at least the minimum Medicare levels, could bolster primary care in certain areas,” Stowers adds.

6 ways the PCP shortage could affect you

It may be more difficult for you to find a primary care physician (PCP) to join (or buy) your practice at a time when patient volume is expected to increase as a result of the Affordable Care Act. Your practice may need to limit or close to new patients because of staffing shortages. Your practice may need to hire midlevel providers-or additional midlevel providers-to perform functions formerly handled by PCPs in your practice. New patients may be sicker when they see you because they postponed needed care. Existing patients may seek care elsewhere due to increased wait times for scheduling office visits. If demand for PCPs is unmet, market forces will expand to fill the void with other professionals or organizations.

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