The Primary Problem

As the population grows, so does the need for effective primary care. Yet the number of family doctors has dwindled, and the trend isn’t expected to change course

By Patrick Kenney

The modern healthcare industry faces an array of challenges, some more vexing than others.

One particularly confounding problem; we have a shortage of primary care doctors. And it’s not just that we’re coming up short in underserved areas—although we are—it’s a widespread national problem. A problem that the Association of American Medical Colleges warned could leave us short nearly 63,000 doctors by 2015.

One factor that cannot be understated is money. When a specialist comes out of school, he or she can expect to earn in the neighborhood of $3.5 million more over a lifetime than a primary care doctor, The Washington Post reported.

“The truth is, there is no incentive [to become a primary care physician],” says Dr. Scott Palmer, an internist at Rush University Medical Center. Palmer has been practicing private primary care at Rush since 1989. But two years ago, he transitioned into concierge medicine.

In the concierge model, patients pay an annual fee that covers their annual physical, labs, etc., with the added benefit of 24-hour access to their physician. Palmer emails and calls his patients and has the freedom to make house calls. With about 400 patients paying between $1,700 and $2,000 per year, Palmer says the economic model makes more sense and gives him more time to devote to his patients.

Dr. Bryan Becker, associate vice president for hospital operations at University of Illinois Hospital & Health Sciences­­ System (UIHHSS), explains that starting around the late 1970s, we saw a “divergence between the cost of healthcare and the CPI (consumer price index).” As more aggressive specialty care took off, a higher and higher value was placed on specialized care over primary care medicine.

Palmer says he got into primary care because “you could help a lot of people; you could be the quarterback, helping people get to the right specialists or do the right tests and take care of them.” But the idealized role of the primary doctor becomes more complicated in the face of declining reimbursements and the debt burden that students are carrying out of medical school.

This might explain why today only about 16–18 percent of medical students pursue primary care, according to the Council on Graduate Medical Education, especially in light of the increasing workload brought on by more patients and growing demands on primary care doctors.

As care models have evolved, the primary care doctors have taken on more responsibility for the health of their patients. Diabetes care is a good example of where primary care doctors are “really doing the frontline treatment for a chronic illness,” says Becker.

“What hasn’t happened is the redistribution of reward—compensation for that extra degree of management that primary care physicians have undertaken,” he says.

Simply increasing compensation for primary care doctors isn’t likely to happen in a way that solves the problem. Primary care physicians treat a lot of patients on Medicare and Medicaid, where reimbursements are necessarily small. Smaller doctor compensation per patient, coupled with fewer doctors for patients to see, results in primary care physicians who are strapped for cash and time.

The goal of the Affordable Care Act—to bring tens of millions of Americans under the umbrella of health insurance, therefore keeping them out of emergency rooms and lowering the cost of healthcare—relies on the primary care sector to squeeze more patients into an already crushing workload. “I just don’t think there’s a good plan in place to increase the number of primary care physicians,” says Palmer.

The key may lie in not simply adding in more primary care doctors, but adding to their teams. Primary care doctors are learning “how best to work with advanced nurse practitioners (NP) in a way that magnifies their effect on their patient population,” Becker says, “using the strength and leverage of that workforce to deliver the best physician oversight of a broader group of patients.”

The NP and physician assistant (PA) are among the fastest growing job sectors of the healthcare industry. There are about 200,000 of them practicing in the United States today, compared to about 700,000 physicians. While the number of physicians shrinks, NPs and PAs are expected to grow, making up an even larger part of the healthcare delivery model.

“Chicago has a large saturation of nurses,” says Deborah Hall-Kayler, president at Healthcare Personnel, Inc., a temporary nurse-staffing agency. “[There’s] a lot of potential for the nurses who want to continue educating themselves.” And more highly skilled nurses could lead to a higher quality of care. “It’s going to pay off for the patient,” she says.

Healthcare delivery is going in the direction of “a group of clinics in a community, [where] one or two physicians are overseeing the work of five to ten advanced nurse practitioners,” says Hall-Kayler.

If we can’t count on compensation to drive med students into primary care, then perhaps a restructuring of the delivery model could help lighten the workload of the primary care physician. “We may be the only industry that hasn’t changed its delivery model in 75 years,” says Becker. “There’s a need to drive interdisciplinary education in the formative stages,” he says. “Medical students, nursing students and pharmacy students interact together as they focus on cases or case scenarios.”

At UIHHSS they’re developing programs to help bring these students together; to start them off thinking in interdisciplinary terms. But this is a relatively new approach. Most of the industry leaders “weren’t reared in an interdisciplinary world,” says Becker. “I’m 50, and it certainly wasn’t part of my education. [Older doctors] may not really ever have encountered it if [they] didn’t reach to understand it on [their] own,” he says.

It’s unrealistic to think that we’ll suddenly come up with the missing primary care doctors to plug the gaps in the old healthcare model. A dated healthcare delivery system and an aging population will require much more than healthcare reform at the government level. In the practical world, it’s clear that there must be a new approach, and that may mean a very different way of thinking about primary care. [email_link]

Published in Chicago Health Winter/Spring 2013