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BHCG Monitor: Focus on Health Care Benefits - Primary Care Challenges

 

Primary Care — Challenges Ahead

The United States (including Wisconsin) is facing a shortage of primary care providers – a shortage that will only grow more acute in the coming years. Dwindling access to primary health care services is both an existing and growing problem, leading to a number of cost and quality concerns. The problem is compounded by an unequal distribution of primary care providers, with rural and central city areas facing the most acute shortages.

The reasons for the shortage are varied, which will require a variety of solutions to effectively address the problem. This article will examine the magnitude of the shortage (both now and in the future), the reasons for the shortage, the impact on employers and their employees and some of the steps that are being recommended by policy experts to address the situation.

The numbers

Although estimates of the current and projected shortages of primary care physicians vary, there is general consensus that a shortage exists and will likely increase. In 2010 the United States had 279, 719 primary care physicians (physicians are counted as primary care physicians if their self-designated primary specialty is one of the following: adolescent medicine, family medicine, general practice, geriatric medicine, internal medicine, internal medicine/pediatrics, or pediatrics). This represents approximately 35 percent of the total active practicing physicians in the country, while many health policy experts suggest that a sound health care system should be comprised of 40 to 50 percent primary care physicians. It was estimated that in 2010 there was a shortage of 16,000 primary care physicians across the country. This shortage is expected to grow to 52,000 by 2025 according to research published in the Annals of Family Medicine. (Association, 2012)

A recent report by the Wisconsin Hospital Association shows similar shortages in Wisconsin. By 2030 they estimate there will be a shortage of between 1,080 to 3,312 physicians with 80 percent of the shortage in primary care. In rural areas the problem is even more acute. A third of Wisconsin’s population lives in rural areas, yet only 11 percent of physicians serve rural areas.

A different opinion

There is a school of thought, outlined in a recent edition of Health Affairs, that current predictions are overestimating the looming primary care physician shortages because traditional doctor-to-population ratios underestimate how technological advances will allow fewer physicians to provide care to more patients. Advances such as using electronic technologies to communicate with patients to reduce in-person visits and the use of electronic health records to reduce the administrative burden on physicians, may lessen the shortage. In addition, the medical home model of care with providers working as a team with other health care professionals may allow for greater efficiencies along with delivering care to certain patients by Physician Assistants (PAs) and Advanced Practice Registered Nurses (APRNs).

The shortage – why?

The primary care provider shortage can be examined from two perspectives: demand and supply. Demand for primary care services will increase substantially in the next 20 years, but not only for the reason most people suspect – an aging population. In fact, according to the Annals of Family Medicine, only 10,000 of the estimated shortage of approximately 52,000 primary care physicians (noted above) will be due to an aging population. They predict a 15.2 percent increase in the U.S. population which will necessitate 33,000 more primary care physicians, while the Affordable Care Act will require approximately 8,000 more.

On the supply side, one factor trumps all. Not enough medical students are choosing careers in primary care, instead opting for generally more lucrative careers as specialists. According to a recent article in the Journal of the American Medical Association, based on surveys of third year residents, only 20 percent of 2012 medical school graduates will be expected to be in primary care in 2015.

While expanding enrollment in medical schools will make a dent in the shortage of primary care physicians, unless a greater percentage of medical students choose primary care, the problem will only get marginally better, while producing more, less needed, specialists.

"The reason there's a real threat of a shortage of primary care physicians is that they are paid much less than other physicians," says Ann S. O'Malley MD, MPH, a senior researcher at the Center for Studying Health System Change. "Their incomes are lower than surgeons and other specialists, and a lot of what primary care physicians do is not compensated. The time they spend coordinating care on the phone, talking to social workers, and talking to specialists about care provided to the same patient just does not get compensated. So between their lower baseline salary and the way our reimbursement system works, it's a much less attractive field for medical students to choose."

The impact

The increasing shortage of primary care physicians will make it more and more difficult for consumers to find timely, and generally more cost effective, primary care, leading to a host of cost and quality issues. In areas already experiencing an acute shortage of primary care physicians, emergency department use for primary care problems – the most expensive way to deliver primary care – is on the rise according to a study by the Center for Studying Health System Change. In addition, a lack of access to a primary care physician can eventually leave consumers with complex or chronic medical conditions without anyone to oversee their care – adding unnecessarily to the cost of care and risking poorer outcomes.

What can be done?

Every employer should be strongly encouraging their employees, if they have not already done so, to establish a relationship with a primary care physician. As the shortage grows, finding a primary care physician willing to accept new patients will become increasingly difficult. Employees without a primary care physician run the risk of not getting recommended preventive exams, using expensive care options (e.g., emergency departments) and not having an advocate to guide them through the health care system should a more serious health issue arise.

On a macro level, policy experts have recommended numerous approaches to address the shortage. There is no one solution, but a combination of these initiatives has the potential to address the shortage. These include:

  • Change reimbursement methodologies to pay primary care physicians for critical work they now perform without reimbursement. This will help to close the income gap between primary care physicians and other specialists, making primary care a more attractive option to newly minted physicians. All payers need to address this issue – governmental programs and private payers – to make this an effective solution.
  • Increase the usage of team-based care, such as medical home models, to promote the most effective use of all professionals (see below).
  • Encourage the entire spectrum of care providers to practice to the full extent of their licenses. With RNs, APRNs, and PAs delivering all the care their license permits, primary care physicians will be freed up to handle the more complex cases, making more efficient use of their time and the health care system more efficient overall.
  • Increase the number of practicing PAs and APRNs by expanding enrollment in these programs in colleges and universities.
  • Increase the use of technological advances such as telemedicine and electronic medical records to lessen the administrative burden on primary care physicians and increase their efficiency.
  • Increase the number of physicians by expanding medical school enrollments.
  • Expand the number of primary care residency positions available.
  • Increase the use of loan forgiveness programs for medical school debt to encourage residents to choose a career in primary care and to practice in locations with critical shortages of primary care physicians.

Summary

By most accounts, the shortage of primary care physicians will continue to grow over the next 15-25 years for a variety of reasons. This shortage impacts both the cost and quality of care. Employers should take action to promote the selection and use of primary care physicians among their employee populations and support policy initiatives that will ameliorate the primary care provider shortage going forward.

Works Cited

Anam, T. (2012). Who Will Care for Wisconsin. Wisconsin Medical Society.

Wisconsin Health Care Workforce 2012 Report. Wisconsin Hospital Association, 2012

Cross, M. (2007). What the Primary Care Physician Shortage Means for Health Plans. Managed Care .

Green, L., & Savin, S. a. (2013). Primary Care Physician Shortages Could Be Eliminated Through Use Of Teams, Nonphysicians, And Electronic Communication.

Projecting US Primary Care Physician Workforce Needs: 2010-2025, Annals of Family Medicine, (November/December 2012).

West, C. D. (2012). General Medicine vs. Subspeciality Career Plans Among Internal Medicine Residents. Journal of the American Medical Association .

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BHCG Monitor: Focus on Health Care Benefits - April 2012