How the surplus of patients will impact primary care

I believe the projected shortage of physicians caused by  the Affordable Care Act will drive primary care into two opposite tracks. Each is a distinct and logical response to the patient overload and each points out gaping holes in our medical education that must be addressed.

The Association of American Medical Colleges  estimates that there will be a shortage of 63,000 doctors by 2015 and 130,600 by 2025 in the wake of the SCOTUS decision to let the Affordable Care Act stand. This tidal wave of newly insured patients has to be served somehow and medical schools and residency programs cannot supply anywhere near these numbers of new physicians in this short of a time frame.

How will healthcare markets respond – especially with regards to primary care?

I see two likely options.

1. Volume driven: Doctor as apex of a care pyramid. In the more traditional practice structure, the physician will be come the leader of a care team supervising a number of physician extenders who provide the majority of the hands on care. The skill and experience of the physician will be saved for the more complicated and severe cases seen that day. The majority of the doctor’s activity will be devoted to leading and coordinating the care provided by the pyramid of NPs and PAs who are their direct reports.

The challenge to this model is the complete absence of functional leadership skills training in most medical school and residency programs. 30 to 50% of these physicians’ time will likely be spend in leadership and management activities for which they are not prepared on graduation.

2. Service driven: Concierge/direct care model. As the typical patient begins to notice they are only seen by a physician on rare occasion, a certain percentage will become willing to pay for that privilege. I suspect this will quickly grow to a tidal wave of new demand for concierge medical services, where you pay a reasonable monthly fee to guarantee you are always seen by your doctor.

The surplus of patients means a shortage of doctors.  As the shortage worsens,  I believe a larger and larger segment of our population will become willing to pay to continue to see their doctor as they do today.

The huge popularity of this service will have another important driving force – the office duties of the physician are exactly the opposite of those in example #1 above. Here the physician is often seeing less than 15 patients a day, providing direct patient care and continuing to have meaningful personal relationships with their patients.

The challenge to this model is the absence of business training, specifically marketing training, in most medical education programs. The concierge model is inherently entrepreneurial and will always involve a fairly sophisticated marketing program to be successful.  This is not an insurmountable obstacle and I have yet to meet a newly board certified MD who understands the essentials of marketing.

So if you have 10 years or more of practice ahead of you, I suggest you look at these models and get ready to be met by a fork in the road. Will you choose to lead a team or build your cash/concierge practice? If you are leaning in one direction, I suggest you get started building your missing skill set — be that leadership or marketing. The wave of newly insured patients is coming.

Dike Drummond is a family physician and provides burnout prevention and treatment services for healthcare professionals at his site, The Happy MD.

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  • PcpMD

    This is an interesting article. Looking at the various factors you’ve mentioned, I’ve more or less come to a similar conclusion. Unless there’s a significant change from the current direction medicine is going (doubtful), PCP’s will either be heavily “augmented” (read replaced) by “physician extenders” in the insurance model (or have the option to continue working in their current capacity at the same pay scale as NP’s/PA’s), or will come to realize that working for a payer other than the patient in any capacity is untenable, and go concierge/retainer/cash pay. Psychiatrists have more or less gone this route long ago – they either take insurance, and provide 15 minute psych med evals, leaving the counselling, therapy and other non-pharmaceutical care to non-MD’s, or remain true to the full scope of psychiatric care that they’re trained to provide, and become cash-only.
    A third possibility is that the government creates expedited immigration and licensing channels to import a lot of relatively cheap foreign doctors to work in the US as PCP’s. That’s how New Zealand is addressing their doctor shortage. Australia too. One in 3 doctors in the UK are trained overseas.
    Whatever the outcome, to me its clear that primary care physicians in the U.S. must be ready to embrace major change in the next 5-10 years.

    • Dike Drummond MD

      Thanks for your comment PcpMD – I can’t see the immigration option coming to pass here although it is always something that could be put into action very quickly if even a single state decided to change their licensing criteria.

      The big challenge to the high volume and high service options are the holes in the medical education system with regards to leadership and marketing skills. There is already too much to teach in too little time to equip doctors for the clinical side of their practice. Most will rely on on the job training or additional coursework to fill in the holes.

      Dike Drummond MD

  • Samir Qamar

    Good article, thank you. You are absolutely correct about doctors requiring business guidance for implementation of membership model practices, such as in Direct Primary Care (DPC). With these types of practices still unregulated by most states, navigating the legal thicket can pose additional challenges. MedLion Direct Primary Care helps doctors set up new DPC practices or assists practicing doctors with DPC conversion. Alongside legal help, MedLion doctors are taught the most successful business tactics that maximize potential, from direct experience.

  • LeoHolmMD

    Correct. There will be two Primary Care systems: One for the rich and one for the poor. Thanks Affordable Care Act. When doctors are faced with choosing between being a manager in a data mining pyramid scheme and actually having a meaningful interaction with patients…guess what they will choose.

    • southerndoc1

      Agree we’re headed towards two systems., but that was well underway before the ACA was passed

    • Dike Drummond MD

      Dr. Holm – if you think there are not two healthcare systems – one for the rich and another for the poor in every nation on the face of the earth – you are fooling yourself. And this article is about choice on the part of the physicians.

      I believe the demand to see a physician will drive people to be willing to pay for that privilege. It just so happens that the concierge/direct pay business model is also more humane for a doctor who is relationship focused. You don’t have to be a volume driven doc in the future if you don’t want to AND you have to get started on building your leadership and marketing muscles now.

      Dike Drummond MD

  • Rebecca Coelius

    Third scenario: The problems that primary care is intended to solve for the healthcare system- initial diagnosis and workup, chronic disease management, preventive medicine, care coordination, etc, will no longer all be the responsibility of a single primary care clinic or doctor. They will be broken up into separate businesses and delivery channels, not all of which will be run by physicians, but perhaps people with management training, or an RN or health coach with a specific focus on say addressing prediabetes and behavior change. This leaves the physicians free to focus on the science of clinical medicine. Given what little complex medical decision making I see primary care doctors able to do in the average clinic, I’m a bit prone to believe we would have more than enough PCPs if they were deployed efficiently instead of asking them to fill all the cracks in our shattered delivery systems.

  • Erika Bliss

    Thanks – excellent article, you sum it up very concisely. In response to the concerns about care for the rich and care for the poor, our experience at Qliance has been that Direct Primary Care appeals to all socioeconomic groups if the price is set appropriately. Our patients run the gamut from very low income to extremely wealthy and everything in between. It’s an issue of how the model is distributed that will determine who has access to it. Lately, payers who cover low income and severely disabled people are looking at the DPC model as a key strategy for controlling costs and improving outcomes. And, DPC offers a very attractive practice environment for doctors who, in their heart, want to be primary care providers, but can’t figure out how they can sustain it over time without financial and professional burnout. We are starting to see more and more companies emerge that will not only operate their own clinics and hire docs but will also help independent docs convert over either partially or in whole to DPC. It’s the only way I can see that we can rescue primary care as a recognizable part of the health care system in a way that is broadly acceptable to patients and that is highly functional and sustainable. I, for one, don’t want to be a manager of a pyramid, I want to have continuous, healing relationships with people I care for — I want to be an “attending” physician in that I can attend to my patients when they need me, not when a system determines that their problems are complicated enough to merit my attention.

  • buzzkillersmith

    Not so fast.
    3. Docs will close their practices and surplus patients will be sent to UC centers and ERs and have crappy or no continuity of care.
    Apex of a pyramid?! You’ve been smoking too much punditry. Concierge-that might happen to some extend.
    Predicting is hard, doctor, especially the future.

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