As a family physician I look forward to the next few years in practice with a sense of uncertainty. One of biggest of these uncertainties is how to help meet the anticipated demand for primary care I expect. A number of changes are coming that will alter the supply and demand equation for patients and primary care providers. These include significant projected population demographics, and others that are due to the increase the number of Americans expected to have health insurance.
The US population is projected by the census bureau to increase gradually over the next 50 years, but the age group breakdown of the US population is going to change more dramatically. This is due in large part to the baby boomer and echo boom groups getting older and to modest increases in anticipated life expectancy. Another factor that will impact the supply and demand for primary care is that there is little doubt in my mind that insured Americans are going to demand more primary care services per capita than uninsured Americans.
Here are just a few of the projections for demographic changes from 2015 to 2025 from the census bureau and projections related to the Affordable Care Act:
- The number of Americans age 95 and older will increase by 48.7% from 576,000 to 857,000, compared to a total population increase of 7.8%.
- The 65 and older population, those who with today’s rules will be Medicare eligible will increase by 17.3 million, to 65.0 million total. This is an increase of 36.4% and will represent 18.8% of the population in 2025, compared to 14.8% of the 2015 population.
- In contrast the number of Americans age 20-64, the typical working age group, will increase by 3.88 million, or 1.11%. In the 20-24, 45-49, 50-54, and 55-59 year old cohorts the number or Americans is actually projected to decrease between 205 and 2025.
- The US physician force is aging along with the rest of Americans. Estimates that 50.8% of licensed US physicians in 2012 are age 50 or older, and that the only age decile of licensed physician numbers that increased was the 50-59 year old group.
- In 2014, less than 5 months from now, a large number of Americans are expected to be added to the insured roles. This is highly likely to increase demand for primary care services. Estimates of as many as 32 million newly insured Americans are predicted. (32% Medicaid, 45% from the newly established exchanges, and 23% from employers)
- As the Patient Protection and Affordable Care Act increases accessibility to health insurance if you change jobs or move your ability to find a primary care physician if you move may decrease. This is a dichotomy I’ve not seen mentioned often.
These numbers project many challenges facing our country, but as a family physician who has not been able to recruit a new physician in over 2 years despite persistent efforts, this is especially challenging. Who is going to provide medical care to this aging population?
I understand that physicians are not the only providers of primary care. Our practice actively integrates both nurse practitioners and physician assistants into patient care. Still I do not see a time where primary care physicians don’t play a key role in taking care of these older Americans with more complex and multiple health concerns. The steady increase in obesity and associated rates of diabetes and its attendant complications will further add to the need for providers of more complex primary care.
It seems that everyone projects varying degrees of physician shortages, especially in primary care. There is little debate that as Obamacare leads to more insured patients in just 5 months, added to the demographic changes noted above, the demand for primary care will rise faster than the supply of providers expected to be available. How will this impact the major stakeholders?
Here are some of my thoughts and predictions:
- It’s going to become increasingly difficult to find a primary care physician quite soon after Jan 2014.
- If you have a primary care physician keep them. If you don’t, consider establishing care with one prior to 2014 or immediately after the New Year. I expect it to become more difficult in many communities soon thereafter.
- If your physician is near retirement and you do not expect their practice to be able to absorb you into their care, consider switching to a younger provider. (Don’t worry, if I am your physician I am not planning retirement in the immediate future and my group will continue to care for you when it is time for me to retire.)
- The 18 new medical schools which will begin to open this fall may help somewhat, but unless increased primary care residency positions open this will only marginally help the situation. In addition without some sort of financial incentive to go into primary care there is no assurance that these schools, despite their hope to graduate more primary care doctors, will succeed in that aspect of their mission.
- If this becomes a crisis of access to primary care it could be the cue to much more radical change in how US health care is funded. There are lots of rumblings about pay for quality, a change from payment for services to payment for results, and how Accountable Care Organizations are going to change the way care is provided and compensated. I anticipate this to fail in its goal of cost containment and quality improvement or at least to be inadequate to be sustainable.
I have made some changes to my practice in anticipation of this increased demand for access to care. I’ve teamed with two really good physician assistants, and worked closely with them to assure we are well aligned and coordinate our care. Together we should be able to provide great access to my existing patients and to remain open to new patients. Others in our group are considering similar changes.
Still, unless we can recruit new family doctors to the group our capacity is going to be filled at some point in time, and I don’t see other primary care groups in our community who are more successful than we have been in family physician recruitment. It is an interesting and challenging time to be a family physician, and how to support the anticipated demand for care in the next few years is going to make it more so. Stay tuned for more as this unfolds.
Edward Pullen is a family physician who blogs at DrPullen.com.