How will primary care handle the influx of patients in 2014?

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

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  • Anthony D

    I think the problem is government and its inability to manage a lemonade stand makes it significantly worse.

    If we wanted to help just a few million then why write a law that
    affects over 300 million people AND about 100 million businesses? Why
    didn’t we simply subsidize the few million by helping to pay their

    And our system was broken because the actual “consumer” was not involved
    in the purchase of medical care. I teach college economics and when I
    get to the chapter on “supply and demand” I ask the class “how much does
    a doctor visit cost?”. Some will say something like “$25″ because that
    is their copay. Others shrug their shoulders. Some guess “$75?” or
    “$100?”. See the problem is WE don’t pay for the services.

    This is why HSA (Health Savings Accounts) are the solution. We get a
    high deductible policy and open an HSA. We deposit money and many
    employers would add to it. Then WE pay the doctor for the visit. And
    what would be our first question? “How much will it cost”. Too much and
    we look for a more affordable doctor. ABSOLUTELY costs will come down
    because there would be an INCENTIVE to lower price. Plus doctors would
    take less just to NOT have to fill out massive paperwork needed by

    Too lengthy to explain here but wouldn’t need a 2000 page law OR tens of thousands of regulation like Obamacare does.

    • edpullenmd

      The whole third party payment system certainly does obscure any relationship to supply and demand economics.

      • buzzkillerjsmith

        Dr. E,
        Plain vanilla supply and demand has essentially nothing to do with medicine. The classic paper was written by Arrow in 1963 and it has not yet been intelligently refuted. Google Arrow medical care if you’re interested.

        Writing “supply and demand economics” in the context of medical care makes intelligent observers roll their eyes. Just sayin’.

        • guest

          Would there be as much “demand” for things like $1200 visits to the ER for the sniffles, if people actually had to PAY for it?

          When people are insulated from costs, it DOES obscure any relationship to supply and demand economics.

          Hand out free stuff, with the guarantee that “someone else” will pick up the tab, and there will always be a huge DEMAND for it. But charge people what that “free” stuff actually costs, and the demand curve might go down.

      • guest

        As the demand from patients for direct-pay and concierge medical practices grows, so does the supply of direct-pay and concierge medical practices. The market does wonderful things when you get the government and its crony capitalist mates out of it.

  • southerndoc1

    Primary care physicians have absolutely no responsibility nor power to solve this problem. This is the last thing we should be spending our time worrying about.

    • Mengles

      As long as primary care physicians see themselves as martyrs in this cause of “access” – something that has not changed in decades – they will continue to lose. If you have problem with “access” – blame your insurance company- not your doctor. Pullen is naive to think that he has any power when it comes to changing access.

      • southerndoc1

        This is another terrible AAFP talking point: that it’s the responsibility of family physicians to figure out how to deal with the expected tidal wave of new patients.

        And it’s the same self- hating mindset that came up with the PCMH: the idea that primary care docs are to blame for everything that’s wrong in our heal are system, and they alone have to do the repair. Family physicians aren’t underpaid, they’re just not working hard enough!

        Someone in the other thread asked why the AAFP leadership is so hostile to their membership. Th get an answer, I’d suggest you start by looking in the DSM.

        • Mike Trene

          “This is another terrible AAFP talking point: that it’s the responsibility of family physicians to figure out how to deal with the expected tidal wave of new patients.”

          They’re brilliant, actually.

          Because citizens who’ve fallen for the hype are necessarily going to be disappointed, if not outright angry, that “Hey, I’ve got my insurance now, why can’t I get all the care I want from whomever I want, and get it NOW?”

          And guess who the AAFP has set up as the villains, the bad guys, the ones who are to blame? Yup. Those lazy, greedy family doctors!

          The ghost of Marcus Welby, M.D. weeps.

        • drgn

          oh that’s good. like that answer on the DSM. The problem is the DSM has been transformed into a device for pharmaceutical manufacturers. It is no longer recognizable as belonging to psychiatry. Ask Dr. Allen who’s posts have been plentiful here.Or maybe I’ll ask Bradley Manning–or was that Chelsea Manning to clarify?

      • ninguem

        Interesting you use the word “martyr”, and you’re right, family medicine has lots of “leaders” with martyr visions.

        Thing is, they make half a million a year in executive positions, they want practicing FP’s like me to be the martyr.

    • Stephen Sutherland

      if primary care physicians do not lead out in resolving the primary care shortage, It is very logical and expected that non-physicians in washington will regulate primary care physicians – determine salaries, organization, systems, everything. So it is critical for PCPS to regulate themselves. very closely for maximum efficiency and demonstrate that effort

  • ninguem

    Ed for Pity’s sake.

    Where are those people getting healthcare now?

    Suddenly snap your fingers and these formerly uninsured have insurance. IF…..and I say it’s a BIG “IF”……the newly-insured have access problems, how is having insurance and not being able to access care because of sudden demand increase, somehow worse than not accessing care ostensibly because of no insurance?

    How about waiting to figure out if there even IS a problem in the first place?

    I for one am getting might tired of the “crisis” talk.

    • Guest

      The government will simply mandate that all physicians accept Medicare/Medicaid insurance.

      Don’t think it will happen? Don’t be surprised if they at least try.

      • ninguem

        I don’t doubt you for a second.

      • Alice Robertson

        That may happen but if you follow the site Obamacare Watch, etc. you can see how it will play out. If a poor person gets the 90% discount on a plan they are still in a terrible mess. Their 10% will still be $200 a month and that’s for the Metallic Plan which has a $3000 deductible and only a 60% payment after that. I simply can’t figure out that’s helping the working poor. The mandate is the part that has Americans up in arms and no bloody wonder.

        Yet there are primary care doctors online who say they want a bureaucracy so they can get a steady paycheck without the worry of exactly what you describe. Then the patients aren’t served well. When you visit the progressive websites it’s a bit astonishing some of the utopias they envision.

        • guest

          “Their 10% will still be $200 a month” ……..

          ………so the full price of this low-level “metallic plan” would be $2000/month? For one person?

      • drgn

        Sounds good in theory but how would they really enforce that?

        • LeoHolmMD

          Board certification.

        • ninguem


          In Massachusetts, you cannot balance-bill Blue Shield, you cannot bill more than the Medicare limiting charge. You sign the affidavits for this with your license renewal.

          They have tried to link licensure to accepting Medicaid in Massachusetts. So far, the bills have not gone anywhere.

    • edpullenmd

      I think a lot of them are not getting healthcare now. My expectations are that there will be greater demand for access to care if people have insurance. I agree that the very poor reimbursement for Medicaid will keep many of these people from finding primary care providers, but many will have commercial payers, and I am simply pointing out some of the scenerios I anticipate.

      • ninguem

        Well, ed, if they’re not getting healthcare now…..if I’m wrong, and there really is an access problem, we’re at status quo ante.

        They still don’t get healthcare.

        Right now, the nurse practitioners, PA’s, pharmacists, naturopaths, chiropractors, massage therapists, cosmetologists, and I think my plumber, are all demanding full scope prescribing authority, the Granny Clampett lay midwives in Oregon want to do C-sections, the veterinary techs are crying out over species chauvinism and four legs versus two legs, the medical and osteopathic programs are adding schools onto the Taco Bell and A+W stands, and over and over and over, it’s the access crisis from Obamacare. It’s a drumbeat, and there’s an agenda behind it.

        It’s like the zombies are coming out of the ground for your brains.

        Global warming is so last year, now it’s the access crisis.

        How about seeing if there is a problem first? If the sky isn’t falling now, it won’t fall next year.

      • T H

        There have been good studies in the ER literature that show one of the first things people do once they ‘get insurance’ of any kind is go to the ER to have their chronic issue (of whatever flavor) looked at.

  • Mengles

    It’s articles like that these, by Dr. Pullen, that make me convinced more and more that it’s the not so smart (street smart) students that go into primary care. Just one question for Dr. Pullen: Were you ever an officer in AMSA at your medical school?

    • Close Call

      Quite the opposite. Concierge/retainer/direct primary care practices are growing. Not many specialties can go off the grid and survive without insurance.

      • ninguem

        I agree, that’s the hope I’m holding onto myself.

      • guest

        I hate the name “concierge”, because it sounds so posh and “one-percenter”, but as a patient currently in between primary care doctors, I will be actively seeking out a direct pay practice. “Concierge” makes it sound like I’m some rich Palm Beach matriarch who wants someone to wait on me hand and foot (and maybe cut the crusts off my cucumber sandwiches and get me front row opera tickets while they’re at it! lol). “Direct pay” sounds more down to earth and sensible, just getting good old fashioned medical care but without all the non-medical government bureaucrats and insurance functionaries crowding into the exam room with us.

        I truly believe that that is the future of primary care.

        • Brian Stephens MD

          I agree, the term concierge needs to go. Im not sure what that means… Provide mints in the waiting room or something??

          I think we are entering a time of “government subsidized health care” vs “Private health care”.

          “Private health care” is taking on a WHOLE new meaning.
          I think that is the term that should be used for concierge/direct care practices.
          It is truly going to be the “new” private practice.

    • edpullenmd

      I was not involved in med student politics, but was near the top of my class. I may be naive, but have been around long enough, and in private practice reasonably successfully for almost 30 years, so think I have some street smarts. Re the above thread suggesting that family physicians are assuming blame for the access concerns and are being made out as villains I don’t have any idea where these concepts are coming from.

      • LeoHolmMD

        If you work for a large hospital system, FM docs are routinely blamed for access problems. “You’re not seeing enough patients”, etc. If you don’t accept a particular insurance, you are perceived as greedy or heartless or whatever. Private practice insulates you from these concepts, fortunately.

      • ninguem

        Organized family medicine and at least some teaching programs. I was in one myself.

  • buzzkillerjsmith

    How will it handle the influx? Not too well.

  • drgn

    A fundamental flaw of the system that still exists with Obamacare is that each provider decides who to contract with and the reimbursement is extremely variable from plan to plan. If ACA reimbursement for PCP’s is similar to Medicare there will be problems with access to care.

  • curmudgeon

    I suspect all this foorah about PCP will be overwhelmed by the fiscal
    crunch of the late teens and mid 2020′s and the inablitly of the system to provide more than basic maintenance care will be stretched beyond any possibility of coverage. High $ pharmaceutical interventions will be
    beyond the reach of all but the most (politically) connected. Tailored
    genetic medicine will wither on the vine. Geriatric medicine will drift
    toward hospice like care at younger ages than it does now. There will
    be too much stress on the federal budget to fund much more by 15 yrs from now, maybe even sooner.

  • Suzi Q 38

    I don’t think that it is going to be as bad as many of you think it is.
    Time will tell.
    The new year is “just around the corner.”

    • Guest

      If you actually had to PAY for medical care, would your life revolve around doctors visits to the extent that it does?

      We are about to get millions of people who previously had to be judicious about deciding when to go see the doctor, and deciding when to demand care, now get insurance just like you have……. and a not small number of them will probably be like you, feeling like they are entitled to run to the doctor for attention all the time because “now I have insurance, I might as well, it’s almost like I’ve already paid for it and i’m ENTITLED”.

      • WarmSocks

        Paying for insurance isn’t the same as paying for medical care.

        People who don’t have a low deductible are quite careful about incurring medical expenses, because (barring a catastrophe) those expenses will likely all be out of pocket.

  • Stephen Sutherland

    I would like to suggest that someone post an article describing just 1 key Initiative that would correct the Primary Care Physicians Shortage very quickly, with the intention of sending that proposal to Washington DC after it reaches a threshold of 20,000 PCP electronic signatures. (just throwing out an idea to see if the physician blogosphere would focus on finding the solution to primary care concerns and send it to washington )
    In my humble opinion, I would suggest that the fastest way to correct the Primary Care Physician (PCP) shortage is to aggressively Incentive primary care service by increasing reimbursement rates for PCP significantly. For example, Medicare and Medicaid could make it law to reimburse 100% of all PCP fees for the next 20 years ***or something of this nature***. I believe an aggressive incentive of this type should have the following effect (a) Primary Care Physicians (PCPs) would re-open private practices asap and grow those private practices to handle capacity much larger than they serve in the employment of hospitals or other practices in which they are unhappy. (b) PCPs would be financially enabled to establish open new practices in underserved and rural areas and build to handle large capacity. (c) PCPs would come out of early retirement and abandon early retirement plans. Numbers could be quantified on each of these points based on surveys. (d) PCPs who exited primary care services by focusing exclusively on cosmetic and medical spas would be encouraged again to provide Primary care services and grow their practice to handle large capacity. (e) New graduates from IM & FM residencies would be encouraged to open Primary care practices instead of working as hospitalist (who do not provide primary care services) (f) Primary care physicians would also be encouraged to practice FULL Spectrum Primary care by adding procedures and services to their practice which would streamline the delivery of service and decrease the number of hospital visits (g) and medical students would be encouraged to enter Family medicine at a rate that increases from 7% to 25% in the next 3 years. I believe studies would demonstrate that 35% of incoming medical students are open to a career in family medicine before the knowledge of primary care reimbursement rates scare the majority away.

    A part of a note could also describe that reimbursements rates, as is, would result in early departure from primary care, resistance to medicare and medicaid patients until it becomes absolutely necessary to have NPs and PAs take over primary care responsibilities function as triage nurses to Specialists – which would increase health care costs. Until NPs and PAs also abandon primary care services for the same reasons.

    As of 2013, the ACA has written into law a Medicaid Reimbursement increase specifically for Primary Care Physicians retroactive to Jan 1, 2013. But from the JAMA article “JAMA Forum: Warning: Dangerous Physician Payment Cliffs Ahead” – medical leaders seem unimpressed and warn primary care physicians not to be encouraged by those increases.

    I was thinking someone should write an article proposing just 1 solid solution or 3 at most that would be strong enough to encourage Primary Care System in the manner described above.

    ( i can’t write such an article i’m just a med student right now and i’m supposd to be studying for Step 2 CK – of ground to cover ) I really hope PCPs will unite and propose — the best solution.

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