Why is there a shortage of primary care physicians?

Next in a series.

Primary care physicians (PCPs) are becoming extinct.  It’s true. Not many medical students choose primary care as their career path. Older PCPs are retiring early. Many others are closing their practices or seeking employment at the local hospital. And there has always been a shortage of primary care physicians in rural and urban poor areas. Today only 30% of all physicians practice primary care (compared to about 70% in most other developed countries and about 70% in the United States fifty years ago) and this percentage is shrinking at a steady rate.

Estimates in the Annals of Family Medicine indicate that America, which today has about 210,000 primary care physicians in active practice, will need an additional 52,000 PCPs by 2025. Good luck. This is based on growth of the population (requiring 33,000 added PCPs), the aging of the population (10,000) and the added number of individuals that will have health insurance as a result of the Affordable Care Act (8000). The number needed almost undoubtedly is substantially higher. And if you accept my premise to be detailed in a later post that a primary care physician (or nurse practitioner or physician assistant) should be caring for only about 500-1000 individuals rather than the current typical 2,500+, then the need is truly much, much greater.

About 25,000 new graduates enter medical practice each year. This represents an increase of about 3% per year while the general population has been growing about 1% per year. Today there are about 29 physicians for every 10,000 population although they are not necessarily distributed evenly across all population areas or groups.

With these numbers one could argue that there is no shortage of doctors. Indeed with the opening of new medical schools and many others increasing class sizes, there should be another 3000 added to the graduating class each year rising to 5000 by the end of the decade. But most graduates enter specialty care rather than primary care training driving the ratio of PCPs to specialists of 30%-70% ever wider. Adding further to the specialist roles (except those with known shortages like general surgery) will only add to health care costs rather than increase quality.

There is good data to support the notion that a primary care-based delivery system increases quality of care and decreases costs compared to our current specialist-based delivery system.

Critical to how many PCPs are trained are two key factors. One is how many trainee (residency) slots are available to train primary care physicians. Medicare pays hospitals to train medical school graduates during their residency. Currently, Medicare pays teaching hospitals $9.5 billion each year to subsidize the training of the next generation of physicians with residency programs that range from three to seven or even more years after medical school graduation. Medicare has kept these “slots” it will cover flat since 1997 and has given no indication of raising this as of yet.

But even more importantly are the absolute numbers of PCP vs. specialist slots available. There are simply many many more specialist slots available. Medical centers want to train specialists. They represent assistance to the faculty or staff physicians and they bring an aura of quality to the hospital. No good professor and chief of, say, neurosurgery at an academic hospital would not want to have his or her own training program. It is a matter of pride. Absent a training program, the best will not choose to work for that medical center and will choose to practice elsewhere. This is a serious conundrum for the medical center that needs the specialty program to drive more revenue. And Medicare has been willing to pay for these specialty training programs over the years while not increasing funding for primary care training.

There is a recent study covering 2006-2008 residency training and Medicare payments. Kenneth Lin, MD, commenting on the article on KevinMD.com, noted by separating out those 20 hospitals that trained the most and the 20 that trained the least PCPs, respectively, among all teaching hospitals in the USA, “the top primary care producing sites graduated 1,658 primary care graduates out of a total of 4,044 graduates (41%) and received $292.1 million in total Medicare graduate medical education (GME) payments. The bottom 20 graduated 684 primary care graduates out of a total of 10,937 graduates (6.3%) and received $842.4 million.”

In other words, the hospitals that got the most money trained a larger proportion of specialists; perfectly logical if that is where the money is. But this makes little sense in an era of serious primary care physician shortages that will certainly worsen in coming years.

The other problem is that primary care is not seen as a desirable career path today. There are multiple reasons. Primary care physicians earn about one half of what a specialist earns. Specialists are generally seen to have a higher level of prestige in the community — “I was sent to Dr Jones, the surgeon.” Most medical school graduates have large debt loads so earning more means paying it off sooner. And with a large debt, it is harder and scarier to take out a loan to start a practice that brings in fewer dollars. But the primary reason is that medical students realize that PCPs are in a non-sustainable business model, one in which they must see far too many patients per day, accept unpleasant burdens with insurers, be on call many hours and yet not be able to offer  what they know would be better care. They see it as a no win situation and so avoid primary care even if that might otherwise be their preference.

Less prestige, high debt loads and a knowledge that PCPs work in a non-sustainable business model forcing them to see an excessive number of patients per day in order to meet overhead and still garner an income about one half that of the specialist is, combined, enough to discourage medical school graduates from selecting primary care as a career.

The next post in this series will focus on the PCP’s need for time — to listen, to think, to prevent, to treat, to coordinate.

Why is there a shortage of primary care physicians?Stephen C. Schimpff is a quasi-retired internist, professor of medicine and public policy, former CEO of the University of Maryland Medical Center, senior advisor to Sage Growth Partners and is the author of The Future of Health-Care Delivery: Why It Must Change and How It Will Affect You.

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  • Dub

    Appears to me the only way PCPs can continue to exist in private practice is to go with a retainer or membership practice. The ones I have spoken with love their practice of medicine with that format. Set my brother up. With the approval of the moderator, I would be happy to post my phone number for physicians to call me. It was a great learning experience, both in learning what to do and importantly what not to do.

  • buzzkillersmith

    Primary care for physicians is done. Stick a fork in it. The PAs and NPs might abandon it, too, especially as the docs bug out and they’re left holding the bag.
    The PCMH idea is risible. There is no hope.

  • http://www.kevinmd.com kevinmd

    Thanks, I corrected it.

    K

    • Deceased MD

      Disqus is not working to give me messages from other posts?

  • futuredoc

    Following up on Dub, the retainer based and membership based PCPs that I have interviewed are very positive with their new practice arrangement. As one said, “I am working just as many hours but I am provided much better care. In the past if a person had high cholesterol, I wrote a prescription for Lipitor. Now, we spend some real time talking about diet, exercise, etc. I may still need to prescribe a statin but it is not my first reflex anymore.”
    Robert, thanks for the spell check!

    Buzzkillersmith, I didn’t know what risible meant. For others like me: laughable, ridiculous, absurd, comical

  • swatdoc

    Maybe reduce the years required for residency to be an office based family physician. Many opt to put the multiple years towards IM or other specialties. Maybe a 2 year post grad program for an office doc might help encourage them to go that route. It wont do much for the typical chaos that we face every day though as FPs

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