Problems with the proposed solutions to the primary care shortage

Projecting future physician workforce needs is a challenging calculation that must take multiple variables into account to avoid missing its mark. In the mid-1990s, the American Medical Association confidently predicted that the penetration of managed care would lead to a large “physician surplus” and convinced Congress to cap the number of graduate medical education (GME) positions subsidized by the Medicare program.

Two decades later, there is a widespread consensus that the U.S. is actually experiencing a physician shortage that will worsen with population growth, the aging of the baby boomer generation, and an influx of newly insured from the Affordable Care Act.

Although medical schools have expanded to meet the anticipated demand for doctors, the AMA and others are still pushing for the GME cap to be lifted so that new medical graduates will have enough places to train. But how has the specialty of family medicine fared, and what else can be done to extend capacity of the existing primary care workforce? These questions were the subjects of two recent Georgetown University Health Policy seminars.

Problems with the proposed solutions to the primary care shortage
Image courtesy of the American Academy of Family Physicians.

Modest gains in the numbers of U.S. and foreign medical graduates matching into family medicine residency programs over the past five years will fall well short of supplying an additional 52,000 primary care physicians by 2025, a shortage projected by the Robert Graham Center.

A recent issue of Health Affairs examined potential strategies to extend primary care capacity in the absence of an (increasingly unlikely) surge in generalist trainees. For example, telehealth technologies could lighten the load on family physicians by promoting patient self-management of chronic conditions; improving medication adherence; and facilitating real-time specialist consultations. A more radical and controversial proposal aims to provide EMT-style training to a new profession of “primary care technicians” who could provide basic primary care services under the supervision of a physician, freeing physicians to “focus on patients with more complex conditions.”

As our discussion pointed out, though, these proposals have serious disadvantages. By reducing face-to-face interactions, telehealth could easily make family medicine less rewarding. Family physicians who end up seeing only patients with multiple complicated chronic conditions could burn out faster, leaving even fewer in the workforce. As a broad cognitive rather than a narrow, procedure-focused specialty, family medicine is less likely to be suited to care by technicians than, say, anesthesiology or gastroenterology.

Finally, given the persistent and growing income gap between family physicians and subspecialists, the real solution to the primary care shortage may still be staring us in the face.

Kenneth Lin is a family physician who blogs at Common Sense Family Doctor. This article originally appeared in the Health Policy Exchange.

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  • ninguem

    Once again.

    There is no shortage of primary care physicians.

    There is a shortage of primary care physicians willing to be screwed.

    You can train all the primary care physicians you want. If all they have available to them are piss-poor offerings, they will LEAVE primary care. You will get no physicians in rural areas, you will get no physicians in inner-city deprived areas unless it’s made worth their while to go there.

    • Lisa

      My father, a professor of optometry, once made a similar comment about optometrists. He was complaining that non of his students wanted to leave the Bay Area when the graduated. They didn’t want to move to the midwest to start practices.

    • T H

      There is a reason my Family Medicine trained self stays at my Emergency Medicine job… plus, in the rural area where I practice, I have more continuity of care with my patients than most of the (few) providers who work in clinics (MDs, NPs, etc.).

  • ninguem

    For what it’s worth, I notice less than half the FP training positions are filled with graduates of USA schools.

    The rest are filled by people who have trained abroad. Foreign nationals, and US citizens trained outside the USA.

    My prediction, and it’s not much of a prediction. The percentage of USA graduates will soon approach 100% of positions offered. The reason for this is, we’re opening large number of USA schools, MD and DO programs, they have recently unified a lot pf the postgraduate training programs.

    That is, they opened the SCHOOLS, but did not increase postgraduate training slots.

    A medical degree without postgraduate training is a useless and expensive piece of paper.

    About this year or next, the number of graduates of USA medical and osteopathic schools, will equal the number of postgraduate training slots. Then afterwards, unless more postgraduate training slots open, there will be more USA graduates than postgraduate positions.

    Musical chairs. Some are left out. Perfectly qualified graduates will find themselves with an expensive and worthless piece of paper.

    About a thousand USA graduates did not match into any programs in this years Match. They have no place to go.

    Notice that number…….1,000……is comparable to the 1,500 or so positions in Family Medicine residencies that went unfilled.

    So, right now, there were about a thousand USA medical students who would rather risk having an expensive and useless piece of paper, than match into those unfilled FP residencies.

    Many of those graduates will, of course, enter those FP residencies anyway, after the Match. The programs scramble to get warm bodies, and the students scramble to avoid unemployment in the face of a quarter-million-dollar student debt.

    So these programs will be getting the bottom of the barrel of the graduates……those who couldn’t match elsewhere…….and probably worse…….they’re getting residents who really didn’t want to be there.

    • Patient Kit

      Perhaps this explains why, with Medicaid, I’m getting such excellent specialist care at a teaching hospital in NYC but such merely adequate primary care in the outpatient clinic at the same hospital.

      I’m being treated by an awesome attending GYN oncologist, who has his flock of lucky residents learning good stuff from him. I’d recommend this doc to anyone who has the misfortune of needing a GYN ONC and I’ll base my next insurance choice on what insurance he accepts..

      On the other hand, when it comes to primary care, I’m being treated by a very stressed out resident who, to say the least, does not inspire confidence. It’s a good thing I’m not shy about speaking up and advocating for myself when I think his suggestions are questionable. He makes me nervous. I avoid this primary care clinic as much as possible unless I need a prescription.

      • ninguem

        I bet when you have a form to fill out, the GYN oncologist sends you to that family doc.

        • Patient Kit

          You will not deter me from “worshipping” my GYN ONC and avoiding the primary care clinic. ;-) I was just noting, in response to your post, that I see a difference in the residents working in specialties and the residents working in primary care.

          Actually, when I needed a letter from my GYN ONC for Medicaid, he told me he would give me a letter on his letterhead — all I needed to do was call his office, talk to his PA and let her know what I needed. Of course he writes my Rxs that are related to my cancer. I went to the hospital’s outpatient clinic for issues unrelated to GYN ONC. He’s great but he’s not my primary care doc.

          This past year has been a real crash course for me on Medicaid. I had to scramble to get my cancer treatment when I was dx after I lost my Blue Cross (layoff). I quickly figured out that my best option was a good teaching hospital and it has worked out fine (except for primary care). But I hope to be off Medicaid soon. I will say that I’ve never been treated for one minute by anyone working in that hospital like I’m a second class citizen because I have Medicaid.

          And finally, to be clear, I do hear what you’re saying and think primary care docs should be paid more fairly. I don’t think the good Blue Cross plan that I had for 18 years before this Medicaid odyssey, was paying primary care docs much either.

          • ninguem

            No…..fine, worship away.

            You’ve got a good situation, hold onto it. Especially if that doc deigns to do an administrative task, I had to pull myself off the floor with surprise.

            Oh, what’s an example. One University where I held a faculty post for a few years.

            Billing for a patient established with your practice. The code for the visits, in increasing complexity.

            99211
            99212
            99213
            99214
            99215

            99211 – usually the doctor’s not even involved. A nurse checks your blood pressure, draws blood for testing, that sort of thing.

            99212 – maybe a doctor checks a wound and takes out stitches.

            99213 – a “typical” medical office visit for maybe one stable problem. Say, high blood pressure and medication refills.

            99214 – multiple problems, The diabetic hypertensive with problems not well controlled, maybe a new problem is brought up as well.

            99215 – Multiple complicated problems, maybe you’re making a decision to undergo surgery, forego treatment in a hopeless case, long counseling, extensive examination.

            That sort of thing.

            Well, the hospital where I was teaching. They got dinged by the Feds.

            Many of their clinics, the patient billing had two checkoffs for billing.

            99214 and 99215.

            The University was a Very Important Place, and it seems everything they did was “Extraordinary”, and they billed accordingly. They never just took out stitches or did medication checks.

            They’re just notorious for padding bills, and they use their political pull to extract far higher payment for the same service, compared to a private practice.

            I bet they didn’t get twenty bucks for that GYN onc office visit.

            But hey, take advantage of what you can. I would. Especially if you’ve got cancer and all that, best of luck to you.

            It’s actually simple. You get what you pay for.

            Or what the government pays for.

            If the GYN onc got paid for their visit, what the FP got for the primary care visit, and vice versa, you’d have the opposite experience of a luxurious primary care visit, and a shabby GYN onc visit.

          • Patient Kit

            Thanks very much for the well wishes. And, eh, I’m just kidding you. I don’t worship any of my docs. I know you’re all human (thankfully). In your shock, perhaps you overlooked that my doc delegated the letter I needed from him to his PA (and I actually wrote it). Good team work, huh? ;-)

            Same doc talked to me on the phone for at least 20 minutes about 6 weeks after he did my surgery, very patiently and thoroughly answering all my questions. It was halfway between my initial post-surgery checoup and my first 3 mo follow up and I called him because I had a few questions that couldn’t wait til our next visit.

            I’m sure you’re right that Medicaid pays more than $20 for a visit with him and they paid a lot more for the state of the art robotic surgery he did on me. But I wouldn’t know what anyone gets paid. Unlike Blue Cross, which sent me reams of statements for every little thing, detailed with the fee submitted and the contracted rate actually paid, I rarely see anything from Medicaid (or Healthfirst, the co that manages my Medicaid). Who knows? Maybe I’ll start getting statements a few years after I’ve moved off Medicaid. But right now, I have no way of knowing what they are paying my docs, all of whom are teaching hospital based. I’ve never gone to the ER, BTW, since I’ve been on Medicaid.

            I do understand the idea of getting what we pay for. And though it’s not exactly the same kind of math that you’re talking about, I feel like I paid a lot of taxes for 35 years — and what I expect to receive from what I paid for years, is to have a safety net catch me the one and only time that I’ve ever needed anything from my government.

            What can I say? I have a very strong survival instinct. I go after what I need aggressively when my life is on the line. If I go down from this illness, I’m going down swinging, not looking.

          • ninguem

            You don’t know what Medicaid is paying.

            Likely the docs don’t know either.

            With Medicaid, it’s way, way behind the scenes.

          • EmilyAnon

            My oncologist said medicaid payment for a routine visit would barely buy him a hamburger. Of course, it could be one of these that even come with a ‘nurse’.

          • Patient Kit

            To be honest, I’m glad my doc didn’t tell me that. “I can’t even buy a hamburger with what they pay me to treat you. Let’s schedule surgery.” Ack!!! The way he treats me (especially compared to the way I was told I’d be treated as a Medicaid patient), I can’t even tell for sure that he remembers I’m on Medicaid. I’m sure he must though.

          • ninguem

            Honestly, he probably doesn’t.

            At that level, he doesn’t need to know, he’s just paid a salary.

            When I was in academics, I didn’t know, it didn’t matter.

            Thing is, of course, when it does matter, then the academic center will simply close to Medicaid, and you don’t get in the door. Not the doctor’s decision, the institution’s decision.

            Thing is, losing the tertiary care, like GYN oncology, will be disastrous to Medicaid from a public relations standpoint. So there is often a battle, but eventually the academic center gets whatever they need, so that doc you worship gets paid appropriately and doesn’t jump ship.

            A primary care doc, we have no such clout, so we’re just told to go pound sand.

            Then people wonder why the primary care clinics are either closed to Medicaid, or the ones that are open, are filled with harassed docs at their wit’s end all the time.

          • buzzkillerjsmith

            Hey ninguem,
            Why did you quit academics? Low pay? Politics? What?

          • Patient Kit

            I have no doubt that the politics can be brutal, but it must have been nice to be able to treat every patient the same with no need to look at the insurance page of the chart. From my patient perspective, that’s certainly a good thing.

          • EmilyAnon

            My doc wasn’t ranting at me. Fortunately I have health insurance through my job (so far). Something triggered him off. I don’t think he’s employed by the hospital because I am billed for my co-pay through his billing company, not the hospital’s.

          • Patient Kit

            I did investigative research and writing for a living before I got laid off. This year on Medicaid, at times (when I wasn’t terrified about having cancer), has felt like I was on an assignment to see what I could find out from firsthand experience (as opposed to doing online research). I don’t think even a FOIA (Freedom of Information Act) request could get me all the info I’d like to know about Medicaid.

        • buzzkillerjsmith

          20 bucks for a level 3 medicaid? My buddy in CA gets 19. You’re way overpaid, doctor.

    • buzzkillerjsmith

      Less than half a spots filled by US grads. Not surprising. Only morons go into family med. I should know because I went into it.

      • ninguem

        That’s DOCTOR moron.

        Let’s have some respect.

  • Dave

    I would add:
    There is NO shortage of PCPs, just a shortage of PCPs willing to live and practice in crappy areas nobody else wants to live. Major cities and places with decent quality of life have no trouble recruiting physicians of all types, but nobody wants to haul their family out into the middle of nowhere unless they already have ties to the area.
    Additionally: while money is a huge reason students don’t go into primary care, many still wouldn’t do it even if the pay were similar because they don’t want to spend their days doing what PCPs do. Yes the pay gap needs to be addressed, but that alone won’t solve the problem. Loan repayment won’t do it either; if it did, every medical student would be lining up to join the military. Students with the heart and temperament to be great PCPs don’t want to spend their lives clicking boxes and copy/pasting.

    • LeoHolmMD

      You can correct this by actually recruiting people from small towns. People from the middle of nowhere actually like the middle of nowhere. Just have to convine the academic snobs to stop recruiting for their darling programs.

      • ninguem

        You are, of course, correct. If you want doctors to practice in rural areas, you train doctors who are FROM those rural areas.

        Given the demographics of rural areas, you might find yourself with a certain……reverse affirmative action.

        The resulting fight (and there surely would be such a fight) would certainly be interesting.

        • Kristy Sokoloski

          The State of Utah is working on such a thing right now with a bill that got passed recently.

        • Patient Kit

          Is the shortage of rural family practice a new thing?

          One of my favorite TV shows of all time — Northern Exposure — was about a NYC doc transplanted to practicing in a rural town in Alaska, where there was a desperate need for a doc. That show first started airing in 1990. The creators of NE were the same two guys who created one of the best TV medical dramas ever made — St Elsewhere.

          • ninguem

            When St. Elsewhere first came out, it was realistic but too dark. It was lightened up to more of a fairy-tale soap opera.

            Reminds me of the book “The House of God”, where I learned the term “St. Elsewhere”, I don’t know if the author coined the term or not.

            I had one take on reading it before medical school, another when re-reading it after internship.

          • Patient Kit

            Admittedly, it’s been a long time since I watched the show (in the 1980s), but I remember it being good dark drama and black comedy. I don’t remember the soapy fairy tale aspect. My sister, who works in the NYC public hospital system (HHC) as a psychotherapist, still refers to her workplace as St Elsewhere all the time — St Elsewhere and The Wire.

          • ninguem

            Try “The House of God” by Samuel Shem (a nom de plume). Samuel Shem is, if I remember correctly, a psychiatrist.

            The medical schools had their major teaching hospitals, then had more peripheral community hospitals. Often Catholic-run, especially in New England in the day. So Saint Elizabeth Hospital, as an example, became St. Elsewhere.

            As in, not the big-shot teaching hospital.

            Massachusetts General Hospital gets called “Man’s Best Hospital”.

          • EmilyAnon

            HOG was made into a movie in the 80′s, just so-so. The book was better.
            http://www.imdb.com/title/tt0087429/?ref_=fn_tt_tt_4

          • Patient Kit

            Thanks to the frequent mentions here on KMD, I now have The House of God on my reading list. It sounds like a book I will enjoy.

          • ninguem

            It’s been my experience that students entering medical school, find The House of God to be sort of slapstick funny.

            After finishing an internship year, they find it sad.

          • Patient Kit

            Not being a doctor myself, I can only imagine the difference reading this pre med school versus post internship/residency. I imagine it would be similar to reading/watching M*A*S*H before and after actually experiencing war firsthand. I really love good dark comedy on serious subjects so, I think it sounds like it could be a good read from a patient’s perspective too.

  • LeoHolmMD

    From the trenches, there does not appear to be a doctor shortage. I see doctors in fierce competition over business, with billboards and ads and whatever. There are whole armies of doctors sitting around on committees, boards, panels, pet projects, admin, on and on. Plenty of doctors doing silly boutique things as well. Almost any administrator will tell you their doctors are not seeing enough patients. Perhaps there is a shortage of doctors who actually want to work for a living. I can agree with that. Most of my day is squandered on data entry and administrative nonsense. Would love for someone to address that instead of shortage mongering.
    The actual problem is a disparity of providers. Perhaps there are not enough rural Primary Care providers. That is a whole different problem than a “shortage”. If you find a hungry homeless person, you don’t just assume there is a food shortage in this country. To the contrary, there is massive abundance. There is a distribution disparity. The solutions are very different than just increasing supply.
    We could have a profession that actually meets demand through sound academic policy. We could use a really novel idea called a “marketplace” that would attempt to match supply and demand. You could correct working conditions for Primary Care providers that would actually draw people to the profession. You could correct the perverse payment system that causes rural Primary Care docs to shut their doors while others thrive off of useless procedures.
    Dereliction of Primary Care has led to this problem. Until that is addressed, there is not a single solution listed above that will address this.
    (I just copied what I did at another blog. Have to be efficient when the “shortage” mongerers are out in force.

    • Deceased MD

      Perfectly stated. In the ’90′s there was an “oversupply” because physicians started being delegated to overseeing the “team” while other disciplines took over. You can always manipulate a shortage or “oversupply”. This is all about their wish to control and dumb down medicine and ultimately destroy HC.

      • ninguem

        There’s a big shortage of physicians in Zimbabwe.

        So, let’s train a gross oversupply of physicians in the USA so some will go to Zimbabwe.

        That makes as much sense as the proposals to fix the USA “shortage”.

  • Deceased MD

    zing! Brilliantly stated.

  • buzzkillerjsmith

    thanks for the info

  • Dub

    Thinking about doing a webinar instructing PCPs on how to go into a concierge or membership practice. Will limit to 10-20 docs. No charge. If interested email jtmdmember@gmail.com with contact info.