The VA scandal over excessive waits for doctors’ appointments is an early warning of things to come. Over the last three years, the demand for primary care appointments at the VA increased by 50% while the number of providers rose by only 9%. With four hundred vacancies for primary care providers, the VA is facing a severe gap in its ability to care for its patients.
It isn’t surprising that the VA is among the first health systems to suffer from a shortage of primary care physicians. With its low pay scales, the VA has difficulty recruiting and retaining doctors. But the shortage will expand as baby boomers age and more Americans gain health insurance. The Association of American Medical Colleges estimates that by 2020, there will be a shortage of 45,000 primary care doctors nationally.
Even now, it isn’t just patients at the VA who face long waits to see a primary care physician. Patients in Boston, where health insurance coverage expanded early and there’s been a subsequent increased demand for doctor’s services, wait an average of sixty-six days to see a family doctor. There are no national reporting requirements or standards on waits to see a private physician.
Many in Congress are now calling for the VA to hire more physicians. And there’s also a push to expand the workforce by training more primary care physicians as well as nurse practitioners and physician assistants, but this won’t be enough to meet the need. So long as the demand outstrips capacity, patients will never have good access to primary care providers.
The average primary care provider is responsible for about 2,300 patients. A doctor would have to work almost twenty-two hours a day to provide all the recommended services to that many patients over the course of a year. Doctors could limit their practices to 1,200 to 1,800 patients, considered the ideal panel size, but this means some patients won’t have doctors at all. Doctors could also stretch themselves further by changing the way they work and care for patients.
At Group Health in Seattle, doctors have twelve in-person appointments with patients a day, a luxurious schedule when many primary care providers are asked to see that many patients in an afternoon. But in addition to those in-person appointments, Group Health doctors also have telephone appointments and provide some care over email. A patient with high blood pressure doesn’t need to come in to a doctor’s office to have his vital signs rechecked and his medications adjusted. It’s a waste of valuable time for both the doctor and patient. At Group Health, such patients are managed virtually over email or the phone. Medical assistants review doctors’ schedules in advance, and when possible, convert in-person appointments to virtual appointments, freeing up more time in the day for the doctor to help other patients.
But Group Health is a capitated system, which means that it receives a fixed payment per patient rather than per service provided, so it’s incentivized to stretch its dollars to buy as much health value as possible. In the traditional fee-for-service model, doctors can’t afford to provide virtual medicine because they are only paid for face-time with patients.
Group Health’s computerized medical records also help further extend physician capacity. Doctors don’t have to call, write or email patients after an appointment to follow up — something that can be very time-consuming — because patients have access to their test results and “after visit summaries” online.
We could also offload the physician from doing unnecessary work in the exam room itself. Much of that work consists of collecting information from a patient and inputting that into a computer. But Dr. Peter Anderson, a doctor in southern Virginia, realized that if he trained his nurses to do this for him, he could see more patients a day. The transformative step wasn’t data entry, it was data collection. He trained his nurses to elicit patients’ stories of their current and past illnesses, obtain lists of their medications, and review preventive screening recommendations. This allowed Anderson to ask his patients questions that were more thoughtful and to perform a better physical exam. Anderson doubled the number of patients he could see in a day from twenty to forty. He also improved the quality of his care and brought in more than enough revenue to cover the extra staffing.
Many health systems will balk at the cost of hiring more medical assistant or nurses to support doctors in their work. But according to Dr. Michael Magill, who helped implement a similar team-based system of care at the University of Utah’s Community Clinics, “It is a false economy to save money on staff support when it decreases your revenue.”
Will patients accept virtual doctoring? And care delivered by a team that includes their doctor? Ultimately, patients want access to their own doctor when they need it.
Celine Gounder is a physician and medical journalist. She can be reached at her self-titled site, CelineGounder.com. All views expressed in this article are hers and should not be attributed to any of her employers.