HCP: Primary Care Workforce with Fatima and Deep

March 20, 2019 | By Matthew Watto, MD

Where do physicians stand in a changing health care market?

Some precocious policy wonks take a deep dive into the evolving trends and future directions for our primary care workforce. Experts, Dr. Fatima Syed and Dr. Deep Shah return to school us on Physician Supply and Demand, the Access Gap, role of NPs and PAs, Retail Clinics, and Managed Care Clinics. ACP members can visit https://acponline.org/curbsiders to claim free CME-MOC credit for this episode and show notes (goes live 0900 EST).

Catch up on our previous discussions with Dr. Syed and Dr. Shah: Episode #62: Pod Save Health Care: The Curbsiders Foray into health policy and Episode #120 Health Policy, Patients, Payments, Paperwork for more context. We also did an overview of health care policy essentials with Dr. Sue Bornstein in Episode #64: Stuff You Should Know About Health Policy

Full show notes available at http://thecurbsiders.com/episode-list. Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com.

Credits

Written and produced by: Fatima Syed MD, MSc; Deep Shah MD, MSc

CME questions by: Chris Chiu MD, Beth Garbitelli MS1,

Hosts: Stuart Brigham MD, Paul Williams MD, Matthew Watto MD,

Images and infographics: Beth Garbitelli MS1

Edited by: Matthew Watto MD, Chris Chiu MD

Guest: Fatima Syed MD, MSc, Deep Shah MD, MSc

Time Stamps

00:00 Disclaimer, intro, guest bios

04:40 Picks of the week

11:40 Defining physician supply and demand

21:30 Why are physicians less productive?

28:23 What does the supply demand mismatch mean for patients?

30:19 Discussion of various care delivery models (retails health clinics, minutes clinics, urgent care centers)

42:15 Physician compensation

53:50 Take home points from Fatima and Deep

59:39 Outro

Primary Care Workforce Pearls

The first and most important question we have to ask ourselves is, “which system would be the best for our patients to receive consistent, high-quality care whenever needed?”. This creates a clear vision. AND, it allows for strategic advocacy to support said vision.

Primary care demand will only go up. Patients are getting older, living longer, presenting with complex medical needs, are more insured than previous generations, and they need care.

BUT, productivity is down. Physicians are seeing less patients than in years past and do less for these patients. This may be attributable to some changes in care delivery eg larger institutions.

‘Decreased productivity’: There’s more than meets the eye. It remains important to focus on external factors that may be impacting physician effectiveness, such as systems problems like time-consuming administrative tasks.

In the past 15 years, there has been tremendous growth in “physicians extenders” (NPs and PAs) across the country. However, this model of incorporating NPs and PAs has not been standardized or perfected.

Projected ranges for physician shortfall in 2030 are between 42,600 and 121,300 physicians, per the AAMC. We don’t know the amount of time physicians will work. Additionally, we lack a full understanding of how NPs and PAs, and new modes of care delivery will impact the health care system.

Fragmentation of care is an ongoing challenge as new models disrupt longitudinal relationships and rapport building in primary care.

Educate yourself on these topics and seek a deeper understanding of national trends. Change will require a grassroots level response.

Primary Care Workforce Show Notes

Key Terms:

Physician Supply and Demand: The balance between the amount of a given service available (namely: physician care) and the desire/need for that service.

Access Gap:  The difference between current uninsured health care utilization and the expected utilization of health care with complete coverage.

“Physician extenders”: Health care providers other than physicians that ‘extend’ care such as nurse practitioners and physician assistants (NPs and PAs).

Retail Clinic: Health clinics based in a corporate or retail space such as drugstores, supermarkets, “big box” stores.

Managed Care Clinic: Patients are assigned to a clinic, which is responsible for providing long-term care (ie: a year or more).

What’s Up, Doc? Primary Care Workforce Demand

An aging population is part of the driving force behind increased primary care demand. But, demographic changes beyond the aging of ‘baby boomers’ are also in play. Preventative care is better. Population health initiatives are more successful. This means providers will have more patients. Additionally, we anticipate patients having longer life spans. Immigration also impacts the amount of patients seeking care.

Bottom line: Primary care demand will only go up. Patients are getting older, living longer, presenting with complex medical needs. Plus, they are more insured than previous generations, and they need care.

Impacting the Shortage

Physician supply equals the number of currently practicing physicians. Trends over time are influenced by the balance of new physicians replacing retiring ones. We can augment the supply by increasing the number of doctors graduating, and influencing immigration policies to increase the supply of foreign doctors. Unfortunately, lengthy training and credentialing are rate limiting steps. Additionally, physicians across all age groups seek to work fewer hours. The age of retirement, which can be influenced by the overall economy, may also affect the shortage in unknown ways.

“Productivity”

Physicians are seeing less patients than in years past. We are less productive, in that we bill less and see less patients even during those hours . Changes in measured productivity can be impacted by the employment models used today versus prior decades. There has been a trend towards decreased productivity as physicians become employees of larger systems rather than self-employed or partners in physician groups; according to a report from The Physicians Foundation, employed doctors see an average of 19.6 patients per day, while a self-employed owner-doctor of private practice sees 23.4 patients per day.

It remains important to focus on external factors that may be impacting ‘productivity’ of physicians. Time-consuming administrative tasks are one example of a systems problem taking physicians away from patient care.

What’s Being Done

We are turning to care delivery from non-physicians. In the past 15 years, there has been tremendous growth in NPs and PAs across the country. However, this model of utilizing NPs and PAs has not been standardized or perfected.

Primary Care Workforce Impact on Patients

Models predict that there will be a deficit of care providers for patients. But, we do not know how severe that deficit will end up being, or the complete scope of the impact.

Projected ranges for physician shortfall in 2030 is between 42,600 and 121,300 physicians, according to the AAMC. The large range speaks to the fact that we don’t know the amount of time physicians will be putting in, we lack a full understanding of how NPs and PAs, and new modes of care delivery (telemedicine, retail health clinics, newer managed care models, etc)  will impact the health care system.

Patient safety

Patient safety, in regards to these new modes of health care delivery, is of particular interest.  While retail clinics have the potential to serve as a stop-gap for patients, they will not be an adequate replacement for long-term health management, as discussed in the ACP Policy Position Paper on this topic.

Care fragmentation

Fragmentation of the care is an unintended side effect of new care models. It becomes more difficult to build longitudinal relationships with patients when they may be splitting their care between retail clinics and a general practitioner. The longitudinal doctor-patient relationship is critical to navigate health challenges such as mental health and other complex/distressing diagnoses. Dr Shah points out that currently, there’s no incentive for minute clinics or retail clinics to provide information to PCPs.

Thinking Outside the Box

One way to address the needs of patients is to have primary care offices build an after hours infrastructure. Adding an after hours code, which would charge a premium rate for providing telemedicine services or office hours after normal business hours, could provide an incentive for widespread adoption. Telemedicine can also be expanded. But once again, physician supply is a rate limiting step for telemedicine, if we want it to be led by physicians.

Subspecialists and primary care workforce

In the short term, financial incentives can be used to make extended office hours more desirable. Additionally, Dr Shah points out that some areas have an excess of subspecialists. These physicians could be incentivized to incorporate primary care into their existing subspeciality practices (eg cardiology, endocrinology, etc).

Looking forward

We are seeing growth of physician bartering groups, trade associations, unions, and staffing companies. These may give physicians more control over the value of their time. The Internal Medicine community is tasked with finding common ground and a more sustainable solution.

Lingering Questions

NPs and PAs

There is a projected surplus of ~40,000 NPs and ~20,000 PAs by 2025 according to HRSA.  We do not have a cohesive plan for how to appropriately leverage all these team members. Consequently, every state must tackle the politically/emotionally charged issue of how to effectively incorporate NPs and PAs. How (if at all) will their roles, responsibilities and privileges differ from those of physicians?

Compensation and workforce

Compensation issues like the gender pay  gap, as well as racial disparities in payment, influence which young people pursue general internal medicine. Additionally, these factors impact which fields they choose as a specialty and subspecialty. Student loan debt is another major factor for graduating physicians. According to the American Medical Student Association, “the median debt burden for graduates of public medical institutions has risen to over $119,000 while that for private school graduates has increased to nearly $150,000” and “41% of students with educational debt report principle in excess of $150,000 and a significant minority reports debt as high as $350,000.” Debates about compensation must acknowledge these factors.

What can you do to get involved?

The first and most important question we have to ask ourselves is, “which system would be the best for our patients to receive consistent, high-quality care whenever needed?”. Once we have a clear vision of what is needed, we must advocate for the policies that will help close the access gap. Finally, we must share our thoughts with community (both in medicine and at-large), and collaborate with patients. Learning our patient’s needs/preferences for care delivery will delineate how to best address them with changes to our health system.

Grassroots level response

Educate yourself on these topics and seek a deeper understanding of national trends. Change will require a grassroots level response. This means knowing how your individual organization works, identifying stakeholders, and investigating who can be engaged to enact changes. Which changes do physicians want at your hospital, clinic, or academic center? Individuals and groups of physicians organizing to create small-scale systems based changes are an important part of how we can trigger the sea change required for broader domestic action.

Compensation from medicare may impact how this story plays out. One key proposal being considered is Patients before Paperwork, which involves addressing the burden of coding and administrative tasks on health care.

Goals and Learning Objectives

Goals

Listeners will recognize the primary care physician’s role as it relates to the primary care workforce and our changing health care landscape.

Learning objectives

After listening to this episode listeners will…

1. Explain what’s driving an increased demand for primary care physicians.
2. Recognize that the provision of primary care may include new models of care delivery including telemedicine, retail clinics, etc. at the cost of hyper-fragmentation
3. Familiarize the audience with compensation trends for primary care physicians in the past decade with the growth of value-based care.

Disclosures

Doctors Shah and Syed have no relevant financial disclosures. The Curbsiders team has no relevant financial disclosures.

Links from the show, plus some extras, to browse at your pleasure

1. Paul’s Pick of the Week: Documentary on Mr. Rogers-  Won’t You Be My Neighbor?
2. Dr. Syed’s Pick of the Week: Annals of Internal Medicine (cover-to-cover) and recent article in Annals titled Ominous Reversal of Health Gains in the United States: Time to Rethink Research Priorities?
3. Dr. Shah’s Pick of the Week: ESPN 30 for 30 Deion’s Double Play and The Road to Character by David Brooks
4. Stuart’s Pick of the Week: Video game Surgeon Simulator
5. Watto’s Pick of the Week: Essentialism: The Disciplined Pursuit of Less by Greg McKeown and the idea of making plans you can look forward to on a daily, weekly, monthly basis.
6. AAMC’s 2018 Update The Complexities of Physician Supply and Demand: Projections from 2016 to 2030
7. U.S. Department of Health and Human Services HRSA’s National and Regional Projections of Supply and Demand for Primary Care Practitioners: 2013-2025
8. Kenneth J. Arrow’s  “Uncertainty and the Welfare Economics of Medical Care”
9. The Physicians Foundation –  2016 Survey of America’s Physicians – Practice Patterns & Perspectives
10. The AMGA 2018 Medical Group Compensation and Productivity Survey
11. EMSI New Data: U.S. Schools Are Training More Nurse Practitioners, But Is it Enough?
12. National Commission on Certification of Physician Assistants – 2017 Statistical Profile of Certified Physician Assistants – Annual Report
13. ACP Policy Position Paper on Retail Clinics
14. The New York Times “Doctors Unionize to Resist the Medical Machine”
15. AMSA Medical Student Debt Fact Sheet
16. Medscape Physician Compensation Report 2018
17. CNN Money “The Gender Pay Gap for Women Doctors is big– and getting worse”
18. ACP Initiative Patients Before Paperwork