• Can we solve the primary care shortage without more physicians?

    The most recent edition of Health Affairs contains a provocative paper by Thomas Bodenheimer and Mark Smith; it opens by imploring we halt our reliance on “policy wish lists” when it comes to the primary care shortage facing the United States. Increasing capacity through new physicians would take decades, they argue. Improving reimbursements isn’t feasible; we’d need to hike Medicare rates for primary docs by 50% to narrow the gap with specialty care.

    The authors propose that “shortage” is a misnomer and we need to reframe the problem to tackle it productively:

    The first step is to redefine the crisis, which is currently mislabeled as a physician workforce shortage. The accurate formulation is a demand-capacity mismatch. Primary care practices could greatly increase their capacity to meet patient demand if they reallocate clinical responsibilities—with the help of current technologies—to nonphysician team members and to patients themselves. Physicians often complain that they are responsible for tasks that team members with far less training could perform.

    Their analysis finds that nearly a quarter of the average family physician’s time could be reallocated to other members of a primary care team, allowing PCPs to see more patients without extending their hours.


    Adding up the potential rechanneling of care from clinicians to nonclinician personnel for preventive, chronic, and acute issues, it is possible that 24 percent (10 percent plus 9 percent plus 5 percent) of clinician time could be saved by sharing the care among a primary care team. The registered nurse and pharmacist workforces are sufficient to add primary care capacity. Expanding the medical assistant workforce could be accomplished quickly and would both enhance primary care capacity and create jobs. Many of these concepts are being implemented in a variety of primary care practices throughout the United States.

    Reorganizing primary care delivery looks promisingly straightforward in the paper; the authors outline specific tasks that could be readily redistributed to registered nurses, pharmacists, or other team members. But these efforts would encounter predictable complications. There are regulatory regimes in many states that prevent the delegation of certain authorities to non-physician practitioners. Less tangible cultural divides are no easier to repair—especially when entrenched payment structures favor the status quo.

    “Reconceptualizing” the primary care shortage in practice will take a lot of policy legwork, but it may be the most viable solution to a problem that’s been percolating for years. The paper—well worth reading in full–sets up a valuable framework for moving forward.

    Adrianna (@onceuponA)

    • Many more organized and larger practices already delegate a lot of responsibility to the “physician extenders”. People who have the knowledge already exist, and existing healthcare professionals could learn the extra skills quite quickly. Massively redesigning the healthcare system to create more PCP’s not only would take decades, and cost a fortune, it would require actually knowing what the PCP demand will be decades in the future.

      The need for more primary care has been conflated with the need for more PCP’s as part of a political effort to raise PCP incomes. This may be a worthwhile goal in itself, but it is not necessary to address the shortage of primary care services.

    • The paper makes a good point overall, but it falls into the obsessive focus on health care ‘teams.’ I know this freaks out the ‘medical home’ and ‘coordinated care’ advocates, but really, most people don’t need this level of health care where every single medical need is under the management or supervision of a primary care doctor. Just go to Minute Clinic if you have a sore throat and think it might be strep.

      Save the ‘coordinated care’ by health care ‘teams’ for the patients that really need it – you’ll save everyone a lot of time, money, and hassle.

      Of course, as long as a visit to your primary care physician is ‘free’ or only costs a $50 co-pay, and visiting a Minute Clinic is ‘out of network’ this won’t happen in most cases, but that’s another issue.

    • Another factor is that many people receive primary care through specialists (commonly internists, ob-gyn but also many others… I once visited a urologist who did a complete annual physical and charged about $500 for it when I only wanted a prostate exam).
      Most specialists were attracted to their specialty because of higher pay, not because of an innate love of ENT or skin diseases.
      A lot of this specialist manpower should be re-purposed to primary care.

    • Well, many people think skin disease and ENT are a lot more interesting than primary care. Same for plastics, optho, ortho, neurosurgery… Money is certainly a motivator, but even with equal pay many specialists would hate to be PCPs.

    • In addition to the team care approach advocated by Bodenheimer and others, there is another potential solution for mitigate at least some of the fallout from the coming primary care physician shortage. That solution involves improving the way doctors communicate with patients before, during and between office visits.

      Thirty years of research demonstrates the most physicians employ the same paternalist, physician-patient communication skills they learned back in medical school….where the physician is in charge and does most of the work and talking…while the patient assumes their traditional passive sick role. This is not a particularly efficient nor effective strategy for getting patients more engaged in taking a greater role in their own care.

      Studies have shown that be adopting a more patient-centered approach to interacting with patients over episodes of care – rather than an acute basis as they do now – they could address issues over a series of visits rather than try and cram every thing in to on visit.

      The problem with physician-patient communication is the illusion that it is occurs. Like team acre…improved physician-patient communication is a relatively inexpensive solution that merits serious consideration.

      Boffeli, T., et al. Patient Experience and Physician Productivity: Debunking the Mythical Divide at HealthPartners Clinics. The Permanente Journal/ Fall 2012/ Volume 16 No. 4.

      Steve Wilkins
      Mind the Gap Blog