The coronavirus epidemic is increasing demands on health
care’s frontline, primary care physicians. Even before the outbreak emerged,
conventional wisdom held that we’re facing a PCP shortage. Quartz this
July warned of a “devastating” doctor shortage poised to strike
America. Later that month, the Washington Post chimed
in with “America to face a shortage of primary
care physicians within a decade or so.” Indeed, estimates from the
Association of American Medical Colleges (AAMC) indicate that the U.S. could face a shortfall of between 21,000
and 55,000 primary care doctors by 2023. Add to this the spikes in demand from
Covid-19 and any future epidemics, and the challenge might seem insurmountable
We’re not here to second-guess the AAMC’s estimates.
Based on typical primary care clinical practice, that assessment makes sense.
But what if there were a way to provide enough primary care to serve the needs
of the U.S. population across the next decade — even with abrupt changes in
demand — without having to add tens of thousands of physicians beyond current
expected supply?
To be sure, there are reasons to worry about whether all
Americans have sufficient access to primary care doctors. Those warning of a
potential shortage are right to highlight our aging, increasingly sick
population, and they rightly note that many doctors are cutting back on working
hours as they burn out or near retirement age.
Even so, some simple math would suggest that we should have
more than enough primary care physicians. By 2025, the Department of Health and
Human Services estimates we should have 190,000 non-pediatric PCPs. Assuming
normal patient panels (about 2,000), that suggests the capacity to care for 380
million people (vs. a U.S. population estimate of 272 million). Estimates from
Ezekiel Emanuel and his colleagues from the University of Pennsylvania
published in JAMA
in 2017 put the figures even higher — 600
million people, nearly twice today’s population — when adding in
all fields related to primary care.
So why the disconnect between our theoretical capacity
and the reality that a growing number of patients lack access to primary care?
There are plenty of contributing factors:
·
Uneven
distribution. Some regions may face a mismatch of supply
and demand (not enough PCPs practicing in rural or impoverished areas, for
example).
·
Incomplete
coverage. With the uninsured rate now rising to 13%
to 14% of the population, a significant
number of people simply can’t afford to access primary care.
·
Inconvenient hours. In many markets, primary care still isn’t available on
evenings, nights, and weekends.
·
Inflexible care
models. Most markets still rely on PCPs to deliver
primary care in a physician’s office — even though physician assistants and
nurse practitioners can deliver much primary care at a lower cost and equally
high quality.
·
Payer aversion. Some practices may limit the number of new patients they
are willing to take on from Medicare, Medicaid, and other public programs
because such patients are supposedly “unprofitable.”
·
Inefficient use of
physician labor. Estimates of physician
productivity suggest that 20% to 30% or more of a physician’s available
capacity is absorbed by clinical documentation, electronic medical record (EMR)
inputs, and other compliance-related work.
If you look closely, none of these factors mean we face
a shortage of physicians — they just suggest we’re doing a bad
job of using our current physician population efficiently. Analyses estimating
shortages base them on an inefficient system: on the care models, labor
practices, sites of care, and process inefficiencies that exist today.
So what’s the solution? It requires abandoning a
one-size-fits-all approach to primary care and embracing different care models
for different types of patients. Recent Advisory Board research and analysis suggests the answer is threefold:
better use of PCPs targeted at specific populations, greater use of
non-physician labor where appropriate, and much broader deployment of
technology to increase access to primary care.
Several top U.S. physician groups — including Iora
Health, ChenMed, CareMore, and Southcentral Foundation — have shown that by
focusing exclusively on Medicare patients and others with high rates of chronic
illness, they could reduce ER visits and hospital admissions by 25% to 40% —
often with physician panel sizes around 400 patients — and they do so
profitably under payment systems that reward better care management. Better
primary care management helps reduce the need for expensive specialist care for
the sickest populations. But wouldn’t this strategy add to our
PCP supply woes?
Not if we look at care models that embrace greater use of
non-physician labor for patients outside of the sickest (and costliest) 5%. For
instance, successful models using a mix of physicians, nurse practitioners,
physician assistants and other clinicians have managed to push primary care
patient panels as high as 5,300 per physician, based on Advisory Board benchmarking.
And some bullish estimates have said artificial intelligence could allow
physician-patient ratios to as high as 25,000 per PCP by relieving doctors of
administrative tasks and speeding up evaluation times. In our most recent
Advisory Board study on the future of primary care, we estimate that
more effective use of non-physician clinical support (such as NPs and PAs)
could have the same impact on capacity as adding 44,000 new PCPs, and targeted
use of AI could allow patient panel sizes to increase by about 30%. Taken
altogether, the 190,000 PCPs expected to be working in 2025 should be more than
sufficient to meet America’s primary care needs.
Most important, leading physician groups that have
adopted some or all of these strategies have achieved these results across
vastly different geographic locations and patient populations, suggesting that
their outcomes could be replicated almost anywhere. Their success speaks to the
power of patient engagement, care coordination, streamlined communication,
technology, and top-of-license care models tailored to each individual patient.
It’s time to stop panicking about a looming “shortage.”
Rather than treating today’s inefficient, hodgepodge system as a baseline for
the future of primary care, we should instead ask two questions: How many
doctors would we really need if best, evidence-based practices were widely
adopted? And how can we encourage adoption of those practices? If we consider
these questions honestly, we’re likely to find that there isn’t a physician
shortage after all. Rather, the real shortage is one of the courage to disrupt
the way things have been done for decades.
Christopher
Kerns is Vice President, Executive Insights at Advisory
Board.
Dave
Willis is Vice President, Health System Strategy at
Advisory Board.
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