By Sumi Dey, MD and Harland Holman, MD
It’s time to serve as a primary care physician.
This is what we tell our students. Why? Because the US Department of Health and Human Services estimates that by 2025 the United States will be short 35,000 to 44,000 adult care primary care physicians. We believe this is a crucial time for medical students to become interested in serving as primary care physicians. If future students will not prepare to care for our nation’s needs, who will?
If a student asks why they should be primary care physicians, this is our answer.
Americans who regularly visit their primary care physician have a 33% lower health care cost and 19% lower odds of dying than patients who visit only specialists. According to the Report on Financing the New Model of Family Medicine, if every American had an established relationship with their primary care physician, it would reduce national health care costs by $67 billion per year.
Primary care access is correlated with more equitable distribution of health within a population and can mitigate the adverse effects of income inequality. This is especially important in the United States, where minorities and economically challenged people are struggling to access regular primary care.
Countries where patients have established relationships with primary care physicians have lower depression and suicide rates. Mental health problems including depression and anxiety are part of patients’ everyday life experience, and often primary care physicians address mental health at almost every visit. According to the National Alliance on Mental Illness, more than 70% of visits to primary care physicians are associated with psychological issues.
Establishing a long-term, strong relationship with a primary care physician plays a crucial role in early disease diagnosis and prevention. The Centers for Disease Control show that disease prevention is important in creating healthier communities and productive lives, and in reducing overall health care costs.
Primary care physicians provide continuity and preventive care for a wide range of medical conditions and undiagnosed health concerns. They also serve as the framework for building a strong health care system that ensures positive, cost-effective health outcomes and health equity for the nation, especially in underserved populations.
Students, it’s time to serve as a primary care physician.
It’s interesting to learn that there’s a significant 14% difference in survival rate in between those who visit primary care physicians and those that only go to specialists accordingly to the report on Financing the New Model of Family Medicine. That’s astonishing since I never that’s a large margin for those who are looking into prolonging their lives. My father would definitely be happy to learn of this. I’ll have a regular consultation with a primary health physician next week. Thanks!
The United States is indeed short about 40,000 primary care physicians. Those who hope to encourage the high ground career choice and others who embrace special admissions, expansions of graduates, special curricula, special training, Teaching CHC, or loan repayment incentives should carefully examine their efforts to see if they are delaying the appropriate treatment. These “solutions” that have all failed for decades, for over a generation of class years of graduates, should be considered unethical, inefficient, and ineffective.
Shortages are predominantly about Triple Threat. Triple Threat is about worsening in three areas – revenue, costs of delivery, and complexity. Revenue is designed to create shortages. Costs of delivery have made margins worse. The complexity of patients has been increasing rapidly due to demographic, family, and community changes as well as meaningless use. The margin needed to survive has been shaved in primary care, mental health, women’s health, and basic surgical services. Generalists and general specialties are impacted most. Those taking one or more fellowships are making a choice to avoid Triple Threat. This is also why these specialties are tumbling at about 2 to 3 percentage points of decline each year as measured in the 2013 Masterfile compared to 2005. They are also aging fast – another indicator of lack of replacement.
Triple Threat is also the major cause of burnout, higher turnover, lost productivity, and movements of primary care trained physicians and clinicians away from primary care before, during, and after training and across the years of practice. Triple Threat impacts do not go away and they appear to be getting stronger.
Family medicine graduates have been counting down from 90% reliable for 30 years of primary care for the 1970s graduates to the 2010s graduates that might manage to keep just above 50%. Similarly rural outcomes have tanked from 30% to 15%. True reforms are needed that focus on specific team member support in the careers and in the locations most needed. They remain the ones who deliver the care despite Triple Threat worsening over the decades since the 1980s.
The US changed from policies supportive of nurses, team members, primary care, women’s health, and basic services to a focus on cost cutting in the 1980s and beyond. The 2010s “reforms” and assumptions and incentives have made matters much worse.
The consequences of Triple Threat can be best seen in counties with the least workforce – as shaped by Triple Threat design. There were 2621 counties lowest in concentrations of physicians in 2010 with 40% of the US population. This is up from 33% in past decades and is on the way to 50% or 200 million left behind in 2800 lowest physician concentration counties by 2040 if not before. More counties and millions more Americans will continue to be added each year for decades to come as small practices and small hospitals and generalists and general specialties decline – until the financial design is addressed.
These lowest concentration counties have highest concentrations of patients with the health insurance least supportive for these patients and for local primary care. These include high deductible and worst public and private plans – worst for patients, worst for populations, and worst for local primary care practices.
The designers have shaped lowest concentration counties to average only 40 to 45 active primary care physicians per 100,000 – about half enough given the populations served. The dollars can be tracked and these counties suffer with less than 13% of health spending and about 25% of the workforce in each of primary care, mental health, women’s health, and general surgical services. About 75% of the rural population (45 million) and 32% of the urban population (93 million) is included. In general most states have a 4 – 8 higher and highest workforce concentration counties and the remainder 50 – 200 are lowest. About 50% of spending and 45% of physicians are found in 1100 zip codes with 10% of the population in 1% of the land area. The financial design is predominantly about concentrating health care dollars, the most lines of revenue, the highest reimbursements in each line, and the most procedures and technology and health care.
For a graphic rendition picture the Red Counties from last election in your mind plus the 60 rural counties with majority Native, African American, and Hispanic populations. Well-intentioned efforts will not overcome the fact of 100 – 150 million Americans left behind depending upon how many you want to include and how far behind you want to indicate. Perhaps the one major flaw of designation of rural or underserved locations is the tendency to think some relatively smaller population is impacted. As with the designs for economics and education, most Americans are left behind and the designs are making the disparities worse.
The strains are unmistakable across the human infrastructure attempting to fill in the gaps across schools, teachers, nurses, small hospitals, small practices, and basic lowest paid services. These are all concentrated in lowest concentration counties.
The demands of measurements, metrics, and higher costs of delivery that compromise primary care are unmistakable – except to associations and institutions and foundations that somehow support them despite the consequences.
About 25% of the primary care workforce attempts to stretch to cover 40% of the population and over 45% of estimated demand based on demographics, situations, conditions, social determinants, and local resources – the real determinants of health and education outcomes. Lowest levels of mental health, women’s health, and general surgical specialties as well as public health all contribute to overload and undersupport for primary care where needed.
There are about 70,000 active primary care physicians in these lowest concentration counties and NP and PA add in to about 90,000 primary care equivalents. The entire proposed high figure of 40,000 for the primary care shortage is actually too low. This 40,000 could be fit into these counties and they and their team members would still be stretched to cover 150 million people by 2020 but there is one major obstacle. They could not even practice in these settings due to the financial design.
Revenue Deficits Shape Deficits of Workforce
An estimated 160 to 170 billion goes to primary care annually in the US – about 6% of private insurance and 10% of public plans. For these counties with 25% of the workforce this translates to 40 billion but the actual figure is less due to 5 – 10% less in the local collections rate and 15% less paid for office services in these counties (Medicare 2011 data) where 36% of active office family physicians serve (AMA Masterfile 2013). Suffice it to say that the revenue limitation is an absolute contraindication to the promotion of any solution that does not inject tens of billions more on the way to 90 billion in revenue growing steadily over the next 30 years to support the necessary physicians, clinicians, delivery team members, and office personnel as well as meeting the billions in demands from innovation, digitalization, certification, and regulation. The figure of 90 billion is a minimum requirement for an end to the shortages.
These practices are being driven backwards financially, not forward to the tune of 6 billion less a year to invest in local primary care.
Meanwhile new permutations of less revenue, higher costs, and worsening complexity are concocted. Lean primary care, lower cost while still forcing costly quality efforts, frugality, and ever more costly technology promise continued increases of cost of delivery on top of the accelerating costs of innovation, digitalization, certification, and regulation. Family physicians practicing where needed must understand the financial changes and they must demand change – but the designers are hardly aware of what is going on or how they are compromising care by their designs.
Accelerating Costs of Delivery Defeat Primary Care Where Needed
We know from the evidence basis that financial incentives do not work to improve outcomes – outcomes shaped predominantly outside of practices. We also know that incentive based payments discriminate against those who care for the complex as they inherently have lower outcomes. We know from CBO reports that micromanagement results in increased costs of delivery about the same as dollars saved. We know from the errors of the Dartmouth assumptions that only 20% of the population was considered and assumptions of overutilization are inappropriate and damaging where 40 – 50% of Americans suffer from underutilization or no access at all. Twelve years later the promises of digitalization regarding costs and quality have not materialized – yet the designers double down and rearrange rather than returning to the basics – the support of the team members to deliver the care. We know that up front investments in primary care work as in Michigan Blue Cross Blue Shield demonstrations – but the primary care medical home certification crowd took the credit, hiding the impact of up front investment in primary care. Most primary care practices need the up front costs. Most cannot afford the $80,000 to $100,000 per primary care physician where margins are already too tight – which is why lowest concentration practices have not participated without special support.
As noted, the situations are most difficult in these lowest concentration counties where primary care is delivered by smaller to smallest practices – those most abused by relatively higher costs of digitalization, innovation, certification, and regulation. These accelerating costs have removed 6 – 8 billion dollars from the primary care practices – dollars that could have supported team members and care delivery. These costs and complications have led to even more costs such as an additional few billion in lost revenue, higher turnover, and lower productivity. All of these higher costs of delivery plus the usual costs tear at the dollars for personnel, practice, care delivery, and caring.
The designers have little clue of the consequences that they have caused. They keep pushing for more. Even the research base is contaminated as few consider the context of the interventions, the differences in the populations being compared – the differences that most shape outcomes.
Complexity is Worse in Lowest Concentration Counties – Via Demographics and Via Meaningless Uses
The innovations have interfered with team member functions, time with patients, time with family, time with colleagues – essentially the most important functions in primary care. These have compromised what is most important about being a family physician.
Primary care physicians live to serve. It is our life. We are different from the designers, innovators, payers, academics, associations, and politicians. Health care is part of their life – a job. It is not their life. It is clear that they have a very limited understanding of primary care, care, caring, team members, or the evidence basis that they continue to violate. Their awareness of most Americans most left behind is even more lacking.
Face reality. No training intervention can address these shortages. More graduates, more types of graduates, or more special training can only rearrange the deck chairs as the initials behind the names are rearranged but workforce where needed does not. This was readily apparent in Nebraska when mapping primary care for 15 years until 2008 across the 80 lowest concentration counties. Few states had a better pipeline and none had the GME design seen in Nebraska. UNMC graduates choosing family medicine were 16 times more likely to be found instate in a county of lowest concentration compared to those not choosing family medicine – but the same concentrations of primary care remained – by design. Well organized rural physician organizations interacting with all of the right local and state players did better at great sacrifice – but Triple Threat remained – as do shortages.
The problem is that these lowest concentration counties need about 70 billion in revenue for sufficient primary care and probably a figure closer to 90 billion because of demographic changes, deficits of mental health and women’s health, population growth, and cost of delivery increases.
The complexity of care will be overwhelming – and will be worse due to changes expected until 2040.
These lowest concentration counties have been growing fastest since the 1960s and are set to grow even faster due to the collapse of housing in higher concentration counties. Disasters, increasing costs of housing, declines in housing support, and increases in the numbers of medically vulnerable and financially vulnerable will make matters worse as lowest concentration counties have available housing and affordable housing. By 2040 there will be 200 million or half of the US population in 2800 counties as the US adds more counties to this category with closures of small hospitals and small practices. There is little evidence of increases in the dollars after adjustments for lower payments and higher costs of delivery.
Half enough primary care stretched with 70 million more people with minimal change in support and multiple dimensions of increasing complexity is apparently the plan – and the designers have not made progress over an entire generation of class years and is so far set for a second failed generation 2010 to 2040.
There is no help on the way from training. The Dean’s Lie involves much more than deans or primary care matches. The necessary increases in workforce where needed are prevented by financial design. There are only so many dollars for so many positions and so many team members. The impact has long been seen in graduating residents as more residents continue training by taking one or more fellowships. General ob-gyn, general surgery, and general orthopedics are in free fall losing 2 to 3 percentage points a year since 2005 (AMA Masterfile 2013 vs 2005). Internal medicine is collapsing even faster and the 13% of lowest concentration county workforce from IM primary care should shrink to less than 5%.
The development of hospitalist workforce has taken 45,000 primary care trained internists and 4% of FM workforce with 12% of FM doing ER work – and that was Graham Center data from a decade ago. Lowest concentration county internists and family physicians with their primary care training and experience have been ideal for hospital based physicians in lower and lowest concentration counties. This is another way that Triple Threat deprives lowest concentration counties of primary care. It also steals experienced primary care workforce shaping the US from the most experience to the least in only a span of 20 class years of graduates.
Designs are wrong that shape half enough primary care and less and less experienced primary care for these most complex populations with the highest levels of chronic diseases, worst behaviors, worse environments, and most challenging situations. Challenges met with sufficient workforce and sufficient support make for a rewarding career. This is not what the designers have shaped and for our sake and for the sake of most Americans, we must make it right. The Future of Family Medicine is entirely about the financial design. The designs of the 1960s and 1970s were what brought this about as more billions were sent via Medicare and Medicaid to these counties with annual increases in payments. This was supplemented by much lower costs of delivery and limited complexity. The 2010 to 2040 period promises to be much different.
If by chance there is not yet enough evidence of the comprehensive prevention of primary care where needed by financial design, consider that four new sources of primary care have been created (FM, MPD, NP, PA) and two of these sources (NP and PA) have had massive expansions. NP in the next few years at 21,000 and increasing by 1000 – 2000 per year will pass US MD in numbers of annual graduates. Both NP and PA together (30,000 annual graduates) will soon pass physician annual entry from all sources.
These counties were promised nurse practitioner and physician assistant solutions that did not work despite massive expansions. The same payment design that concentrates physicians also concentrates NP and PA much the same. Since 1980 the NP graduates have increased 15 times from 1500 to over 21000 and PA from 1500 to 9000. There have been two and a half doublings of DO and multiple doublings of Caribbean graduates and 25% of physician workforce is filled from international graduates. But the focus is on GME and training rather than counties lowest in health spending, access, and determinants of health.
This should make it clear that training program increases and expansions of graduates are not capable of addressing shortages. Expansions of insurance plans least supportive of local primary care are also no help.
Great reads Sumi, a good source for young students why primary care physicians should pursue as a career. Good explanation! Even for parents who are reading this post right now, surely will learn something and can encourage their children why Internal Medicine Doctor is important part in the medical world.
From: Houston Concierge Medicine & Wellness Center