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The Big Shortage: Rethinking The Need For More Primary Care Doctors



August 2nd, 2012

Editor’s note: For more on ways that the traditional primary care model could be rethought, see the Health Affairs May 2010 thematic issue “Reinventing Primary Care.”

Although primary care is regarded as the backbone of the healthcare system, there are serious concerns that we will not have enough primary care physicians to meet the needs of the population, particularly given the upcoming expansion of insurance coverage made possible by health care reform. The response to this shortage has been to do all we can to increase the supply of primary care physicians. But there are deep changes underway in technology and society that point to a radically different notion of primary care, one which requires not more primary care physicians, but a fundamentally new approach to providing primary care.

Currently, patients see their primary care doctors about three times a year. Typically, these appointments last 20 minutes at most. If you generously assume an equal amount of consultation time by phone, patients interact with their doctors for two hours a year on average, leaving 8,758 hours on their own. In other words, virtually all decisions patients make about their health take place without their primary care physician.  In reality, only patients and their loved ones – not doctors or nurses or anyone else – can manage their health. The job of the primary care physician, then, should be to create and manage a system of care that will provide their patients with the tools to do just that.

Such an approach would align primary care with other major social trends: more and more people resisting having decisions made for them, preferring and demanding to take control of their own health. These trends have been hastened by the availability of new technologies, especially the Internet, which is quickly democratizing access to information.

A recent survey of low-income Californians, commissioned by the Blue Shield of California Foundation, found that an overwhelming majority of patients preferred to see a doctor than any other kind of care provider. But when researchers probed deeper, they found that many patients were open to receiving care from a team of healthcare professionals, and through non-traditional means like text messages, email, and other online tools. In fact, the patients who were the happiest, most loyal, and most proactive about their own health were those who had an ongoing relationship, not with a single doctor, but with a regular care team.

Lessons From Iora Health

Several years ago, I started a company called Iora Health to build new practices from scratch, based on the team model of primary care, with the patient very much a part of that team. Each practice is paid a fixed amount per patient, rather than for each service performed, which enables more flexibility and incentive to manage patients’ health differently.

Under this model, each patient works with their doctor and a personal health coach to come up with a shared care plan, and then receives education and support in person, by email, video, and in groups. Doctors spend more of their individual time managing the teams and tending to the sickest patients. The teams bring in specialists as consultants on an as-needed basis. We also designed an IT system from scratch to streamline coordination across teams and better engage our patients in their own care.

Iora has taught us is that many – if not most – visits to primary care physicians can be: eliminated altogether through guided self-service supported by decision-making tools; dealt with in a different setting, such as in a group; or taken over by another member of the care team. Under this approach, we estimate that each physician could potentially double the number of patients she manages effectively. Even if we use much more conservative numbers, the projected shortage of 30,000 primary care physicians would rapidly turn into a surplus.

Bringing The New Model To Scale: Revamping Medical Education And Power Allocations

Of course, to make this model work on a much larger scale, we need very differently-trained physicians than those we have today. While some degree of science training is critical to understand the body and its illnesses, so is a background in engineering, systems design, statistics, economics, informatics, psychology, management, and leadership – all of which are either missing or covered in cursory fashion in the current medical curriculum. In addition, the teamwork involved in this potentially transformative practice calls into question the separation of doctors, nurses, medical assistants, and other medical professionals throughout their training, and argues for integrating team training at a much earlier stage.

This new vision for primary care requires several fundamental power shifts – from the hospital and specialists to the primary care physician, from the primary care physician to members of her team, and from all of us in the health system to our patients. Power is zero sum. No one likes giving it up voluntarily, and this transition will not come without some pain and disruption. However, it is ultimately in the medical industry’s interest to adapt and innovate with consumer trends, or risk becoming obsolete, as many travel agents, book stores, and stock brokers have learned over the past several years.

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2 Trackbacks for “The Big Shortage: Rethinking The Need For More Primary Care Doctors”

  1. JAMA Forum: Social Status and Health: A Coming Issue for Physicians « news@JAMA
    April 17th, 2013 at 4:16 pm
  2. The Big Shortage: Rethinking The Need For More Primary Care Doctors – Health Affairs Blog | Doctor Data | Scoop.it
    August 8th, 2012 at 6:49 am

4 Responses to “The Big Shortage: Rethinking The Need For More Primary Care Doctors”

  1. Raymond Simkus Says:

    My practice has been paid under a capitation scheme for over 10 years. I work in British Columbia and was part of a pilot project on primary care reform; we switched from a fee for service payment to a capitated system. If the payment formula pays the same amount for each patient the result will be ‘cherry picking’ of healthy patients and a disincentive to look after sick patients. The payment formula here is that there is a base rate based on age and sex, then there is a correction factor for disease load based on the Johns Hopkins ACG calculation for each patient.

    The more things you find wrong with a patient the more you would get paid for that patient. This provides an incentive to seek out disease and make an early diagnosis. Then since you are not paid by the visit there is an incentive to optimize the treatment of the patient so they do not have to come in for so many visits. There is a negation in that if the patient sees another primary care physician the government pays that physician and deducts that amount from my pay. This provides an incentive to be available and not just register as many patients as you can and then not be available.

    The patients and the physicians that have been working under this system love it. The physicians can do what seems most appropriate in terms of services provided rather than being constrained by the fee-for-service system. Physicians that are not doing this have concerns that they will not know exactly how much they will get paid for any individual service but I think it is time to move past the 18th century piecework mentality.

  2. HealthyTJ Says:

    I think this is a good start to thinking about ways to improve the effectiveness and efficiency of the Primary Care System. Many good ideas here. However, I have a few addendums.

    First, we must remember that the capitated payment (one payment for each patient) would need to be calculated based on certain criteria- otherwise the facility will run out of funds. Some patients are chronically ill and will be more cost intensive for care. There should be a capitation fromula that takes into account the overall numbers of patients according to need of a few criteria: chronic Illness (yes or No), age range of some sort (65+ between 45-64, 30-44, 18-29, 12-17, 2-11, and 0-2), smoker (yes or No), and maybe Gender. This way the capitation payments will more accurately reflect the resource costs.

    Second, I think it is extremely onerous for us to expect the Primary Care Physician — who is meant to be the expert in MEDICAL science and care and the locus for care management — to also be expert in Statistics, engineering, management, etc. They already have 8 years or more of schooling and it is not easy schooling!

    My proposal would be to have one or two Health Care Managers on Staff to help the Primary Care Physician with care management decisions. There could be one on staff that is an expert on population health and epidemiology (statistics) and one who is more of an administrative expert, who can help with planning and programming, marketing, patient communication, staff management, Electronic Health Record Implementation and Management, and so on. This way the Primary care physician can focus on his or her expertise, perhaps get better at managing teams, while the other one or two will handle the more management and planning issues to make this new idea of Primary care work.

    Without these two addendums, I do not think this vision could move forward.

  3. carmelmarymartin Says:

    One of the problems related to the shortage of primary care doctors is the refusal to recognize training from other countries with well established primary care models. Not only would a more fluid workforce ensure if UK, Australian and other country qualifications were accepted without the humiliating requirements to practice in the US, but the US could learn from experiences elsewhere.
    Mutual recognition of practice and education among high standing universities and regulating authorities is commonplace between countries with high standards of primary care delivery systems, yet the US and to some degree Canada stand out as isolationist. This could be due to protectionism by some specialties who seek to control the supply to maintian incomes, but it is counterproductive for primary care.
    Action needs to be taken to address this matter, as there are many primary care physicians in the US who are unable to practice or unwilling to undergo outdated and humiliating US registration processes

  4. CAnder Says:

    Dr Fernandopulle runs a very innovative primary care system dropping the fee for service model and maintaining health through a health care team financed by a monthly fee. This type of system may be a breakthrough in addressing primary care needs. However I would caution the Doctor about making a pronouncement that there really isnt a shortage of primary care doctors. I have a great fear that State governments will solve the primary care shortage , especially in the medicaid system by simply declaring that all primary care will be done by physician extenders. I am all for collaboration , but the system still needs a physician in charge

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