SALT LAKE CITY — America doesn’t have enough primary care doctors.
While industry experts have long noted the growing shortfall, COVID-19 has made the issue real to consumers, many of whom recently put off all but dire health care needs to avoid being exposed to the virus.
Now, not being able to get consistent basic care doesn’t feel like a distant problem. COVID-19 has made the shortage feel more real to patients — and made it worse. Possible solutions have been seen in the pandemic, too.
“Over the last few months as our nation has battled coronavirus, we have seen in stark detail how fragile and quickly overwhelmed America’s health care system truly is; and we’re nowhere out of the woods of this public health emergency yet,” Dr. David Skorton, president and CEO of the Association of American Medical Colleges, told reporters recently.
The association predicts the United States will be short at least 21,400 and as many as 55,200 primary care physicians by 2033, noting rural communities and those of color already feel pinched. The report looks that far ahead because physician training takes many years, so solutions to a future shortage must be found now, Dr. Janis Orlowski, association chief health care officer, told the Deseret News.
Others see the shortage, too. The Kaiser Family Foundation reported last September that the United States has 7,578 existing primary care health provider “shortage areas,” with a combined population of 77.6 million people. Kaiser said 14,087 practitioners are needed for those areas, which include territories and the District of Columbia.
Primary care includes internal medicine doctors, family physicians and pediatricians. In 2016, more than half of Americans who went to the doctor consulted a primary care provider, the Centers for Disease Control and Prevention said.
Primary care doctors see a person’s big health picture, including acute conditions like a broken arm or flu and chronic ones like allergies or heart disease. Part of their job is coordinating care when specialists are needed, said Dr. Paul Wirkus, president of the Utah chapter of the American Academy of Pediatrics.
“With patients who have complicated health issues, not coordinating care can be a disaster,” he said, while for otherwise healthy patients, “having a big picture is incredibly helpful. I think what we hope to achieve in primary care is that medical home — the repository of your health information.”
The Washington Post reported that “patients who regularly see a primary care physician also have lower health costs than those without one.”
Driving shortages
Planning for medical access is important, like planning for public transportation or figuring out how many schools an area will need, Orlowski said.
Projections look at existing conditions, then factor in expected changes, using scenarios to decide what’s apt to happen. Population growth and aging primarily drive the shortfall’s growth. The U.S. population will increase by more than 10% by 2033. Meanwhile, 10,000 baby boomers turn 65 each day, the report says. Older Americans consume a lot of health care services.
Making matters worse, 40% of practicing physicians will turn 65 between now and 2033.
The association’s projection was prepared pre-COVID-19. The group predicts the pandemic is “likely to have short- and long-term consequences, including changes in specialties physicians choose, the educational pipeline, licensure and reimbursement regulations, how medicine is practiced and workforce exit patterns.”
COVID-19 pressure points
COVID-19 has shown what happens when people can’t get in to see a primary care physician, Orlowski said, noting how a pandemic stresses the health care system.
The pandemic has also highlighted the importance of managing chronic medical conditions like heart disease and diabetes, said Dr. M. Austin Healey, a family medicine physician in Provo. He said a sharp focus on managing long-term conditions is common for primary care providers.
When the pandemic started, doctors in his practice, Intermountain North Canyon Family Practice Clinic, started calling their patients with high-risk conditions to tell them what to watch for and provide guidance on staying safe.
Wirkus said he knows his young patients’ medical histories and chronic conditions; he maintains a growth chart that tracks their development. As important as it is to be able to see specialists (many of whom are also in short supply, the association says), “you still need someone at the center coordinating care and, to some extent, refereeing. I expect one of my jobs is to help choose the right kind of specialist.”
Wirkus noted a dramatic decrease in kids getting immunizations on schedule when the pandemic hit. He said when children don’t see their primary care provider, underlying problems, including developmental issues, may not be detected.
Others report adult conditions have worsened. A recent Primary Care Collaborative survey found nearly 45% of general practitioners saw exacerbated chronic conditions because patients haven’t had access to primary care during the pandemic.
COVID-19 has hurt doctors directly, too, leaving some primary care practices “unstable at the same time that more than half of clinicians report an increase in non-COVID morbidity and mortality that appears to result from COVID-19 related obstacles to accessing health care. Mental stress on this workforce is at historic highs,” the survey report says. “There is a growing toll, including social isolation, economic stress, and deferred patient care.”
CNBC said of 2,700 primary care practices asked how things were going amid COVID-19, 51% were unsure what would happen to them financially over the next months; 42% had laid off or furloughed staff. And 13% thought they’d have to close within a month,“ worsening the primary care shortage.
A report by physician research firm Merritt Hawkins and The Physicians Foundation found “many plan to change jobs, opt out of patient care roles or retire in response to the COVID-19 epidemic.”
Boosting the numbers
COVID-19 has been eye-opening in promising ways, too.
“One positive result of the pandemic is that barriers to accessing physician services through telemedicine may be reduced, which will be critical as the nation deals with a growing physician shortage,” Travis Singleton, executive vice president of Merritt Hawkins, said in a news release about its report.
The shortage, though, has no simple fix. The Association of American Medical Colleges said “addressing the shortage will require a multi-pronged approach, including innovation in care delivery; greater use of technology; improved, efficient use of all health professionals on the care team; and an increase in federal support for residency training. The magnitude of the projected shortfalls is significant enough that no single solution will be sufficient to resolve physician shortages.”
Several measures — including some that proved their worth during COVID-19 — could boost primary care, experts said.
Association recommendations include increasing the number of medical schools, pushing for more funded residency spots, and using inter-professional teams more effectively. “Not all medical care needs to be provided by physicians,” said Orlowski. Nurse practitioners, pharmacists, dietitians, social workers and others can form teams that stretch primary care resources.
The number of student slots in U.S. medical schools have increased by more than a third in the last 14 years. But a freeze since 1997 on Medicare payments for resident training is problematic. Hospitals and others have funded those slots, but they are at risk whenever money is tight, said Orlowski, who is among experts believing the freeze should be lifted so the training is assured.
Health care systems are among those tackling the shortage by changing primary care itself. Family doctor Healey’s practice is part of a model called Reimagined Primary Care, which takes the emphasis off fee-for-service care and puts it on managing wellness. The model is run by Castell, an Intermountain Healthcare company. It pays salaried doctors to keep patients well through prevention and good care management, Healey said. Treatment is not as heavily appointment-based, making it more accessible and reducing bottlenecks. Doctors and patients can use telehealth, phone calls and in-person visits as needed. Healey said he and his patients believe the model gives them more time, not less, to address health concerns, thus treating more patients.
“I really think this kind of thing could change the trajectory of medical spending in a system and possibly America if it were to be adopted, providing better care for less,” he said.
While telehealth has been around a long time, the pandemic gave it a boost as physicians discouraged in-office visits. Advocates say changes that temporarily lifted barriers to telehealth, like relaxed rules and increased payment, should become permanent.
Some recommend letting practitioners in other states care for patients to expand primary care within shortage areas. Letting doctors come out of retirement to practice telehealth has been suggested, too.
Consumer preference can also change care. Orlowski said millennials aren’t necessarily looking for a family doctor. They are drawn to “just-in-time care:” I broke my arm. Fix it. Still, consistent ongoing care is more apt to include blood pressure monitoring, considering family medical history and guidance to stay healthy overall, Orlowski said.
“That’s some of what’s missing if you don’t have a medical home,” she said.