real is the anticipated 2014 surge in demand for primary care
and resulting shortage of availability and accessibility? Is it
overhyped, or will adequate marketplace solutions emerge, or
will there be a significant unaddressed problem?"
2014 will be a year of transition
and further education around the exchanges and health
insurance in general, with far less than the desired number
of uninsured actually securing coverage. So likely any 2014
bump in primary care needs will more or less be able to be
absorbed by existing capacity and recently developing but
fast growing alternate channels like retail clinics and
telemedicine. Over time, say three or more years, if the
uninsured continue to dwindle and become more comfortable
with the use and value of health insurance, demand for
primary care could outstrip supply and create an opportunity
vacuum for additional new entrants or models.
In Massachusetts where universal
health was implemented in 2006, even though the number of
uninsured was relatively small at 6%, there continues to be
some concerns with accessing preventive services - 1 in 5
adults report difficulty in finding a PCP who will see them.
And Massachusetts just passed a law that requires Nurse
Practitioners and Physicians Assistants to be considered
PCPs and reimbursed by insurers accordingly. Nationally, we
may need to see a lot of changes and innovation to meet this
challenge - new payment schemes like ACOs that reward PCPs
for better care coordination could help. Group visits could
increase in popularity and self-care through technology (a
la Dr. Eric Topel at Scripps Translational Science
could help ease the pressure as well. The delivery landscape
still seems flexible and dynamic enough to rise to a primary
care shortage challenge.
Chief Strategy Officer, Keenan
At the same time 76 million "Baby
Boomers" will reach the ages of 50 to 67, 30 million more
people will become insured through the Affordable Care Act
(ACA). Once considered a major concern only for rural areas,
the shortage of primary care physicians (PCPs) in the face
of this increasing demand is now becoming an issue
throughout the country. As older PCPs are retiring, newly
graduated MDs are going into more lucrative subspecialty
practices. According to an Agency for Healthcare Research
and Quality study published in the Annals of Family Medicine
(Nov/Dec 2012), nearly 52,000 more PCPs will be needed to
handle over 100 million additional office visits annually by
PCP shortages could quickly escalate into a
crisis without rapid policy intervention. When patients have
to wait months for an appointment with their doctor, routine
preventive care is delayed, people are sicker when they get
the visit, and the cost of the care that is eventually
delivered is much higher. Without an adequate supply of
PCPs, controlling the trend of health care expenses will be
an uphill battle.
Physician training takes place
mainly in hospitals, a setting where medical specialization
predominates, while PCPs practice in offices. PCPs also earn
considerably less than specialists, so medical school
graduates with large student loans to pay off have an
incentive to choose subspecialties instead of primary care.
Pay for Performance and Accountable Care Organization
approaches could be part of the efforts to cure these
structural inequities. But it becomes a "chicken and egg"
enigma as the supply of PCPs is needed for these incentives
to work in building the supply of PCPs.
demands may help with narrowing the PCP compensation gap,
but real solutions to this problem will take creativity.
Because it takes 10 years to train a physician, we need to
have sufficient capacity in our medical schools with
specific pipeline training and local student tracking
programs, like those developed at the University of
California, Riverside, including community-supported
mentoring in primary care.
We can expect the
shortage of PCPs to be a serious, persistent problem for the
health care system. To address it, we have to leverage the
time and talents of available physicians. Companies like
Teledoc are innovating telemedicine. Combined with m-health
solutions for remote monitoring of chronic conditions,
technology can efficiently help doctors serve more patients.
Another strategy is reorganizing practice structures, with
centralized electronic health records, so that physicians
are "quarterbacking" physician assistants and nurse
practitioners to handle routine primary care. This allows
doctors to focus their available time on diagnosis and
The influx of millions of Americans with new health
insurance overage will likely increase overall demand for
health services and particularly stress primary care
resources, at least in some parts of the country. However,
this can also be the impetus for employers and other
stakeholders to reexamine and rationalize how care is
provided. Less inappropriate use of the emergency room and
greater use of physician extenders will be a natural
Plan sponsors should also consider
further leveraging new technologies and concierge services
such as e-visits, telehealth and on-site clinics to support
routine care and consider innovate approaches to establish
virtual medical homes. Hopefully, this surge in demand for
services can help to motivate and drive innovation in
delivery that can lead to more efficient and effective
approaches to how we manage the health of each of our
Founder, Center for
Health Value Innovation
In the words of Rodney King, "Why Can't We Just Get Along?"
A large portion of the American citizenry is covered by
primary care, and there are already existing gaps in primary
care access in rural counties as well as the poorer sections
of some cities. The very real fear is that Medicaid
expansion, which will make Medicaid larger than Medicare in
terms of beneficiaries, will exponentially make the primary
care even more strained.
But there is light in this
tunnel. Commonwealth Fund recently published a report from
the Capitol District's Physician Health Plan in NY, that
showed team care, overseen by a physician but relying on
nurse practitioners and care coaches/coordinators, worked
well to see the patients, build better outcomes, improve
health care quality and reduce total costs. North Shore
Physicians Group, just north of Boston, had similar results.
Kaiser and others have been performing team-based care for
many years, with good outcomes.
primary care can also occur in retail and worksite clinics
with good results, but the transmission of diagnosis,
treatment, followup must be shared with the patient
coordinator, which is typically the primary care physician.
The issue is that physicians, who are trained to
diagnose and solve the health problem, must be willing to
give up some of this control to the qualified team members.
One recent press release from the Florida Academy of Family
Practitioners notes that "If a nurse practitioner is calling
the shots for a patient, it will only further fragment the
system," a message that diminishes the effect of a talented
group of clinicians and stalls the collaboration.
Florida is one of the states with acute shortages of primary
care, so the caution from the Academy may be somewhat
warranted. But it's also an opportunity for Florida's
primary care physicians to set the new standard in
collaboration and improved outcomes that would traverse the
state. Michigan is beginning to transfer learnings from one
county to another, using the primary care physicians more
effectively as quarterbacks, building their teams and
showcasing better outcomes in health and finance through
patient-centeredness, technology support, and consumer
engagement. There is as much opportunity to build these
successes across America as there is to call attention to
the lack of primary care in certain areas. But those primary
care physicians who can create teams with nurse
practitioners, pharmacists, mental health experts, lifestyle
and financial coaches, and care coordinators can succeed and
prosper in this new climate.
Member of the Firm, Epstein Becker & Green, P.C.
The hypothesized "surge" in demand
for primary care is likely to be more of a gradual rise in
the water level as participation in exchange mediated plans
will build over time and not be a tsunami. That said, there
is now, and will be, demand for more available and more
accessible primary care.
The "surge" I have observed is in
the furnishing of primary care in urgent care and in retail
settings. Those settings are responding to consumer demand
for accessibility. They are also using innovative staffing
and leveraging physicians with nurse practitioners and
physicians assistants. I suspect that we will see further
advances in innovation in primary care delivery independent
of, but also responding to, newly covered populations.
On-Demand: Webcast: Driving More Efficient Operations & Better
On-Demand: Managing Complex Billing Environment in Advance of
Health Care Reform
Avoid Readmissions through Collaboration, July 11, 2013
Cost Trends and Implications, July 18, 2013
Readmissions Web Summit, August 22, 2013
Depression in the Workplace: Why it Matters and What You Can Do
About it, October 16, 2013
Accountable Care Web Summit, December 12, 2013
CD-ROMs of Past Events
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