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How 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?"

   Sander Domaszewicz
 Sander Domaszewicz

Alexander Domaszewicz


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 Institute; could help ease the pressure as well. The delivery landscape still seems flexible and dynamic enough to rise to a primary care shortage challenge.

 Henry Loubet
 Henry Loubet

Henry Loubet
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 2025.

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.

Marketplace 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 treatment plans.

 michael thompson
 michael thompson

Michael J. Thompson
Partner, PricewaterhouseCoopers

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 consequence.

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 targeted populations.

  Cyndy Nayer
 Cyndy Nayer

Cyndy Nayer
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.

Extensions of 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.

  Mark Lutes
 Mark Lutes

Mark Lutes
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.

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ARC: Avoid Readmissions through Collaboration, July 11, 2013
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