Primary Care Physicians (PCPs) make up the lion’s share of the medical workforce and are the main point of contact to the healthcare system for most. For many, the PCP is the one with the acumen to determine whether a medical episode is life-threatening or mundane. This unique position in a person’s care journey allows for PCPs to have greater control to steer patient outcomes, compared with most other nodes in the healthcare ecosystem. Concordantly, the literature shows that access to, and use of, primary care medicine in the US is associated with higher value care and better health outcomes.
However, the larger trend in the US Primary-Care workforce is looking grim. Studies from the AAMC predict the “U.S. could see an estimated shortage of between 21,400 and 55,200 primary care physicians by 2033”. With the eruption of the global pandemic, american healthcare has felt the strain of an acute need for more doctors, especially in rural areas. It is because of such pressure that CMS announced the Primary Cares Initiative, which aimed to improve primary care to deliver greater value to patients. This Initiative is what created new models, such as Direct Contracting. These models are meant to combat the dearth of doctors to care for our population.
Despite the call for more primary care doctors, Medical School graduates are becoming less and less likely to “Match” into primary care residencies. In 2019, for the first time, more doctors entering primary care roles were osteopathic or foreign graduates than were US trained medical doctors. Several factors likely explain this ongoing and escalating trend. Firstly, primary care doctors get paid categorically less than specialists, on average. In recent years, primary care physicians have seen slow increases in salaries, however, the gap in compensation between family care physicians and specialists remains substantial. Secondly, due to their role as a nexus in the healthcare system (and the requisite ‘air traffic control’ function they play), primary care physicians experience disproportionate EHR fatigue. Primary care physicians spend more than half of their work day interacting with the EHR, with nearly a quarter of that computer work happening after clinic hours. Experts who’ve noticed the trend have advised hospitals to employ other medical professionals to share in the responsibility of completing the EHR workload and other paperwork required by insurance.
From discussion with Pearl’s physicians, a general sense emerges that doctors are steering away from PCP placements for 1 of 3 reasons. Firstly, from as early on as Medical School, a clear hierarchy in prestige emerges among specialties and PCPs occupy the lowest rung. Secondly, there are many studies documenting the challenges PCPs face regarding EHR fatigue; doctors in primary care specialties spend over half of their workdays–in addition to at-home work–doing rote tasks such as data entry or filling insurance forms. Lastly, the disparity in salaries between PCPs and specialists is wide, albeit shrinking slowly. Overall, PCPs are not satisfied with their responsibilities, and it shows: only 62% of internal medicine doctors said they would choose to go into their specialty again — the lowest percentage on record for all physician specialties surveyed.
As many new doctors are choosing against Primary Care as a specialty, the aging demographic of the provider segment bodes poorly for future access to care. Over 40% of family physicians, the largest PCP segment, are 55+. Such age distribution adds strain to the ability of primary care to support a growing population. Furthermore, older physicians are more likely to have practice ownership; 54.3% of physicians over 55 own their practice, while only 25.5% under 55 do.
Another trend, running in parallel, is the trend away from owning practices. The American Medical Association reported in 2019 that for the first time, more physicians are employees rather than owners of a practice. This represents a larger trend in the healthcare industry as a whole: health-system consolidation. Experts have expounded on the likelihood of continued hospital, provider, and medical care acquisitions and consolidations in the coming years, exacerbated by the financial stress put on providers during the Covid-19 pandemic. As seen in other industries (e.g. media) the earliest adopters in the consolidation game often have an early competitive advantage to later entrants. Between 2012 and 2018, the market share (based on patient revenue) of the 10 largest health systems grew to represent nearly 25% of the market. And consolidated systems have demonstrated outsized success. Per a 2018 study, “revenue grew for the 10 largest health systems nearly twice as much during this period compared with the rest of the health systems and independent hospitals in the market (82% vs. 45%). In fact, the largest employer of physicians in the US is a Fortune 500 company, Optum Health.
While many tout the advantages of integrated healthcare networks for care coordination and information sharing, the downside of this trend towards consolidated medicine is one that policymakers should keep a watchful eye on: as hospital networks consolidate over a geographic region of care, they have greater leverage over the cost of medical services in that area. Policymakers must continue balancing these factors to prevent unnecessary and artificial increases of medical costs. At the end of the day, patient access to high value care should be the guiding principle at all times.
This trend away from physician-owned practices is tied closely to the underlying shift in values towards prioritizing financial security. When a physician is trying to balance independence with employment, financial security is a critical determinant of a doctor’s choice to own, or work within an employment or partnership setting. Many perceive practice ownership in direct tension with financial security due to the financial risk exposure that comes from operating a small entity. These risks are exacerbated by the money and time committed to handling administrative duties. Many insurance payment models rely on fee-for-service (FFS) which incentivizes doctors to see a high volume of patients, but, PCPs spend more of their workday inputting data than they do with the patient. Services that can ensure steady income while assisting with the clerical load will allow primary care providers to spend time on what matters: care for the patient.
Primary care physicians have their work cut out for them in the coming years. With an aging population, the estimated shortage of doctors will pose threats to collective access to care. Primary care requires a paradigm shift and fulsome operational support to make the specialty more appealing to new doctors.