More than ever, primary care continues to be one of the most needed specialties in the country. What are we doing to increase the number of primary care doctors?
by John Andrew Estialbo, Staff Writer; Tim Herb, Staff Editor.
Primary care and family medicine continue to exceed demand for other medical specialties, and as was the case for many years, primary care physicians continue to be one of the most sought-after doctors for many healthcare systems. So much so, in fact, that it has overrun demand for specialties like radiology, cardiology and other subspecialties.
“The lack of supply of these physicians is complicated by many factors,” remarked Craig Fowler, VP for Training and Recruitment for Pinnacle Health Group (PHG). “—healthcare reform, the medical home model, accountable care organizations and the ever-growing shift to direct employment arrangements.” It is exacerbated by fact that at least 32 million uninsured patients will be added to the service of primary care doctors under the current healthcare reform.
This is reflected by the gap between supply and demand in many communities across the country. Current surveys indicate that a primary care doctor serves 631 people. In Northwest Georgia, the ratio for a primary care physician is 1 to 1,078 for Whitfield County, and a ratio of 1 to 5,791 in Murray County.
The US Department of Health and Human Services, for instance, has designated Missouri as a ‘health provider shortage area,’ which means one in five people in Missouri do not have access to primary healthcare. According to Thomas McAuliffe of Missouri Foundation for Health, the situation is worse in rural communities. In fact, according to Missouri Primary Care Association, only around 12% of Missouri’s graduating residents went on to become family medicine practitioners in 2009.
Meanwhile, the Massachusetts Workforce Study revealed that internal medicine, family medicine, dermatology, general surgery, neurosurgery, orthopedics, psychiatry and urology are among the specialties that have significant shortages in physician supply. Access to care is a problem. Family medicine, for instance, has an average wait time of 36 days, and at least 47% of these physicians are only accepting new patients compared to 70% last year. The problem is worse in Barnstable and Worcester, Massachusetts. Internists’ average wait time for new patients is at 48 days, and approximately 50% of IM clinics accept new patients. These are compared to cardiology, where 82% of cardiologists accept new patients with an average of 28 waiting days.
In Oregon, a primary care physician in an urban community services 720 patients, while those in rural areas care for up to 1,298 patients. This is further confounded by the fact only that three hospitals have at least 27 residency slots, which restricts training of primary care physicians and consequently leads to importing them.
Mike Broxterman, PHG’s Chief Operating Officer added, “The case of primary care physician shortage is not a new one, but there have been recent trends in light of the healthcare reform. Generally, states with low supply of primary care doctors, like those in the West and South, are more than inclined to pay more to attract these physicians.”
Primary care doctors have drawn attention over the past years in terms of recruitment and retention. PhysicianCareer.com’s recent talks with its physician members, for instance, reveal more than just the trends in supply and demand. Broxterman added, “Many within our PhysicianCareer.com community factor in the willingness to enter into primary care, and as a result a lot of residency slots are not filled by an in-house recruiter. Some of the doctors we’ve talked to say that it is not surprising that a resident would find interest in dermatology, cardiology or surgery rather than primary care, even in the face of anticipated increase in patients through the healthcare reform.
“They also highlight the importance of work-life balance, practice environment and geographical location, where a main percentage of them would prefer structured workflow, shorter calls and employed arrangements. This puts a lot of stress with getting full-time primary care physicians.”
“Moreover,” Fowler added, “The growing population and steadily rising percentage of retirees and baby boomers in the country are generating an even bigger demand for primary care physicians while decreasing supply at the same time. Another factor is patient satisfaction and maximizing the value of payments spent on healthcare service, something that the reform underscores.”
Both the government and healthcare systems have developed a variety of initiatives in hopes of bolstering the supply of primary care physicians, most of which are incentives. Some are also maximizing their workforce by also including nurses (practitioners and registered) and physician assistants to their programs. “This is particularly true for hospitals that are setting up accountable care organizations,” said Fowler. “Anyone who can provide primary care will add value to their primary care delivery.”
The Centers for Medicare and Medicaid Services (CMS) cited the successes of strengthening primary care in different facilities nationwide. The Community Care of North Carolina reported a decrease in preventable hospitalizations for asthma by 40% and lower visits to the emergency room by 16%. Group Health Cooperative of Puget Sound lessened its emergent and urgent care visits by 29% and hospital admissions by 6% while Geisinger Health Plan cut its admission rates by 18% and hospital readmissions by 36% annually. Meanwhile, Wisconsin-based QuadMed employee clinics have reported higher patient satisfaction and lower admissions and visits.
With these, CMS have initiated the Comprehensive Primary Care Initiative where CMS will pay primary care doctors for improved care management and offer them sharing in savings they generate after two years. This means CMS will pay a primary care physician a risk-adjusted, monthly care management fee for their Medicare Fee-for-Service beneficiaries. For two years, the per-beneficiary, per-month (PBPM) will average to $20. All participating physicians can also have a percentage of savings in Medicare’s Fee-for-Service.
In Arkansas, the Office of Rural Health and Primary Care services the state by coordinating with the National Health Service Corps (NHSC) by providing primary care professionals loan repayments and scholarships when they serve their communities. NHSC’s initiatives also include education loans, tuition, living expenses, loan repayments, federal income and employment tax exemptions.
The Oregon Health Authority collaborated with various organizations such as Office for Oregon Health Policy and Research, Travel Oregon and the State Workforce Investment Board, in anticipation of House Bill 2366. This proposed bill seeks to develop strategies for recruiting primary care doctors, which include best recruiting practices, updating their existing programs and making Oregon a more desirable practice environment.
Meanwhile, Minnesota’s State Loan Repayment Programs aim to improve access to primary care through recruitment and retention of primary care professionals in urban and rural communities. This includes educational loans of up to $20,000 annually for doctors working full-time in non-profit private or public hospitals in federally designated Health Professional Shortage Areas, much like NSHC’s.
Broxterman cited, “Aside from preferring work-life balance and geographic location, our PhysicianCareer.com community members are also zeroing in on signing bonuses, CME allowances, overtime, merit and certification pays, even among our baby boomer physicians. They’ve also discussed with us housing and relocation assistance, as it is a growing problem among doctors who wish to sell their homes when they relocate.
A major percentage of facilities are utilizing these added benefits to attract primary care doctors. However, seeing that the marketplace is highly competitive, administrators should always set a proactive initiative to lower turnover rates and maximize their retention programs. Moreover, they should address the challenges of working with a multi-generational workforce, incentivizing their healthcare professionals and ultimately providing an optimal environment for these physicians.”