Primary Care Shortages: Strengthening This Sector Is Urgently Needed, Now and in Preparation for Healthcare Reform

With total health insurance costs at approximately 17% of the US Gross Domestic Product,¹ a rapid growth rate, rising rates of chronic diseases, such as diabetes, and an aging population, changing the dynamics—the fundamental drivers—of the US healthcare is key. The 2010 Census estimates 16.3% of Americans do not have health insurance, and that the percentage of people with employment-based health insurance decreased from 56.1% in 2009 to 55.3% in 2010.²

The employment picture is also weak. In 2010, 16.2% of the US population was either unemployed, had temporarily given up searching for a job, or was working part-time while looking for full-time employment.³ A national survey of employer-based health insurance showed that average premiums for family coverage in 2011 totaled $15,073 (9% higher than in 2010), with employer contributions of $10,944 and employee contributions of $4129.⁴

In addition, the United States faces strong headwinds from the weakness of the international economy, a financially led downturn that tends to last longer and be deeper than other recessions,^5,6 and hyperpartisan politics. The need for accessible, affordable health insurance will be even greater in 2014 than it is now.

Figure 1

This article reviews the current shortages in primary care physicians (PCPs) and other healthcare professionals that must be greatly ameliorated before the major expansion of the US health insurance system in 2014, when the Patient Protection and Affordable Care Act (ACA) provides health insurance alternatives to individuals and to businesses with 50 or more employees. The article also discusses several examples of transformative initiatives in the US healthcare system that have been shown to improve the quality and lower the cost of care. Figure 1 depicts the key ways in which the US healthcare system may need to move forward to meet these challenges.^7-11

The Challenges of the Current PCP Shortages  
The United States is currently facing shortages in physicians and other healthcare professionals that are needed to provide care in the PCP office setting. A December 2010 Council on Graduate Medical Educa­tion report estimated that there were 242,500 PCPs in the United States in 2010, and almost 25% (55,000) of them aged ≥56 years.¹²

The average compensation for PCPs is approximately only 55% that of other medical specialties, leading to a cumulative lifetime net income gap of approximately $3.5 million for the individual PCP.¹² This essentially results from the resource-based relative value system (RBRVS) on which the Medicare fee-for-service (FFS) schedule payments are based.

A likely unintended consequence of the RBRVS is a bias toward viewing skill in terms of expertise in conducting a specialized procedure as opposed to professional time, as well as expertise in making a correct diagnosis by differentiating among multiple potential conditions, or improving chronic conditions that are typically associated with increased morbidity and cost. The Medicare FFS schedule is used not only in Medicare; it also influences managed care organization (MCO) and Medicaid physician reimbursement payment amounts.

A closely related challenge is the very low percentage of medical school students who are choosing to go into primary care. A related challenge is that approximately 59 million Americans, almost one fifth of the US population, live in areas with health professional shortages.¹³

Shortages in a number of other primary care healthcare professionals exist, notably with nurses—the single largest provider group in the United States.^14,15 A minority of nurses are employed in the ambulatory care and in public and community care settings.¹⁴

Many healthcare professional shortage areas in the United States are in rural and inner-city areas, where the population is medically underserved. State-by-state and county data are available on the US Department of Health and Human Services website.¹⁶ Rural areas may be unable to financially support a PCP’s practice,¹² and there may be other practice challenges and lifestyle issues. Solutions may well require innovations in current practices (as discussed below).

Inner-city areas present their own challenges, and until the ACA’s enactment, Medicaid’s low payment rates may well have created significant disincentives. In a telephone interview on October 8, 2011, with Michael Collins, MD, an internist with 30 years of experience in primarily treating commercial and Medicare patients, as well as inner-city Medicaid patients, he commented on the greater complexity and the number of medical problems his Medicaid beneficiaries have, including an increased incidence of serious mental illness.

Table 1

Transforming the US PCP workforce will require significant changes. The ACA includes a number of measures to support PCPs.¹⁷ Table 1 provides a summary of the primary care model as outlined by key ACA provisions.

The funding levels in the ACA for these priorities—such as $1.5 billion for the National Health Services Corps—are reasonable and in all likelihood may be cost-saving, by averting increasing morbidity and hospitalization levels in the United States.¹⁷

In 2 separate telephone interviews conducted on September 21, 2011, with Virginia L. Hood, MD, President of the American College of Physicians (ACP), and with Glen R. Stream, MD, MBI, FAAFP, President of the American Academy of Family Physicians, they both expressed strong support for the ACA. Dr Hood and Dr Stream are both concerned that hyperpartisan politics in Washington, DC, as well as concerns about the deficit, may derail the funding needed for these key initiatives to support primary care, which are very likely to reduce, or at least restrain, the growth of healthcare costs in the United States.

Dr Hood noted that the Workforce Advisory Com­mittee has not yet met, and funding for a number of other initiatives to support a strengthened PCP-based system has either not been provided or has been relatively low. Furthermore, the number of PCP slots at residency programs, which has not changed since 1997, is particularly problematic, according to Dr Hood. And Dr Stream suggested that scholarships are a more powerful incentive than debt forgiveness to draw medical students into primary care.

Given the current intense Republican opposition to “Obamacare,” various national polls showing ambivalence toward the ACA, uncertainties related to potential Supreme Court action on the ACA, and the hyperpartisanship in Washington, it may be valuable to bring forth a separate new bill that focuses solely on key primary care–related provisions in the ACA, as identified in Table 1, for which bipartisan support can be expected.

Initiatives to Strengthen Primary Care
The politics surrounding Federal Emergency Man­agement Agency (FEMA) expenditures in the wake of multiple unexpected natural disasters, and the passage of a bill to fund FEMA in late September 2011 with bipartisan support, suggests this as a possibility. Strengthening of the PCP model, which is desperately needed, and quickly, is currently being held hostage to politics: there is a strong likelihood that this situation will continue, given the current political environment.

Tax Incentives
Considering strong negative feelings toward Obamacare and congressional concern about any spending increases, Donald B. Marron, Director of the Urban-Brookings Tax Policy Center, in an interview conducted on September 14, 2011, discussed alternative strategies for providing tax credits for PCPs and training. “People do respond to tax credits,” Mr Marron commented, noting that there would have to be identifiers recognizable by the Internal Revenue Service for program qualification.

Increasing the level of tax credit (ie, financial incentives) for PCPs working with identifiable underserved populations may be a successful strategy. To encourage medical school students and residents to join primary care, another strategy could be to have costs associated with medical school training for PCPs depreciated through income tax credits, with the depreciation schedule’s structure developed in such a way that it strongly incentivizes students and residents.

Particularly because years in residency are rigorous and have low pay, accelerated depreciation could provide a strong incentive to choose primary care. Safeguards, such as a 5-year commitment to work primarily with Medicaid or patients in underserved areas, would of course need to be put into place. These are some strategies that deserve to be further explored in line with Mr Marron’s suggestions.

Patient-Centered Medical Home
Among the different ongoing initiatives aimed at improving the quality and reducing the cost of healthcare in the United States, one that stands out is the patient-centered medical home (PCMH). In his interview, Dr Stream commented that various articles published in peer-reviewed journals demonstrate that PCMHs improve the quality of patient care.^18-20 Both Dr Stream and Dr Hood discussed the importance of the PCMH as a multidisciplinary team effort that includes not only PCPs but other healthcare providers as well.

Dr Stream used the imagery of a football team, where the PCP is the quarterback, but the team as a whole and individual members of the team have considerable flexibility in their activities, always working toward the goals of improved patient care and better outcomes. In different practices, effective models, and which healthcare providers should be involved, vary significantly.

Nurses in Primary Care
In an interview conducted on September 29, 2011, with Peter McMenamin, PhD, Senior Policy Fellow of the American Nursing Association, Dr McMenamin discussed the value of advanced practice nurses (APNs) and physician assistants (PAs) as physician extenders who can prescribe medications. APNs and PAs receive substantial training related to pharmaceuticals, an important fact because of the importance of drugs and the issue of patient adherence in improving outcomes in chronic diseases. Dr McMenamin pointed out, however, that there is “substantial variation between states in terms of APNs’ scope of practice,” with greater restrictions in Southern states. Many PAs work with surgeons or other specialists; therefore, potentially the growth of this profession may not have as strong an impact on primary care.

Additional healthcare professionals that can be valuable in developing the care-provider team include registered nurses, licensed practical nurses (LPNs), case managers, health coaches, and medical assistants. By reviewing multiple cases and coordinating care, case managers can work to ensure delivery of high-quality care and improved outcomes. Health coaches can help to work through particular problems or focus on and achieve specific goals.

In his interview, Dr Collins commented that high-quality, well-trained medical assistants can be extremely helpful in taking a thorough medical history, which includes understanding patient stress levels. Stress can make medical conditions worse or even lead to the false appearance of a medical condition when the cause is simply very high stress. In addition, he noted that medical assistants’ salaries are significantly lower than those of other healthcare professionals, making it cost-effective for them to spend time with patients.

A 2011 Institute of Medicine report highlights the critical need for more nurses.¹⁵ Increasing the number of nurses in PCP offices is key to the success of the PCMH model. In his interview, Dr McMenamin noted that there is a shortage of nursing faculty. He also pointed out the issue of faculty aging, which creates additional challenges in educating registered nurses and APNs. He commented that APNs can play multiple roles in the PCMH model, including seeing patients, developing coordinated health plans, and acting as case managers. APNs receive substantial training related to pharmaceuticals and have prescribing authority in all 50 states.

Physician Assistants in Primary Care
In an interview conducted on September 9, 2011, with Robert Wooten, PA-C, President of the American Association of Physician Assistants, Mr Wooten said that PAs can play a substantial role in primary care, and in addition to the approximately 150 PA programs that currently exist, about 40 new programs are preparing for credentialing. According to the 2010 Census, there were more than 83,000 PAs in the United States in 2010.²¹ Mr Wooten added that PAs can undertake many of the traditional roles of PCPs, which can be particularly valuable in rural and other areas when PCPs are unavailable, or in roles such as case management or professional activities associated with medication management, which is essential for successfully managing patients with chronic conditions.

Although the difference in pay is not nearly as monetarily large as between PCPs and specialists, the issue of pay disparities between specialties also affects PAs. However, more than 30% of PAs choose primary care—the largest specialty they select—and they certainly are an important contribution to the primary care workforce.²¹

Figure 2

PCMH’s Success in Managing Chronic Conditions: TEAMcare
It is well known that chronic disease is an enormous driver of healthcare costs in the United States.²² Diabetes, which is frequently associated with high blood pressure and/or hypercholesterolemia, is exploding, both in terms of the number and severity of patients with diabetes, as well as treatment costs.²² Figure 2 provides projections about the number of patients with diabetes and the cost burden to the US healthcare in 2033, if, as a society and as individuals, we do not substantially change course.

Table 2

An excellent example of the PCMH in action—albeit within the context of a closed-staff model HMO—is TEAMcare’s work with patients who had depression and diabetes (the majority of patients) and/or cardiovascular disease.⁷ Table 2 presents 12-month data from the TEAMcare study.⁷

In a September 9, 2011, discussion with Elizabeth H.B. Lin, MD, MPH, a family physician and researcher with Group Health Research Institute in Seattle, WA, about what can explain why TEAMcare was so successful with such challenging disease states, she noted the importance of identifying and treating depression first, so that patients can become more active as partners in managing their disease. Dr Lin also said that despite the social stigma of depression, there is a very well-validated instrument, the Patient Health Questionnaire (PHQ-9) with which to measure it. Typically, depression in patients with comorbidities has been overlooked to focus on hypoglycemia, systolic blood pressure, or low-density lipoprotein levels.

Dr Lin explained that the TEAMcare approach is truly multidisciplinary. Teams include PCPs, nurse case managers, and consultant psychiatrists, as needed. The team can be expanded to include PAs, LPNs, medical assistants, and clinical pharmacists. Another notable component of this approach, according to Dr Lin, is the concept of “treat to target,” in which the patient is involved in selecting the target (eg, weight vs exercise) and the specific clinical goal. Creating personal connections between patients and members of their healthcare team is important, and this is potentially one of the factors in TEAMcare’s (and the PCMH’s) success.²³

Changing Patient Behavior: The Ochsner Health System Model
In a September 12, 2011, telephone interview, with Patrick J. Quinlan, MD, Chief Executive Officer at Ochsner Health System, one of America’s top integrated health systems, Dr Quinlan stressed the importance of not accepting the US current high health burden as inevitable. “The first step is to reduce the disease load to prevent what’s preventable, since about 50% of the disease burden is related to lifestyle factors,” and to moderate what is not, Dr Quinlan said. He noted the importance of caring about one’s own health and taking personal responsibility for it. Dr Quinlan also highlighted the importance of the primary care model and of a team-based strategy, which could potentially include social supports such as family members, groups, or others who could help patients in maintaining healthy choices, such as weight loss, smoking cessation, and exercise. He reinforced the importance of direct personal support, noting that telephonic support alone is a poor substitute.

Dr Quinlan further addressed employers’ shared interest in effective wellness programs. When asked what helped motivate people’s behavior the most, Dr Quinlan replied “a pedometer.” Ochsner Health System uses Virgin HealthMiles, an employee wellness program in which employees use a pedometer to record their steps and periodically measure their blood pressure, weight, body fat, and body mass index at kiosks located throughout the 13,000-employee Ochsner system.²⁴ Employees can measure their progress, and data are uploaded to a central system.

Dorothy Cain, RN, the system coordinator at Ochsner, commented in a September 28, 2011, interview on the high employee participation rate (87%), adding that daily activity and accountability are important to the program’s success. Successful program participants can significantly reduce their health insurance premiums for the following year, according to Ms Cain. This is logistically easier for Ochsner, and it also benefits employees, because premiums and employer contributions have been rising significantly faster than wages. It also avoids the sales tax that cash or gift card rewards incur, she said. Ms Cain discussed the importance of upper-management commitment to wellness, noting that with the unsustainable rise in healthcare costs, this shift is in fact occurring.

Strategies to Strengthen the PCMH Model
A number of strategies could help with underserved rural populations. For example, Family Medicine Spokane offers residency and medical school training and participates with other specialties in the Colville, WA (population of approximately 5000 people) rural training track.²⁵ In the interview mentioned earlier with Dr Stream, he said that in very sparsely populated regions in the Northwest, Midwest, and other areas, an APN could schedule clinic visits several days per week and work with a PCMH to deliver the full spectrum of care needed. A central PCMH base and multiple satellites could cover a very wide geographic area.

Funding the higher level of care, coordination, and case management required in this type of model re­quires more than an encounter-based payment schedule. Dr Stream noted that including a care or case management component—a per-member, per-month (PMPM) amount—to pay for the infrastructure needed to establish and operate as a PCMH is important, as is a pay-for-performance component. Dr Stream commented that current payment mechanisms are typically insufficient for the levels and nature of care needed for patients with chronic conditions.

A number of new healthcare payment models have either been implemented or are being considered. MCOs have greater flexibility in terms of how they pay physicians: a number of MCOs, Medicaid programs, and others are experimenting with new payment systems.

In the interview with Dr Hood, she discussed the example of Vermont’s multipayer Blueprint for Health, for which the 2010 annual report demonstrates very favorable results in terms of reduced hospital admissions for Medicaid patients, as well as reduced costs for hospitalizations and overall care.⁸ Another payment example is the PCMH model created by Community Care of North Carolina (CCNC), which provides care-coordination payments for Medicaid patients. As shown in a study of CCNC’s Medicaid program, which was conducted by Treo Solutions, an independent health analytics company, the program achieved  $1.5-billion savings over a 3-year period (from 2007 to 2009) for its Medicaid enrollees.²⁶

In an interview conducted on October 5, 2011, with Yul D. Ejnes, MD, FACP, of Coastal Medicine, a primary care practice in Rhode Island that has more than 80 physicians, Dr Ejnes discussed how Blue Cross of Rhode Island—a nonprofit MCO and the state’s largest payer—has contracted with several large practices to develop PCMHs that meet guidelines developed by the ACP several years ago.

According to Dr Ejnes, the practice is reimbursed based on a risk-adjusted PMPM payment amount, a slightly enhanced FFS basis, and performance-based criteria, such as following national guidelines for screening and treatment of patients whose disease characteristics place them at particularly high risk for serious medical events. To expand patients’ access, the practice is also open on Saturdays. Dr Ejnes said that the new payment mechanisms helped pay for salaried nurse case managers who provide care coordination and case management. He commented that these changes made the “practice of medicine more fun, and that [his] time was now freed up to interact with patients.” He also noted the reduced time he had to spend on administrative tasks.

Finally, the use of H-1B visas, and potentially changing the H-1B program so that PCPs would not need an employer sponsor, could be another way to increase the number of primary care providers in the United States. In addition, other countries, including Canada, Denmark, the Netherlands, and England, have programs to attract designated, highly skilled workers to their countries. A program like this in the United States could potentially be useful in rural areas, because many countries have substantial rural populations.

Conclusion
There is a great deal to be done in a short time to prepare for the changes in the ACA and to reverse the charging and very destructive drivers of America’s growing healthcare costs. This is something that as Americans working in a business environment and as a country, we cannot afford. Dr Stream expressed optimism that we can turn the situation around thanks to the clear understanding of what is needed to be done, the possibility of robust solutions, and the national sense of urgency. More innovation—particularly with regard to realignment of financial incentives to strengthen primary care and increase the number of PCPs and other healthcare providers who choose or move to primary care—is needed to meet America’s growing healthcare quality and cost challenges.

Author Disclosure Statement
Ms Collins has no conflicts of interest to report.

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