Elisabeth Rosenthal: Primary- care crisis intensifies
These measurements of health-care service levels for specific areas of the U.S. came out in June 2020 through the Health Resources and Services Administration (HRSA), an agency of the Department of Health and Human Services (HHS).
States in red have Rhode Island-based CVS’s Minute Clinics, which are cutting into traditional primary-care practices.
“We have a specialty-driven system. Primary care is seen as a thankless, undesirable backwater.”
— Michael L. Barnett, M.D., health-systems researcher and primary-care physician in the Harvard Medical School system
I’ve been receiving an escalating stream of panicked emails from people telling me their longtime physician was retiring, was no longer taking their insurance, or had gone concierge and would no longer see them unless they ponied up a hefty annual fee. They have said that they couldn’t find another primary-care doctor who could take them on or who offered a new-patient appointment sooner than months away.
Their individual stories reflect a larger reality: American physicians have been abandoning traditional primary- care practice — internal and family medicine — in large numbers. Those who remain are working fewer hours. And fewer medical students are choosing a field that once attracted some of the best and brightest because of its diagnostic challenges and the emotional gratification of deep relationships with patients.
The percentage of U.S. doctors in adult primary care has been declining for years and is now about 25 percent — a tipping point beyond which many Americans won’t be able to find a family doctor at all.
Already, more than 100 million Americans don’t have usual access to primary care, a number that has nearly doubled since 2014. One reason our coronavirus vaccination rates were low compared with those in countries such as China, France, and Japan could be because so many of us no longer regularly see a familiar doctor we trust.
Another telling statistic: In 1980, 62 percent of doctor’s visits for adults 65 and older were for primary care and 38 percent were for specialists, according to Michael L. Barnett, a health-systems researcher and primary- care doctor in the Harvard Medical School system. By 2013, that ratio had exactly flipped and has likely “only gotten worse,” he said, noting sadly: “We have a specialty-driven system. Primary care is seen as a thankless, undesirable backwater.” That’s “tragic,” in his words — studies show that a strong foundation of primary care yields better health outcomes overall, greater equity in health-care access, and lower per-capita health costs.
One explanation for the disappearing primary-care doctor is financial. The payment structure in the U.S. health system has long rewarded surgeries and procedures while shortchanging the diagnostic, prescriptive and preventive work that is the province of primary care. Furthermore, the traditionally independent doctors in this field have little power to negotiate sustainable payments with the mammoth insurers in the U.S. market.
Faced with this situation, many independent primary-care doctors have sold their practices to health systems or commercial management chains (some private-equity-owned) so that, today, three-quarters of doctors are now employees of those outfits.
One of them was Bob Morrow, who practiced for decades in the Bronx. For a typical visit, he was most recently paid about $80 if the patient had Medicare, with its fixed-fee schedule. Commercial insurers paid significantly less. He just wasn’t making enough to pay the bills, which included salaries of three employees, including a nurse practitioner. “I tried not to pay too much attention to money for four or five years — to keep my eye on my patients and not the bottom line,” he said by phone from his former office, as workers carted away old charts for shredding.
He finally gave up and sold his practice last year to a company that took over scheduling, billing and negotiations with insurers. It agreed to pay him a salary and to provide support staff as well as supplies and equipment.
The outcome: Calls to his office were routed to a call center overseas, and patients with questions or complaining of symptoms were often directed to a nearby urgent care center owned by the company — which is typically more expensive than an office visit. His office staff was replaced by a skeleton crew that didn’t include a nurse or skilled worker to take blood pressure or handle requests for prescription refills. He was booked with patients every eight to 10 minutes.
He discovered that the company was calling some patients and recommending expensive tests — such as vascular studies or an abdominal ultrasound — that he did not believe they needed.
He retired in January. “I couldn’t stand it,” he said. “It wasn’t how I was taught to practice.”
Of course, not every practice sale ends with such unhappy results, and some work out well.
But the dispirited feeling that drives doctors away from primary care has to do with far more than money. It’s a lack of respect for nonspecialists. It’s the rising pressure to see and bill more patients: Employed doctors often coordinate the care of as many as 2,000 people, many of whom have multiple problems.
And it’s the lack of assistance. Profitable centers such as orthopedic and gastroenterology clinics usually have a phalanx of support staff. Primary-care clinics run close to the bone.
“You are squeezed from all sides,” said Barnett.
Many ventures are rushing in to fill the primary-care gap. There had been hope that nurse practitioners and physician assistants might help fill some holes, but data shows that they, too, increasingly favor specialty practice. Meanwhile, urgent-care clinics are popping up like mushrooms. So are primary-care chains such as One Medical, now owned by Amazon. Dollar General, Walmart, Target, CVS Health and Walgreens have opened “retail clinics” in their stores.
Rapid-fire visits with a rotating cast of doctors, nurses, or physician assistants might be fine for a sprained ankle or strep throat. But they will not replace a physician who tells you to get preventive tests and keeps tabs on your blood pressure and cholesterol — the doctor who knows your health history and has the time to figure out whether the pain in your shoulder is from your basketball game, an aneurysm, or a clogged artery in your heart.
Some relatively simple solutions are available, if we care enough about supporting this foundational part of a good medical system. Hospitals and commercial groups could invest some of the money they earn by replacing hips and knees to support primary care staffing; giving these doctors more face time with their patients would be good for their customers’ health and loyalty if not (always) the bottom line.
Reimbursement for primary-care visits could be increased to reflect their value — perhaps by enacting a national primary care fee schedule, so these doctors won’t have to butt heads with insurers. And policymakers could consider forgiving the medical school debt of doctors who choose primary care as a profession.
They deserve support that allows them to do what they were trained to do: diagnosing, treating, and getting to know their patients.
The United States already ranks last among wealthy countries in certain health outcomes. The average life span in America is decreasing, even as it increases in many other countries. If we fail to address the primary care shortage, our country’s health will be even worse for it.
Elisabeth Rosenthal is a KFF Health News reporter.
Elisabeth Rosenthal: erosenthal@kff.org, @RosenthalHealth
Michelle Andrews: Sanders is right to assert that millions can’t find a physician
From Kaiser Family Foundation Health News
Sen. Bernie Sanders (I-Vt.) has long been a champion of a government-sponsored “Medicare for All” health program to solve long-standing problems in the United States, where we pay much more for health care than people in other countries but are often sicker and have a shorter average life expectancy.
Still, he realizes his passion project has little chance in today’s political environment. “We are far from a majority in the Senate. We have no Republican support … and I’m not sure that I could get half of the Democrats on that bill,” Sanders said in recent remarks to community health advocates.
He has switched his focus to include, among other things, expanding the primary-care workforce.
Sanders introduced has introduced legislation that would invest $100 billion over five years to expand community health centers and provide training for primary-care doctors, nurses, dentists, and other health professionals.
“Tens of millions of Americans live in communities where they cannot find a doctor while others have to wait months to be seen,” he said when the bill was introduced. He noted that this scenario not only leads to more human suffering and unnecessary deaths “but wastes tens of billions a year” because people who “could not access the primary care they need” often end up in emergency rooms and hospitals.
Is that true? Are there really tens of millions of Americans who can’t find a doctor? We decided to check it out.
Our first stop was the senator’s office to ask for the source of that statement. But no one answered our query.
Primary Care, by the Numbers
So we poked around on our own. For years, academic researchers and policy experts have debated and dissected the issues surrounding the potential scarcity of primary care in the United States. “Primary care desert” and “primary care health professional shortage area” are terms used to evaluate the extent of the problem through data — some of which offers an incomplete impression. Across the board, however, the numbers do suggest that this is an issue for many Americans.
The Association of American Medical Colleges projects a shortage of up to 48,000 primary-care physicians by 2034, depending on variables like retirements and the number of new physicians entering the workforce.
How does that translate to people’s ability to find a doctor? The federal government’s Health Resources and Services Administration publishes widely referenced data that compares the number of primary care physicians in an area to its population. For primary care, if the population-to-provider ratio is generally at least 3,500 to 1, it’s considered a “health-professional shortage area.”
Based on that measure, 100 million people in the United States live in a geographic area, are part of a targeted population, or are served by a health care facility where there is a shortage of primary-care providers. If they all want doctors and cannot find them, that figure would be well within Sanders’ “tens of millions” claim.
The metric is a meaningful way to measure the impact of primary care, experts said. In those areas, “you see life expectancies of up to a year less than in other areas,” said Russ Phillips, a physician who is director of Harvard Medical School’s Center for Primary Care. “The differences are critically important.”
Another way to think about primary-care shortages is to evaluate the extent to which people report having a usual source of care, meaning a clinic or doctor’s office where they would go if they were sick or needed health-care advice. By that measure, 27 percent of adults said they do not have such a location or person to rely on or that they used the emergency room for that purpose in 2020, according to a primary-care score card published by the Milbank Memorial Fund and the Physicians Foundation, which publish research on health care providers and the health care system.
The figure was notably lower in 2010 at nearly 24 percent, said Christopher Koller, president of the Milbank Memorial Fund. “And it’s happening when insurance is increasing, at the time of the Affordable Care Act.”
The U.S. had an adult population of roughly 258 million in 2020. Twenty-seven percent of 258 million reveals that about 70 million adults didn’t have a usual source of care that year, a figure well within Sanders’ estimate.
Does Everyone Want This Relationship?
Still, it doesn’t necessarily follow that all those people want or need a primary-care provider, some experts say.
“Men in their 20s, if they get their weight and blood pressure checked and get screened for sexually transmitted infections and behavioral risk factors, they don’t need to see a regular clinician unless things arise,” said Mark Fendrick, an internal-medicine physician who is director of the University of Michigan Center for Value-Based Insurance Design.
Not everyone agrees that young men don’t need a usual source of care. But removing men in their 20s from the tally reduces the number by about 23 million people. That leaves 47 million without a usual source of care, still within Sanders’ sbroad “tens of millions” claim.
In his comments, Sanders refers specifically to Americans being unable to find a doctor, but many people see other types of medical professionals for primary care, such as nurse practitioners and physician assistants.
Seventy percent of nurse practitioners focus on primary care, for example, according to the American Association of Nurse Practitioners. To the extent that these types of health professionals absorb some of the demand for primary-care physician services, there will be fewer people who can’t find a primary-care provider, and that may put a dent in Sanders’ figures.
Finally, there’s the question of wait times. Sanders asserts that people must wait months before they can get an appointment. A survey by physician-staffing company Merritt Hawkins found that it took an average of 20.6 days to get an appointment for a physical with a family physician in 2022. But that figure was 30 percent lower than the 29.3-day wait in 2017. Geography can make a big difference, however. In 2022, people waited an average of 44 days in Portland, Ore., compared with eight days in Washington, D.C.
Our Ruling
Sanders’s assertion that there are “tens of millions” of people who live in communities where they can’t find a doctor aligns with the published data we reviewed. The federal government estimates that 100 million people live in areas where there is a shortage of primary care providers. Another study found that some 70 million adults reported they don’t have a usual source of care or use the emergency department when they need medical care.
At the same time, several factors can affect people’s primary-care experience. Some may not want or need to have a primary-care physician; others may be seen by non-physician primary care providers.
Finally, on the question of wait times, the available data does not support Sanders’s claim that people must wait for months to be seen by a primary care provider. There was wide variation depending on where people lived, however.
Overall, Sanders accurately described the difficulty that tens of millions of people likely face in finding a primary-care doctor.
We rate it Mostly True.
Michelle Andrews is a reporter for KFF Health News.