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The Problem with U.S. Health Care Isn’t a Shortage of Doctors

The coronavirus

The coronavirus epidemic is increasing demands on health care’s frontline, primary care physicians. Even before the outbreak emerged, conventional wisdom held that we’re facing a PCP shortage.

Quartz this July warned of a “devastating” doctor shortage poised to strike America. Later that month, the Washington Post chimed in with “America to face a shortage of primary care physicians within a decade or so.”

Indeed, estimates from the Association of American Medical Colleges (AAMC) indicate that the U.S. could face a shortfall of between 21,000 and 55,000 primary care doctors by 2023. Add to this the spikes in demand from Covid-19 and any future epidemics, and the challenge might seem insurmountable

We’re not here to second-guess the AAMC’s estimates. Based on typical primary care clinical practice, that assessment makes sense.

But what if there were a way to provide enough primary care to serve the needs of the U.S. population across the next decade — even with abrupt changes in demand — without having to add tens of thousands of physicians beyond current expected supply?

To be sure, there are reasons to worry about whether all Americans have sufficient access to primary care doctors.

Those warning of a potential shortage are right to highlight our aging, increasingly sick population, and they rightly note that many doctors are cutting back on working hours as they burn out or near retirement age.

Even so, some simple math would suggest that we should have more than enough primary care physicians. By 2025, the Department of Health and Human Services estimates we should have 190,000 non-pediatric PCPs.

Assuming normal patient panels (about 2,000), that suggests the capacity to care for 380 million people (vs. a U.S. population estimate of 272 million). Estimates from Ezekiel Emanuel and his colleagues from the University of Pennsylvania published in JAMA in 2017 put the figures even higher — 600 million people, nearly twice today’s population — when adding in all fields related to primary care.

So why the disconnect between our theoretical capacity and the reality that a growing number of patients lack access to primary care? There are plenty of contributing factors:

Uneven distribution. Some regions may face a mismatch of supply and demand (not enough PCPs practicing in rural or impoverished areas, for example).
Incomplete coverage. With the uninsured rate now rising to 13% to 14% of the population, a significant number of people simply can’t afford to access primary care.

Inconvenient hours. In many markets, primary care still isn’t available on evenings, nights, and weekends.

Inflexible care models. Most markets still rely on PCPs to deliver primary care in a physician’s office — even though physician assistants and nurse practitioners can deliver much primary care at a lower cost and equally high quality.

Payer aversion. Some practices may limit the number of new patients they are willing to take on from Medicare, Medicaid, and other public programs because such patients are supposedly “unprofitable.”
Inefficient use of physician labor.

Estimates of physician productivity suggest that 20% to 30% or more of a physician’s available capacity is absorbed by clinical documentation, electronic medical record (EMR) inputs, and other compliance-related work.
If you look closely, none of these factors mean we face a shortage of physicians — they just suggest we’re doing a bad job of using our current physician population efficiently.

Analyses estimating shortages base them on an inefficient system: on the care models, labor practices, sites of care, and process inefficiencies that exist today.

So what’s the solution? It requires abandoning a one-size-fits-all approach to primary care and embracing different care models for different types of patients. Recent Advisory Board research and analysis suggests the answer is threefold: better use of PCPs targeted at specific populations, greater use of non-physician labor where appropriate, and much broader deployment of technology to increase access to primary care.

Several top U.S. physician groups — including Iora Health, ChenMed, CareMore, and Southcentral Foundation — have shown that by focusing exclusively on Medicare patients and others with high rates of chronic illness, they could reduce ER visits and hospital admissions by 25% to 40% — often with physician panel sizes around 400 patients — and they do so profitably under payment systems that reward better care management. Better primary care management helps reduce the need for expensive specialist care for the sickest populations. But wouldn’t this strategy add to our PCP supply woes?

Not if we look at care models that embrace greater use of non-physician labor for patients outside of the sickest (and costliest) 5%.

For instance, successful models using a mix of physicians, nurse practitioners, physician assistants and other clinicians have managed to push primary care patient panels as high as 5,300 per physician,  based on Advisory Board benchmarking.

And some bullish estimates have said artificial intelligence could allow physician-patient ratios to as high as 25,000 per PCP by relieving doctors of administrative tasks and speeding up evaluation times.

In our most recent Advisory Board study on the future of primary care, we estimate that more effective use of non-physician clinical support (such as NPs and PAs) could have the same impact on capacity as adding 44,000 new PCPs, and targeted use of AI could allow patient panel sizes to increase by about 30%. Taken altogether, the 190,000 PCPs expected to be working in 2025 should be more than sufficient to meet America’s primary care needs.

Most important, leading physician groups that have adopted some or all of these strategies have achieved these results across vastly different geographic locations and patient populations, suggesting that their outcomes could be replicated almost anywhere.

Their success speaks to the power of patient engagement, care coordination, streamlined communication, technology, and top-of-license care models tailored to each individual patient.

It’s time to stop panicking about a looming “shortage.” Rather than treating today’s inefficient, hodgepodge system as a baseline for the future of primary care, we should instead ask two questions: How many doctors would we really need if best, evidence-based practices were widely adopted? And how can we encourage adoption of those practices?

If we consider these questions honestly, we’re likely to find that there isn’t a physician shortage after all. Rather, the real shortage is one of the courage to disrupt the way things have been done for decades.

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