INNOVATION AND CHANGE
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access with 22 million people gaining coverage with the Affordable Care Act . The medical community was able to accommodate this additional population . Dr . Emanuel does not provide details on appointment availability , variation in access or quality of care in his opinion .
Still the AAMC raises the concern that by 2034 , the U . S . population will have grown 10 %, to reach 363 million Americans . Much of that growth will be in the population over age 65 . The pediatric age group is expected to have a much lower growth rate . So with older Americans , there will be even greater need for both primary care and specialty care doctors .
Appointment Availability Concerns
The Medical Group Management Association ( MGMA ) lists a number of reasons for difficulty with medical appointments :
• Appointment no-shows — An MGMA survey showed that 44 % of responding medical practices indicate that no-shows are the greatest challenge to their practices . All the Kentucky Technical Advisory Committees of the Department of Health and Family Services echo this concern . No-shows reduce the number of patients actually seen .
• Physician aging — The AAMC notes that currently 40 % of actively practicing physicians will be 65 years or older within the next decade . The U . S . is following European leads in increasing the number of medical students to add to the physician workforce . However , Europe is taking steps to create stronger pathways for students to go into primary care fields .
• Medical student debt — The AAMC also notes that the average debt for medical students graduating in 2021 was $ 203,000 . Going into specialty areas , especially procedurally based specialties , can help the new doctor achieve financial independence much earlier . Debt is a large contributor to the reduction in new primary care physicians .
• Geographical maldistribution — The federal government ’ s Agency for Healthcare Quality and Research ( AHRQ ) notes that while specialty care is very much concentrated in urban areas , primary care physicians are more likely to practice in rural areas than specialists but are still more concentrated in urban areas than the general population . 3
• Status / prestige — A number of studies have shown that medical students perceived prestige or status of specialty influences their choice of profession . The procedural specialties that involve the chest and higher have the greatest perceived prestige . Primary care , while not at the lowest end , is not perceived as having high status . 4
• Health systems / practice styles — Of the 246,000 PCPs , 12,000 are in concierge practices so have smaller panel sizes . Another 13,000 are semi-retired and not seeing a full panel of patients . Because of the differences in expectations , practice support and incentives , there are differences in RVUs generated by employed doctors compared to those in independent fee for service . This can have an impact upon access and availability for primary care physicians .
What Can Be Done ?
Kentucky has created incentives for medical students to move into primary care roles through loan forgiveness programs . Recently , the University of Kentucky received a $ 16 million grant to increase primary care physicians in the Commonwealth . There may be more incentives generated to help motivate medical students to pursue careers in primary care . So far , the efforts are still fledgling ones .
Dr . Frank Opelka with the American College of Surgeons , expressed to me his vision that the future of primary care will be the oversight of nurse practitioners . In that role , the PCP would be manager , advisor and the doctor taking care of the sickest patients in the practice . The movement , however , has been from the physician compact model to independent nurse practitioners and physician assistants to pick up the slack of reduced PCP availability . Most of these nurse practitioners are working in office settings where there is the option for physician co-management . 5 That may allow for greater optimization of the professional strengths of physicians and nurse practitioners and / or physician assistants . It may require more training of primary care physicians to learn co-management skills ; but such a model can ensure patients have greater access and that there is oversight for quality of care .
References
1
“ The Complexities of Physician Supply and Demand : Projections From 2019 to 2034 ” Association of American Medical Colleges , June 2021 https :// www . aamc . org / media / 54681 / download ( last accessed Oct 29 , 2023 )
2
“ No Physician Shortage Despite Dire Warnings : Zeke Emanuel ” Interview in MediScape Internal Medicine , Jan 24 , 2018 , https :// www . medscape . com / viewarticle / 891569
3
“ The Distribution of the U . S . Primary Care Workforce ” AHRQ Publication 12-POO1-4-EF ( https :// www . ahrq . gov / research / findings / factsheets / primary / pcwork3 / index . html #:~: text = Uneven % 20geographic % 20distribution % 20of % 20 the % 20health % 20care % 20workforce , they % 20still % 20are % 20more % 20concentrated % 20in % 20urban % 20areas .) Last Accessed Oct 30 , 2023
4
Pfarrwaller E , Voirol L , Piumatti G , Karemera M , Sommer J , Gerbase MW , Guerrier S , Baroffio A . Students ’ intentions to practice primary care are associated with their motives to become doctors : a longitudinal study . BMC Med Educ . 2022 Jan 11 ; 22 ( 1 ): 30 .
5
Julian Grant , Lauren Lines , Philip Darbyshire , Yvonne Parry , “ How do nurse practitioners work in primary health care settings ? A scoping review ,” International Journal of Nursing Studies , Volume 75 , 2017 , Pages 51-57 ,
Dr . James is the Chief Medical Officer for Passport Health Plan by Molina Healthcare .
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