Brandon Liu
The current political push for efficiency and quality-oriented health care reform comes at the same time that demographic shifts are expected to cause substantial physician shortages in the future.
By 2030, the population of Americans 65 or older is expected to double to approximately 72 million as the “baby boomer” generation reaches retirement age. With this increase in senior citizens comes an increased demand for health care services1. In 2008, the Association of American Medical Colleges projected a shortage of 45,000 primary care physicians (PCPs) by 2020.2 Separate studies have pointed to even more drastic shortages once insurance expansion under the Affordable Care Act is factored into demand.3
The importance of primary care cannot be overstated. Primary care practice (PCP) serves as “the patient’s first point of entry into the health care system and as the continuing focal point for all needed health care services”.4 A PCP thus provides entry-level contact and care for an undiagnosed patient, acting as a coordinator for the patient’s access to the health care system as a whole by conducting overall health assessments, providing preventative care, and coordinating care with appropriate specialists when necessary. Today, the PCP is at the center of the health care paradigm shift towards a model of population health management. This new model provides coverage across a large patient population by emphasizing care coordination between professionals and optimizing strategies for specific groups while minimizing health care costs.5 The PCP’s role as the most basic provider of health care additionally corresponds with statistical evidence demonstrating better health outcomes in communities where PCP-population ratios are higher.6
The predicted physician shortages will result in decreased access to care for millions of individuals. A study from 2000 conducted by primary health care advocates James Macinko, Barbara Starfield, and Leiyu Shi attempted to quantify the health impact of PCPs within a population. Their study estimated that adding one PCP per 10,000 people would reduce predicted all-cause mortality (the mortality rate for a population across all causes) by 5.31 percent. Translated nationally, this would avert 127,617 deaths. Macinko, Starfield, and Shi also replicated this study on an international level, analyzing 18 Organization for Economic Cooperation and Development countries over three decades, and found similar results. Thus, the impending physician shortage threatens the health of Americans not only in decreased access to care, but also in poorer population health care outcomes as well.
By itself, increasing PCP supply will not fill the gap in demand. Most projections incorporate a PCP supply cap at about 8 percent growth by 2020, which only amounts to about 20,000 more PCPs added to the 207,000 currently in the work force. Projections show a relatively flat supply curve and reflect beliefs that PCP supply is being outpaced by demand.7
Though the reforms of the Affordable Care Act have sought to increase the attractiveness of primary care and have funded more primary care residency positions, it will be impossible to generate a major correction in the supply curve in the short time span between now and 2020.
Other proposals to meet the demand for primary care services call for expanding scope-of-practice laws in order to engage other medical personnel like nurse practitioners (NPs). NPs do not undergo residency training, but are typically trained to perform the same tasks as PCPs and possess substantial clinical training. Meanwhile, projections of NP supply show increases of 30 percent, from 55,400 in 2010 to 72,100 in 2020, and nurse-managed health clinics already independently provide primary care services to low-income, underinsured, and uninsured patients.8
But of greatest importance to note is that while the primary care demands of the nation are rising, the supply of primary physicians has remained flat. An adequate solution to the issue will need to incorporate a long-term vision for addressing the supply-demand mismatch. And until then, effects on the healthcare system and on healthcare outcomes will only become more pronounced.
1. Centers for Disease Control and Prevention. The State of Aging and Health in America 2013. Atlanta, GA: Centers for Disease Control and Prevention, US Dept of Health and Human Services; 2013.
2. Krupa, Carolyne. “Physician Shortage Projected to Soar to More than 91,000 in a Decade.” American Medical News. American Medical Association, 11 Oct. 2010. Web. 03 Apr. 2014.
3. Petterson, S. M., W. R. Liaw, R. L. Phillips, D. L. Rabin, D. S. Meyers, and A. W. Bazemore. “Projecting US Primary Care Physician Workforce Needs: 2010-2025.” The Annals of Family Medicine 10.6 (2012): 503-09. Print.
4. “Primary Care.” AAFP Policies. American Academy of Family Physicians, n.d. Web. 05 Apr. 2014.
5. “Population Health Management Solutions.” Health Catalyst. Health Catalyst, n.d. Web. 07 Apr. 2014.
6. Starfield, Barbara, Leiyu Shi, and James Macinko. “Contribution of Primary Care to Health Systems and Health.” The Milbank Quarterly 83.3 (2005): 457-502. Print.
7. U.S. Department of Health and Human Services, Health Resources and Services Administration, National Center for Health Workforce Analysis. Projecting the Supply and Demand for Primary Care Practitioners Through 2020. Rockville, Maryland: U.S. Department of Health and Human Services, 2013.
8. “For Policymakers.” NNCC ». National Nursing Centers Consortium, 2011. Web. 08 Apr. 2014.
Image:
9. Proimos, Alex. And you haven’t been to your doctor because?. Creative Commons Flicker, Available at https://www.flickr.com/photos/proimos/6870109454. Accessed December 5, 2014