This post is part of a two-part series on the primary care shortage in America from Elation’s Director of Primary Care Advancement, Dr. Sara Pastoor. Follow along for part two of the series next week.
Defining the shortage
In June 2021, the AAMC (Association of American Medical Colleges) published its seventh annual report on physician shortage projections, a study performed by the Life Science division of IHS Market. The Complexities of Physician Supply and Demand: Projections from 2019 to 2034 analyzes physician supply based on trends in physician workforce and healthcare delivery, as well as physician demand based on population demographics, population health goals, and the impact of advanced practice nurses and physician assistants.
The findings of the 2021 study continue to raise alarms, as did the predecessor studies dating back to 2015. The current projections forecast that physician demand will grow faster than supply. The projected shortage by 2034 of primary care physicians (17,800 – 48,000) is almost as large as the projected shortage for all other specialties combined (21,000 – 77,100). The primary care shortage is particularly concentrated in rural and low income urban areas.
However, the AAMC summary report did not include in its supply and demand projections physician shortages in a health equity scenario. In a separate analysis, the researchers modeled the primary care physicians needed if “everyone utilized care as if they had equivalent utilization patterns to non-Hispanic White, insured populations living in suburban metropolitan areas.” The results were staggering. In 2019, the primary care physician deficit needed to close the health disparity gap was 50,500, exceeding the highest AAMC supply/demand projections predicted by 2034, which were based upon current utilization patterns.
In a study published in the Annals of Internal Medicine in 2021, researchers used statistical models to estimate the effect on life expectancy of alleviating primary care shortages in areas of low primary care density. Their findings indicated that 7,000 lives could be saved annually and life expectancy for the average American would increase by 2 months if the United States added 95,754 primary care physicians to support these specific underserved areas – a number which far surpasses the AAMC projections.
In 2020, it was estimated that over 30 million Americans were uninsured, with many more underinsured, creating a barrier to access to primary care, and disproportionately affecting minority groups and low income populations. A study published in JAMA Internal Medicine in 2020 found that the proportion of adult Americans with an identified source of primary care decreased by 2% from 2002 to 2015, and was on a continued decline, with an average of 25% with no identified source of primary care. This translates into over 80 million adults without a PCP, and a >6 million drop from 2002 to 2015.
These data are alarming
In a report from the Commonwealth Fund, adults with a primary care physician had 19% lower odds of premature death compared to adults who only seek subspecialty care. It has also been found that having a regular source of primary care is associated with a 33% lower total cost of care compared to the use of subspecialists only. Clearly, primary care improves health and life expectancy while decreasing total cost of care, and yet we have a critical shortage in the United States, and it seems to be getting worse. In a May 5, 2021 report by the National Academies of Sciences Engineering and Medicine entitled Implementing High Quality Primary Care, leading healthcare experts warned of a failing medical system in the U.S. and recommended that every American have a primary care physician, asserting “Without access to high-quality primary care, minor health problems can spiral into chronic disease, chronic disease management becomes difficult and uncoordinated, visits to emergency departments increase, preventive care lags, and health care spending soars to unsustainable levels.
If primary care is so important, both to individuals and to the medical system, why is there a shortage?
There is no single or simple answer to why there is a primary care shortage. There are many drivers behind the declining workforce, but that isn’t where the story ends.
(1) Growing demand: Many cite growing demand from an aging population, with baby boomers aging into Medicare “by the thousands”.
(2) Financial disparities: Primary care salaries are 30% lower than subspecialty salaries, ranking 24th, 27th, and 29th out of 29 specialties, and the debt of graduating medical students is large and increasing.
(3) Prestige and lifestyle: Subspecialties may carry more prestige and offer a better lifestyle than primary care.
(4) Distribution disparities: The distribution of primary care is uneven, with too few practicing in rural or impoverished areas, and the aforementioned lack of access related to insurance barriers further complicates the distribution issue.
(5) Lagging recruitment: Current recruitment practices disproportionately steer new and aspiring physicians into non-primary care fields.
(6) Burnout: PCP burnout ranges from 13.5% to 60%, and the most common predictor is practice environment.
(7) Workforce decisions: Primary care physicians are more likely to retire early or shift their careers into administrative roles. In a national survey done in March 2021, 1 in 3 primary care clinicians reported they expected to leave primary care within 5 years.
Recruitment into primary care specialties plays a significant role
According to a 2020 report, only 32% of U.S. physicians actively practice in a primary care specialty – despite 50% of outpatient visits in the U.S. being in a primary care setting – and this number has been declining over the past decade. Experts have called for an increase in this proportion to 40%. Family Medicine residents from US medical schools fell from 77% in 1998 to 45% in 2016. The American Academy of Family Physicians reports that only 1 in 8 medical school graduates chooses to enter a family medicine residency each year, and the AAFP has a goal to increase that number to 1 in 4 by the year 2030. Yet, the vast majority of physicians complete their medical school training in big hospitals which glamorize subspecialty and inpatient care. It’s an indoctrination into the status quo of subspecialty-driven sick care, and paints a grim picture of primary care.
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