The Primary Care Shortage in America (Part 2)

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. You can read part one here.

Perhaps the most critical driver for the primary care crisis in the U.S. is the problem of burnout 

In the pay-for-volume “productivity” model of reimbursement, which preferentially rewards procedural-based specialties and undervalues those specialties requiring intense cognitive work, primary care has become an inhospitable profession for many who envisioned a career providing comprehensive, whole-person care. Unfortunately, the productivity model has forced primary care physicians into a business model of doing more with less, and cranking out “volume” based solely on the measurement of work that generates revenue, rather than work that creates value. This tightening of the vice around primary care in order to maintain financial viability, combined with the disruptor known as the Electronic Health Record (EHR), has, over time, created numerous unintended consequences which have stripped primary care of its efficacy and robbed physicians of the joy in practice – not to mention the direct and indirect negative impact to patients, and the ripple effect of negative consequences across the healthcare system and increased cost to payors.

The focus on “productivity” has a domino effect on both quality and cost. Physicians are expected to maximize the amount of patients seen face to face, cramming more and more patients into a day’s schedule in order to generate enough revenue to cover the overhead and earn an income, which leads to the well-known problem of physicians unable to spend appropriate time with each patient and chronically running behind schedule.  Patients experience long waits, only to feel rushed during the encounter, which neither the patient nor the physician enjoys. Doctor visits take on a narrow focus, and important details are too often missed. Patients with multiple problems frequently have to be seen in more than one visit, thus fragmenting and delaying care, increasing costs, and eating up primary care access which is already in short supply. Wait times for primary care appointments are weeks to months, and the resulting access void has led to an overpopulation of urgent care clinics and free-standing emergency rooms, both of which compound fragmentation, increase costs, and compromise outcomes. Many of these same urgent care clinics are now staffed by primary care physicians who have fled independent practice in disillusionment, further increasing the shortage of physicians offering longitudinal primary care. Primary care physicians also often shrink their scope of practice in an effort to simplify operations and maximize throughput. The result is an increased dependency on subspecialty care, which further fragments and delays care, increases costs, and often compromises quality of care.

Perhaps most importantly in this model – the one in which primary care patients are run through a turnstile at breakneck speed all day long – is that the most valuable part of primary care, the doctor-patient relationship, is sacrificed at the altar of productivity. It is this longitudinal relationship, empowered by familiarity and trust, which attracts many medical students into a primary care discipline in the first place, and is perhaps the most prominent factor in how patients and families assess the value of primary care to them personally. In the absence of this relationship, both physicians and patients suffer. 

Behind the scenes, there is a crisis of administration

Primary care physicians spend an extra 1-2 hours doing “paperwork” for every 1 hour of face to face patient care. This includes documentation in the EHR as well as a daily avalanche of clinical and clerical tasks which distract clinicians from providing exceptional care and spill over into their free time. While these tasks are necessary, and many of them even create value for the patient, they can be tedious, time consuming, and often demoralizing after an exhausting day of patient care. A significant portion of these tasks are nuisance activities tied to rule-based healthcare practices, as required by payers to meet benefit rules and a wide variety of business metrics. EHRs which promised greater efficiency and better outcomes have failed to deliver either one, and in fact have added to workload and driven up the overhead burden, with the cost of technology usurping funds which could have been invested in resources that drive value to patients.

Moral injury: the cost of a fatally flawed system

Within this context, it is not difficult to grasp why primary care -uniquely designed to promote health and keep patients well – is in short supply. It has been disempowered, and under-resourced by a dysfunctional healthcare system which places a premium on invasive procedures and subspecialty-driven sick care. Primary care has been overwhelmed and driven to burnout by insurance rules, reimbursement processes, and technology – burnout which recently has been recharacterized as moral injury. 

Moral injury in healthcare was first described by SimonTalbot and Wendy Dean in their 2018 opinion piece, “Physicians aren’t burning out. They’re suffering moral injury.”  The distinction the authors make recognizes the cognitive dissonance experienced by physicians when forced to choose between competing priorities: on the one hand, productivity, metrics, EHR documentation, insurance bureaucracy, and even personal time; on the other hand, the very health and wellbeing of their patients. This double bind, particularly conspicuous in the primary care setting, leaves a burden of anguish and guilt that is cumulative over time, eroding self esteem with a constant and crippling infusion of “not enough.” Primary care physicians dedicate years of expensive training and their entire professional identities to serving their patients and their communities as a common good, only to feel as though they are forced to serve a diabolical master instead – one which does not have their patients’ best interests in mind. And yet, physicians seem to carry the sole accountability for patient experience, operational efficiency, and health outcomes.

What is the solution? 

As Talbot and Dean put it, “Physicians are smart, tough, durable, resourceful people. If there was a way to MacGyver themselves out of this situation by working harder, smarter, or differently, they would have done it already.” In fact, a growing number of primary care physicians have, in a way, “MacGyvered” themselves out of primary care misery by walking away from the fee-for-service (productivity) payment model. 

One innovation which has been growing in popularity is opening practices paid via a subscription model known as Direct Primary Care. This model of financing primary care frees physicians up to care for fewer patients per physician without the administrative burden created by insurance carriers, which allows them to spend more time with patients and create more flexible business models that are built around the patients’ needs for access, time for comprehensive visits, and care coordination. In most cases, the fees are paid out of pocket by the patient, since it is not a covered insurance benefit (by design). In this model, the patient controls the money, and the doctor is directly accountable to the patient. 

In a 2020 comparison case study, patients engaged with a DPC practice had better patient experience, lower ER and hospital utilization, and lower total cost of care.  Notably, physician overall (personal and professional) satisfaction was 99%. Critics of the DPC model argue that because patient panels are smaller, the impact to the primary care shortage is worsened.  However, DPC advocates argue that career satisfaction is a major contributing factor to the shortage, and the DPC model solves for this.  It also potentially decreases referral rates for subspecialty care with potential to shrink the compensation disparity between primary care and subspecialty care.  

Another innovation picking up momentum involves start-up primary care platforms contracting directly with employers or other payers, financed directly without fee for service billing. This may manifest as a per member per month fee (capitation), a cost plus model, performance incentives, shared risk contracts, or a combination of these. Physicians working in these models are employed, and the impact to physician and patient experience, quality outcomes, and cost of care, while generally quite favorable, varies depending on the payment model and contractual obligations. Physicians who choose an employed status in one of these models sacrifice significant professional autonomy in exchange for the financial security, reduced stress of managing a business, and more time with patients, with the reward of providing better care.

New financial models may help soothe some of the burnout and improve professional satisfaction, but they do little to right a sinking ship. Incremental changes which result in a gradual evolution may be too little, too late when this crisis calls for revolutionary interventions: 

  1. Create opportunities to recruit for representative diversity of the primary care workforce starting in primary school to help address primary care shortages in underserved areas. 
  2. Federal student loan relief programs should recognize primary care in alternative payment models to alleviate concerns about educational debt while allowing primary care physicians to break free from the traditional but failing fee-for-service practice model. 
  3. At least 40% of medical school recruitment should focus on students who show passion for primary care specialties.  
  4. Medical school education should be overhauled to minimize the indoctrination into hospital-centric, subspecialty-driven sick care and expose all medical students to community-based primary care in DPC and similar innovative practice models, so that they experience the power and influence of primary care to change lives. 
  5. Increased investment in primary care at the policy level is critical, as well as the number of federally funded residency training slots in primary care fields. 
  6. New payment models should focus on incentivizing the value that only primary care can deliver, with multi-payer alignment and targeting of specific non-medical needs to address social determinants of health.  
  7. The technology industry should deliver digital ecosystems that decrease technology-related burnout and empower and enable primary care to be proactive, informed, comprehensive, coordinated, and patient centered. 
  8. Primary care residency programs should inform and prepare residents with the expertise and confidence to enter independent practice – this includes business acumen, exposure to various financial models, and financial incentives which make this an attractive option. 

With the right investments and radical changes to better support a robust foundation of primary care in the U.S. medical system, primary care will flourish, as will the healthcare system and society along with it.

Dr. Sara Pastoor

about

Sara J. Pastoor, MD, MHA is Elation's Director of Primary Care Advancement and leader in primary care advocacy. Dr. Pastoor is a board certified and clinically active family medicine physician. Her experience as a primary care innovator spans a career in military medicine, academic medicine, private practice, and employer-sponsored delivery models. She received her MD from Rosalind Franklin University of Health Sciences and MHA from Trinity University.