Primary care is an important part of health services that improves overall health and prevents problems that may lead to more expensive emergency room visits and hospitalizations. Compared to specialty and inpatient care, primary care is relatively inexpensive and more easily delivered.
And yet, a recent publication of the Association of American Medical Colleges reports that by 2025 the United States will face a shortage of primary care physicians in the tens of thousands. While the shortfall is smaller than previous predictions, there are still concerns that the lack of physicians will increase wait times for non-urgent appointments and have other negative consequences for patients.
In fact, these consequences are already evident. According to the New Mexico Primary Care Association, wait times for non-urgent appointments in 2012 were already one to four weeks in the state. A report from the Institute of Medicine and the National Research Council connect poorer health outcomes in the United States compared to other high-income democracies to “more limited access to primary care.”
The anticipated shortages are driven by a number of factors. These include the growing number of older adults who will need more complex care; an aging workforce and anticipated retirement of current physicians; younger physicians entering better-paid specialties rather than primary care; and an increasing demand for primary care once the Affordable Care Act is fully implemented.
Only one in five graduating internal medicine residents plans to go into primary care medicine. Providing incentives for entering primary care, such as scholarships and loan forgiveness, is one way to address the shortage. The National Health Service Corp, for example, pays a portion of student loans for a four-year commitment at a community health center where much of primary care takes place.
Training more doctors, however, is not the only solution. It may not even be the best course of action. Some scholars and advocates argue that the issue is not really a need for a fixed number of physicians, but a gap between the demand for primary care services and the capacity of primary care to meet that demand. Reshaping traditional primary care, rather than increasing the supply of physicians, may be the most effective way of closing this gap.
One way to address the gaps is to use more non-physicians. Nurse practitioners and physician assistants can be given more autonomy and empowered to provide more care in a number of ways. They can provide more of the routine care to increase the overall capacity of a clinic and free physicians to spend time with patients suffering from more complicated and serious. The availability of primary care services could also be expanded with more nurse-managed clinics which already exist and provide services with little physician involvement. Other professionals such as health educations and social workers can be used to provide health education and prevention counseling.
A National Center for Health Statistics study of community health center visits from 2006 to 2008 provides support for the greater role of non-physician health care providers. About a third of community health center visits during this time were to physician assistants, nurse practitioners, and certified nurse midwives, rather than physicians. For the most part, there was no significant difference in the type of services provided by physicians and these other health care providers. A 2009 study by the RAND Corporation found that nurse practitioners provide care of equal quality to that of primary care physicians at a lower cost and with higher levels of patient satisfaction. In both of these studies, physician assistants and nurse practitioners provided more health education and disease counseling than physicians – both of which are important for overall health management and prevention.
Achieving this system of reorganization requires more physician assistants, licensed practical nurses and aides; changes to current Medicare, Medicaid, and insurance payment; and laws that allow a broader scope-of-practice for non-physicians. Currently, regulations vary across states in terms of whether physician assistants and nurse practitioners can prescribe medication or diagnose and treat illnesses without the supervision of a physician. In states with the least restrictive regulations patients are more likely to receive primary care from nurse practitioners than in states with more restrictions.
In 2010, the Institute of Medicine proposed that nurse practitioners should be able to admit patients to hospitals or hospices, lead medical teams and medical homes, and be reimbursed at the same rate as physicians for providing the same services. Perhaps not surprisingly, physician organizations were against this proposal.
A subsequent national survey found significant disagreement between physicians and nurse practitioners in their attitudes about the scope of work for nurse practitioners. A much higher proportion of physicians did not agree that nurse practitioners should lead medical homes or should be paid equally for the same services and more physicians believed that they provide a higher quality of care than nurse practitioners. While most respondents overall agreed that having more nurse practitioners would improve the timeliness of care and access to health care services, only one in three physicians reported that more nurse practitioners would improve safety, effectiveness or equity of care. In fact, one in three physicians felt there would be a negative effect.
Overall it seems that meeting the expected shortage in primary care services needs to be addressed on multiple levels. Increasing the number of primary care physicians is one approach, but changing regulations and professional cultures to expand the role of non-physicians in primary care will be important as well.
