Opinions differ on the extent of the current PCP shortage. Nevertheless, there is clearly a “huge maldistribution problem,” says Robert Phillips, MD, MSPH, director of the Washington, D.C.-based Robert Graham Center, a primary-care research center. Rural and underserved areas already are being shortchanged as more doctors locate in more affluent and desirable areas, he says.
That phenomenon is hardly unique to primary care, but Dr. Phillips says the deficit in frontline doctors could cause disproportionately more hardships in rural and underserved communities given the shrinking pipeline for medical trainees. A decade ago, almost a third of all medical graduates were placed into primary-care residency training slots. Now, he says, that figure is a bit less than 22%. “We can’t even replace the primary-care workforce we have now with that kind of output,” Dr. Phillips says.
Already, many doctors are no longer accepting new Medicaid or Medicare patients because their practices are losing money from low reimbursement rates. The Affordable Care Act’s significant expansion of insurance benefits, Dr. Grover says, will effectively accelerate the timetable of growing imbalances between supply and demand. “I think the challenge you face is, Will the ACA efforts to expand access fail because you’re giving people an insurance card but you have nobody there to take care of them?”
Reasons Aplenty
Some medical students simply aren’t interested in primary care. For the rest, however, interviews with doctors, analysts, and federal officials suggest that the pipeline has been battered throughout its length. Of all the contributing factors, Dr. Phillips says, the main one might be income disparity. In a 2009 study, the center found that the growing gulf in salaries between primary care and subspecialty medicine “cuts in half the likelihood that a student will choose to go into primary care,” he says. Over a career, that gap translates into a difference of $3.5 million. “It dissuades them strongly,” Dr. Phillips says.
At the same time, medical school tuitions have increased at a rate far outstripping the consumer price index. “What we found is that when you hit somewhere between $200,000 and $250,000 in debt, that’s where you see the dropoff really happen,” he says. “Because it becomes almost unfathomable that you can, on a primary-care income, pay off your debts without it severely cutting into your lifestyle.”
Lori Heim, MD, former president of the American Academy of Family Physicians and a hospitalist at Scotland Memorial Hospital in Laurinburg, N.C., says the prevailing fee-for-service payment model has failed primary-care providers, requiring them to work more to meet soaring outpatient demand but reimbursing them less. “People talk about the hamster wheel,” she says. “And that has created more workplace dissatisfaction. Not only does it impact students, but it also impacts the number of primary-care physicians who want to stay in the community, practicing.”
Frederick Chen, MD, MPH, associate professor of family medicine at the University of Washington in Seattle, can relate. “I came from community practice, where you’re seeing 30 to 35 patients a day, and the pressure was entirely on your productivity, and that’s not fun,” he says. “So we’re burning out a lot of primary-care physicians, and students are seeing that very easily.”
The larger theme, several doctors say, is one of perceived worth. Leora Horwitz, MD, assistant professor of internal medicine at Yale School of Medicine in New Haven, Conn., says she has to think holistically about her patients’ symptoms, medication lists, family history, home situation, and other factors during her limited time with them. She bristles at the notion that specialists might spend their time considering only one aspect of her patients’ care yet bill twice as much.