Not enough primary physicians OR Nurse Practitioners: It's the money, stupid!

“Like doctors, more nurse practitioners are heading into specialty care”, a recent article in the Washington Post (June 17, 2024) by Michelle Andrews, a contributing writer for KFF News, and McKenzie Beard, makes the point that

Nurse practitioners have long been a reliable backstop for the primary-care-physician shortfall, which is estimated at nearly 21,000 doctors this year and projected to get worse. But easy access to NPs could be tested in coming years. Even though nearly 90 percent of nurse practitioners are certified to work in primary care, only about a third choose the field, according to a recent study.

That study, called ‘No One Can See You Now: Five Reasons Why Access to Primary Care Is Getting Worse (and What Needs to Change)’ was published by the Millbank Memorial Fund, and goes on at length to explain those reasons, and what needs to change.

Spoiler Alert: Like physicians, primary care nurse practitioners make less money, often for more work, and far less restricted scope of practice. Or, borrowing from an old political mantra, “It’s the money, stupid!” Or, as the WaPo article quotes Candice Chen, an associate professor of health policy and management at George Washington University, “We get what we pay for.”

It is, of course, more than just the raw amount of money. It is also how much NPs – and physicians – are paid for the amount of work that they do. This work is undervalued for primary care, based upon the notion that, somehow, being expert in a narrow specialty and knowing a lot about a little, is worth more than having a broad knowledge and being able to help a lot of people, most people, a great deal. Thus, subspecialists dramatically limit their practices to what they feel most expert at and expect the primary care clinician to do everything else. This often includes preparing people for a procedure and following them up after, which are both completely the responsibility of the person doing the procedure. Subspecialists particularly like to send paperwork back to primary care. “Your primary care doctor (or NP) will have to take care of this.” Implication: ‘Unlike primary care clinicians, I do important things.’

I would argue that managing people’s health is doing important things. Which is what the primary care clinician (family physician, general internist, general pediatrician, or the NPs that work in these fields) does. Managing the actual person, you, not just one of your diseases, or one aspect of one of your diseases; being knowledgeable about you, your life, and the interactions of all your conditions and the impact that they have on the rest of your life.

How might this manifest? Let’s say you have knee pain. You go to your family physician, who examines it, and decides that you need an x-ray. They review the x-ray and the report, and decide that you might benefit from seeing an orthopedist. They fill out the referral. Then, after the consultation and recommendation from the orthopedist, they review it, and decide how to implement the treatment. That is a lot of work. The orthopedist was done in a few minutes. Guess who gets paid, altogether, more?

Like the physicians that employ them, NPs are often very expert in their limited area (say, heart failure management), but often do not know how to manage that problem in the context of a person whose other diseases or medications may complicate that. This is where the (underpaid) primary care clinician, physician or NP, has to come in. It is a lot of responsibility, a lot of work, and often a lot of extra hours. One NP profiled in the WaPo article is taking training to become a dermatological NP. This is one of the medical fields with the highest pay/work ratios. Most of its work is not emergent and can conveniently be scheduled during the day during the week, and is less likely than many other specialties’ work to interfere with treatment for other conditions. And it is very highly reimbursed.

Should people be paid based upon the amount and difficulty of their work? If we did, people doing the most difficult work that everyone agrees needs to be done but that most people do not want to do (e.g., picking up the garbage, doing farm work in the hot sun) would be paid more than those who get fancy offices and lots of perks and boss folks around (e.g., CEOs). But difficult can have other definitions; this is really a separate discussion. In health care, for physicians (and now NPs) it should be how they contribute to the system. Currently the usual measure is money, that is, how much a given practitioner brings into the practice, or more commonly now, to their employer (often a health system), which is based on how much payors (insurers) pay for different things. That amount is not God-given, but a matter of policies that could be changed. Two mechanisms through which the amount of reimbursement is set are the RUC and the facility fee. The RUC is a group of non-governmental physicians appointed by the AMA that makes recommendations on how Medicare money should be divided up between specialists – like “one gallbladder removal is worth 6 complete examinations”, or whatever. Medicare is not required to accept their recommendations, but they usually do. And – surprise – the RUC is mostly made up of subspecialists, not primary care clinicians!

The facility fee is an amount that Medicare (and other insurers, see below) tack on to the physician fee if the practice is owned by a health system rather than a physician, and is often several times the fee for the procedure. To be clear, this means that if I receive a procedure today from a physician in their office and you get the same procedure in the same office by the same physician next week, but in the interim that practice has been acquired by a health system, the charge will be MUCH more. Medicare or your insurance may pay it, or most of it, but your co-pay will be much higher, and all of our premiums go up. This practice is hardly ever made apparent or explained in advance to patients (“Hi, thanks for calling. Just to let you know, Dr. Smith’s practice was just acquired by the MuchProfit Health System, so you will be charged three times as much for your procedure as you would have been last week.”) This is so insidious (not to say evil, but it is evil) that even doctors are often surprised, as revealed in the essay by Dr. Danielle Ofri in the New York Times (June 17, 2024) ‘Even Doctors Like Me Are Falling Into This Medical Bill Trap’ and the follow-up letters and comments from other physicians.

The fact that facility fees and the RUC are about Medicare does not mean that they do not affect the fees, cost, and reimbursement from other insurers. Almost all insurers payment rates are set as multiples of Medicare. That is, if Medicare pays $100 for something, they may pay $150 or $200 (and, more recently, those multiples are lower, with patient responsibility higher). Changing these two factors, facility fees and RUC allocations, for Medicare will affect all insurers and make a real difference in income (which is why most subspecialists and hospitals oppose them).

Should primary care clinicians be paid more, or subspecialists less, or somewhere in between? Whichever, by decreasing the difference more clinicians are likely to enter primary care specialties. And, whichever, the raking off of facility fees to increase the wealth of hospitals, not to mention the pocketing of huge profits by insurers, has to stop.

Medicare for All, or "Eat well, take your medications, and good luck!"

I have often written about the need for a universal national health insurance plan in the US, even more frequently recently. This is in part because the rise in costs and cuts in health coverage for Americans, including especially those who are in states that did not expand Medicaid as part of the ACA, have continued to erode our health coverage and increase our cost. It is also in hope that the Democrats in Congress will not abandon a real “Medicare for All” program in favor of a non-solution such as “Medicare for More” or almost anything that maintains for-profit insurance companies.

A Nurse Practitioner friend writes:

Many patients I see are very complex and, I think, not NP (Nurse Practitioner) appropriate but no one else is there for them because they are uninsured. And they tell stories of meeting with cardiologists who talk about several interventions and then when the MD finds out no insurance just says to them, “Well, be sure to eat well and take your medications and good luck”. 

And every day I see the effects of having so many people without insurance. I see the ones who ended up in the ED because of preventable problems. Yesterday I saw a 33 year old mother of two who had hypothyroidism, no insurance, ended up with severe cardiomyopathy [heart muscle disease] and heart failure all for lack of thyroid medication due to lack of care due to lack of insurance -- and she works in an MD office doing billing to keep our health care system going for those with insurance!!!

This situation is neither rare nor new. It happens to that particular NP every day. NPs in many states work under “collaborative agreements” with sponsoring physicians, and in others have independent practice privileges. When the patients are too complex for them, “their” doctors may be unwilling to take them, if they are uninsured. In addition, in many cases, the NPs (or PAs) practice in remote sites – sometimes very remote. But, the reality is that even if the physician is willing to see them, even if the patient is seen initially by a physician and not an NP, ultimately there is a similar outcome for those people without insurance or with poor-quality insurance. This scenario happens all providers, physicians included, except those who refuse to care for poor, uninsured, and poorly insured people.

It is essential that everyone who cares for, or about, people realize this, including the politicians who make the decisions and the pundits who opine about such things. They may be well insured, and likely most of the people that they know personally are (although every day that number grows smaller and the financial and health exposure of those who thought they were well insured grows larger), but many, many people are not. Whatever sticker shock insured middle class people have when they get sick or need medication (see the graph on the cost of Humalog ®, the most common insulin for people who need that drug to stay alive, vs inflation), it is much worse every step you go down the ladder of income into poverty, down the levels from “good” to “fair” to “poor” to “no” insurance.

It is also critical to remember that any reform plan that does not cover 100% of everyone will leave people like the woman described above out, and the stories that physicians and other health providers have to tell about how their patients cannot get the care they need will keep coming. For a plan to not only be “good”, but to be affordable, every single person in the US needs to be IN. It is most affordable if it goes all the way, putting everyone in one plan (Improved and Expanded Medicare for All), because that would eliminate the massive profits of the insurance companies that have administrative overheads of over 30% (compared to Medicare’s 1-3%) and would tightly regulate the profits (and whatever your favorite expression is for money made over costs for “non-profits”) of providers. Other plans that are seen as compromises are, like so many “compromises”, lose-lose. By dealing in the insurance companies and their profits so they won’t oppose the change (as ACA did) we build in this cost to our system, siphoning off at least 1/3 of the dollars ostensibly spent on health care to overhead!

One of the most widely supported bad ideas is continuing Medicare Advantage, also known as Medicare Part C. Basically, the insurance company that sponsors such a plan takes the money you’d get for regular Medicare (Parts A and B) and you kick in an additional payment, and you are covered, as in an HMO, for a variety of other services that traditional Medicare does not. It sounds like a good deal, and it generally is for the recipient with all the plusses (extra services at usually lower cost) and minuses (limited choice of providers, limit to geographic coverage area) of an HMO. At first, it seems to be a win-win, for patients and the insurance companies represented by America’s Health Insurance Plans (AHIP). AHIP has garnered letters of support just recently from 302 House members and 66 Senators, of both parties. The problem is that the insurers get extra money that traditional Medicare doesn’t, costing the public a lot (and sometimes involving fraud). Continuing Medicare Advantage not only gives some people better coverage, and makes a single Medicare for All again financially challenged, it costs the government more and makes insurers richer.

A real Medicare for All – not a bunch of different plans, some of which cost more money and spend a lot of that on insurance company profit -- is not an unrealistic pipe dream. What is actually unrealistic is keeping the current system (or, better, non-system) we have, or some minor modification of it, and expecting that it will lead to better health for more people and lower cost. That won’t happen, and the idea meets Einstein’s definition of insanity: doing the same thing over and over and expecting different results. High costs – proportionately higher for low-income people – and poor health outcomes – also higher for low-income people – are baked into that system.

Or, we can not do a comprehensive include-everyone program. We can stay with what we have, or some “part way compromise”. Read the story above again. Memorize it. Because, if we don’t have a universal health plan like every other developed country, it will continue to repeat thousands and thousands of times a day, in every city, state, and rural area in the USA.

If not, be sure to eat well and take your medications and good luck!

On interdisciplinary patient care and the corporate takeover of health care

The following is a gues post by Seiji Yamada, MD, MPH

In July 2015, on the 50th anniversary of the founding of the University of Hawaiʻi John A. Burns School of Medicine, the school invited its alumni for a Saturday morning symposium on "Transformative Medical Education in Hawai`i."  The last panel of the morning, on the future of medical education in Hawaiʻi, featured the deans of medicine, nursing, social work, and the associate director of public health.

Dr. Peter Donnelly - Kanaka Maoli family physician, practicing on the Neighbor Islands, my mentor in Hawaiian Pidgin and how to be local (I fail abjectly on both counts) - asked what the panelists think of nurse practitioners telling him that they can do anything he can do, at less cost.  One panelist suggested, "If you can't beat them, join them," so you might as well go get your MBA.

The claim that a non-physician provider can do the work of a physician at less cost ignores (perhaps willingly) the distinction between earning less and costing less.  Certainly non-physician providers earn less than physicians.  Dr. Stephen Kemble - psychiatrist and a stalwart for single-payer, who had been decrying the business takeover of health care from the audience all morning - noted that with regards to the provision of mental health, the evidence shows that non-physician therapists can actually cost the mental health system more than psychiatrists.  (He was citing an unpublished study performed by a Hawaiʻi health insurance outfit.)

Of note, a study in the September 2015 issue of Medical Care found that diabetic patients cared for by nurse practitioners had comparable rates of  preventable admissions as primary care physicians. The provider who cares enough to invest the time to talk with and assess the patient may also decide upon less intensive courses of care. The medical profession as a whole must shoulder part of the blame for the present situation.  Specialty control over the reimbursement system results, naturally, in disproportionately higher reimbursement for procedures and disproportionately lower reimbursement for primary care. See Outing the RUC: Medicare reimbursement and Primary Care. [1] This ensures that most medical students will choose specialty training so that there are not enough primary care physicians to care for all of us.  To the extent that physicians obtain MBAs and figure out how to game the extant reimbursement system [e.g. hire an N.P. to consult on patients so the gastroenterologist can perform colonoscopies in the surgicenter (anus to anus time of under 10 minutes) all day] - the proceduralist specialties are complicit.  Indeed, there is no reason why the gastroenterologist should explain the risks, benefits, and the bowel prep for screening colonoscopies.

We family physicians learn during residency that the practice of primary care is, in many ways more complex than specialty practice. [2] A well-trained, experienced provider of any discipline can deal with many complex patient problems for which a less intensively-trained, less experienced provider may order unnecessary tests or referrals.  Thus, while a primary care physician may earn more than a non-physician provider, the cost to the health care system may be less.

In addition, the provider who cares enough to invest the time to talk with and assess the patient may also decide upon less intensive courses of care.  These days, you can be largely assured that if you presents to the ED with a headache, you’re going to get a CT scan of your head.  If you present with abdominal pain, you’re going to get a CT of your abdomen.  Many patients with symptoms clearly suggested of reflux are kept in the hospital for observation to “rule out myocardial infarction.”  So, conversely, while a primary care physician may earn less than an emergency physician, the cost to the health care system may also be less.

While part of the problem may be that the nursing profession is eager to escape the yoke long placed upon it by the medical profession - perhaps the larger problem is what Dr. Kemble identified as the incursion of the business model into health care.

The business model is predicated on delivering a standardized product with quality controls on what can be measured at prices that the market will bear.  Thus at any fast food franchise, one can reasonably expect a hamburger without too much E. coli in it, at the price listed behind the counter.  The MBAs who run our health care systems have no concept of the importance of, for example, a longitudinal patient-doctor relationship to health outcomes.  If they can replace an experienced primary care physician with a lower-paid "provider," it's better for the bottom line. 

We in family medicine should not be picking a fight with the nursing profession.  (For the sake of patient outcomes, I am happy to help nurse practitioners improve their practice, and I am happy to learn from them what they do best.)  I think that the main problem is the marketplace model of health care.  Capitalism has always depended on maintaining a certain percentage of unemployment in order to keep workers a little afraid of losing their jobs and therefore toeing the line.  The corporate takeover of health care means pitting the lowest rung of the physician class, the primary care physicians, against a growing workforce of providers with different qualifications eager to take their jobs.  From where I stand, I think that all health workers need to unite against that.

[1] Freeman J. Outing the RUC: Medicare reimbursement and Primary Care. http://medicinesocialjustice.blogspot.com/2011/02/outing-ruc-medicare-reimbursement-and.html

[2] Freeman J, Petterson S, Bazemore A. Accounting for Complexity: Aligning Current Payment Models with the Breadth of Care by Different Specialties. Am Fam Physician. 2014 Dec 1;90(11):790. http://www.aafp.org/afp/2014/1201/p790.html

Creating team based care: are non-physician providers more effectively used in primary or subspecialty care?

The shortage of primary care physicians in the US, which I have often discussed (most recently in “When is the doctor not needed? And who should take their place?”, January 5, 2013), has become a national theme. The Robert Graham Center of the American Academy of Family Physicians (AAFP) has done much of the work in documenting this shortage, such as in the article “Projecting US Primary Care Physician Workforce Need” by Petteson, et al., discussed in my post “Health reform, ACA, and Primary Care: Is there still a conundrum?”, December 24, 2012. Essentially the problem is we have too few primary care doctors for the current population, the demand for them will continue to grow, and the rate of production (medical students entering primary care specialties) is below that even needed to replace those who retire. The growth in demand is a result of (in order of impact): population growth, aging of the population, and a more-or-less-one-time blip from increasing coverage under ACA (although for the latter, the people with a need for care were already there; it is just that with having insurance they will be able to seek it more easily).

 In a recent issue of Health Affairs, Green and colleagues argue that “Primary Care Physician Shortages Could Be Eliminated Through Use Of Teams, Nonphysicians, And Electronic Communication “.^[1] This is not a new concept; it is a central component of what is known as the “Patient Centered Medical Home”. The article suggests that many functions now carried out by physicians can be done by others, ranging from nurse practitioners and physician’s assistants, to nurses, to others on the health care “team”. It also suggests that many problems that now require face-to-face communication (trips to the doctor’s office) could be done by phone or “virtually”, such as by structured email or web-based visits. Thomas Bodenheimer and his colleagues in San Francisco have done much of the work in this area, most recently published in Annals of Family Medicine “Estimating a Reasonable Patient Panel Size for Primary Care Physicians With Team-Based Task Delegation”.[2]

Green, et al., use computer simulation models to estimate the “panel size” (number of patients that can be cared for per doctor) by the employment of such techniques; they add calculations for “pooling” of physicians, that is, sharing of patients among a group of doctors. This allows greater efficiency by “smoothing out the bumps” that may occur when one physicians has more or fewer patients coming in for same-day care or not showing up for their appointments by allocating them among the group. Using these statistical models they estimate that the ability of patients to access care (get in to be seen) would be dramatically increased by the implementation of such policies.

The work done by both the Green and Bodenheimer groups is convincing, and provides a model for more efficient primary care practice that would help to address the problems our country faces from having too few primary care doctors. Indeed, these approaches utilize the “crisis” as a way to actually improve both access to and quality of patient care. There are, however, challenges to implementation of this model. One is payment; while health systems in many parts of the nation have demonstrated that it is possible to restructure their practices to achieve these advantages, this is most effective in settings in which the provider is also the insurer (notably Kaiser). In those parts of the country where this model of care is less prevalent, where most payment to medical providers is “fee for service” for face-to-face visits to doctors, there is not only no incentive to change, there is a large negative financial incentive since any non-face-to-face care is, essentially given out free.

A second challenge is that such models only work where there is a large enough concentration of patients and providers to achieve the benefits of scale; as with most such analyses, it leaves out the needs of rural populations. Some large systems, such as Geisinger in Pennsylvania, have been successful in creating such efficiencies in their clinics in rural areas, but Geisinger is atypical; there are not many like it. In addition, it is a financially integrated system (like Kaiser) – that is, it is also the payer -- and it works in a relatively-densely populated rural area of northeastern Pennsylvania, not like the vast empty frontier counties of the West.

It is interesting to me that so much of this emphasis on efficiencies, and particularly the use of professionals other than physicians to provide care, has been on primary care. This, I am sure, is due in part to the need for primary care in all settings, while much specialty care can be centralized in larger cities. It is also because there is not a shortage of many non-primary-care specialists for the needs of the population (although there are for some, such as general surgery, especially in non-urban areas). The reason usually given for this non-shortage is largely that these specialists make so much more money than primary care doctors, so medical students are attracted to them. To the extent that some specialties also have more regular work hours and a limited scope of work, it may also increase their attractiveness.

The limited scope of work (although not, necessarily, less difficult work, especially when considering surgical interventions) also makes them, in many ways, more appropriate fields to use non-physician professionals than primary care. This is the reverse of the usual assumptions that sub-specialists are seeing difficult problems, while primary care providers see mostly colds and blood pressure checks. In fact, primary care is complex, as it sees both undifferentiated patients and those with multiple chronic diseases. Most specialty care is more routine, seeing a much more limited set of diagnoses with a more limited set of interventions; for the typical subspecialist, less than a half dozen diagnoses may account for 80% of visits, while for a family doctor the top 20 are probably 30%. Thus, the breadth of knowledge and skills in making complex decisions and appropriately prioritizing problems, require a level of sophistication and training not taught or developed in most other health professionals (family nurse practitioners are one other provider group where there is at least an effort to have this breadth of training). It is, then unsurprising that most of the tasks suggested for nurses and others to increase the efficiency of primary care practices have limited scope: maintaining disease registries, calling for recommended preventive care, screening a small set of diagnoses.

This type of narrow, in-depth scope of work is much more characteristic of subspecialty care, and it is one of the reasons why expanded-scope nurses and physician’s assistants have found so much use in these practices. They follow people with congestive heart failure for cardiologists or diabetes for endocrinologists, they manage chemotherapy recipients for oncologists, they use algorithms to care for people in intensive care units, they do pre- and post-operative care for orthopedists and other surgeons. And they do not go outside of the set of diagnoses and treatment options with which they are familiar; following the model of the physicians with whom they work, when a patient’s problem is not in their narrow area, it is referred.

The targeted but limited expertise of such nurse specialists have explains why they function so well clinically in subspecialties. What explains why it works financially is that the doctors (or hospitals, or health systems) that employ them are reimbursed at subspecialist physician rates (already very high) for work that is done by others; thus they can afford to pay such “physician extenders” relatively well compared to folks working in primary care. Reimbursement for “teams” follows the model of reimbursement for physicians: care for a limited set of diagnoses in a detailed way, especially when it involves procedures, is paid much better than management of complex sets of interactive diagnoses.

Unfortunately, the problem with such practice is challenging because the same person often has multiple conditions, and interventions that help one may make another worse. While efforts to build teams, and have each professional work at the “top of their license”, is important, so is payment. As long as primary care is reimbursed at lower rates it will continue to face challenges in recruitment of physicians, nurses, and other team members. 

We need to develop and implement great strategies for team-based care. We also need to dramatically decrease the ratio of income for subspecialists and their subspecialist teams relative to those working in primary care.

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[1] Green LV, Savin S, Lu Y, “Primary Care Physician Shortages Could Be Eliminated Through Use Of Teams, Nonphysicians, And Electronic Communication”, Health Affairs, 32, no.1 (2013):11-19

doi: 10.1377/hlthaff.2012.1086

[2] Altschuler J, Margolius D, Bodenheimer T, Grumbach K, “Estimating a Reasonable Patient Panel Size for Primary Care Physicians With Team-Based Task Delegation” , September/October 2012 vol. 10 no. 5396-400 doi:10.1370/afm.1400

When is the doctor not needed? And who should take their place?

A lengthy editorial in the New York Times, December 16, 2012, "When the doctor is not needed”, discusses how a variety of other health professionals can help to meet the health care needs of the American people when there are not enough physicians. The editorial names, specifically, pharmacists, nurse practitioners, retail clinics (mostly staffed by nurse practitioners), “trusted community aides”, and self-care. It is very good that the Times recognizes the shortage of doctors (and, here, primary care doctors) and the fact that the planned fixes in the Affordable Care Act are not likely to solve the problem, issues that I have often addressed, recently in Health reform, ACA, and Primary Care: Is there still a conundrum? (November 24, 2012). It is also good that the Times recognizes the important contributions that can be made by health professionals other than physicians, by “trusted community aides” and very importantly, by self-care.

As the editorial points out, both pharmacists and nurse practitioners (and physician’s assistants) have a significant knowledge base, and can (depending on state law) practice independently. In our clinic, we work closely with both, and even have a real interdisciplinary educational clinic in which medical students, nursing students, and pharmacy students see actual patients together, under the supervision of faculty from all three disciplines. We have long had nurse practitioner faculty seeing patients with us, and an NP is the medical director of our clinic. Pharmacists work collaboratively with us, particularly in the hospital, and can manage not just drug refills but dosage adjustments and alternative drug regimens in the outpatient setting as well. As the Times editorial and my earlier posts make clear, the promise of ACA to produce sufficient numbers of primary care physicians is likely to take a long time, if it comes at all, as a result of the combination of adverse reimbursement and the long pipeline to produce doctors. If we are to have any hope of having adequate primary care for our population, everyone – doctors, nurses, nurse practitioners, pharmacists, physician’s assistant, et alia, will have to work “at the top of their license” so that doctors are not expected to “do it all”, and the others have the opportunity to really demonstrate their skills.

Unfortunately, however, it will not solve the problem. I don’t say this because I am a doctor (I am) or a primary care doctor (I am), or because most of the statements about the effectiveness of pharmacists and nurse practitioners cited by the Times come from pharmacists and nurse practitioners. I say it because the biggest problems in access to health care are economic and geographic, about people in rural areas and poorer parts of urban areas not being able to access health care because there are no providers there. This is not going to change if we have more pharmacists or nurse practitioners; they want to stay in the cities and suburbs from which they come just like the doctors. They do not “diffuse” into underserved areas. The retail clinics at which many work, often actually based in chain pharmacies, may provide a significant service (see my previous post, Retail clinics: power to the patient, June 28, 2012), but they are also located in cities and suburbs, and serve basically the same population that more traditional medical practices do.

In addition, there is the issue of money / health insurance. Many people, particularly the working poor, whether in cities or rural communities, do not have health insurance. And while some may have the cash to go to a retail clinic, if one is available,  most are unlikely to have enough to cover a big ER or hospital bill. Maybe ACA will help, but its primary method of expanding coverage will be through expansion of Medicaid, and this looks as if it will not happen in many states, which have said they will not participate or (like mine, Kansas) have not yet said. Plus, even if Medicaid is expanded, this does not mean that people will be able to access care. Maybe through a retail clinic, maybe via a nurse practitioner or primary care doctor. But specialist care is becoming increasingly unavailable to Medicaid (and, of course, uninsured) patients, as noted in this recent article by Anna Gorman in the Los Angeles Times, “Health care crisis: not enough specialists for the poor”, December 15, 2012. Health policy expert and retired family physician Don McCanne commented on this in his “Quote of the Day” (December 17, 2012), noting that from the beginning of Medicaid (Medi-Cal in California) this has been a problem.

Dr. McCanne says that there have been enough specialists for Medicare, but I fear even this may be changing; our hospital notes that Medicare is its worst payer and that it loses money on Medicare patients. And, as physician practices continue to be acquired by hospitals (which I discussed on December 1, 2012, in Gaming the system: Integration of healthcare services can just raise costs, not quality), the cost of care is increasing (as noted by the Charlotte Observer, in “As doctors flock to hospitals, bills spike for patients”, December 17, 2012). And pharmacists and nurse practitioners are even more likely than physicians to be employed by big hospitals or health system or other corporations (such as the chain pharmacies in which most pharmacists work and which host most retail clinics).

Now “trusted community aides”, as the NY Times editorial calls them, are something different. While that editorial refers to two pediatric practices, in Houston and Harrisonburg, VA, where patients pay about $17 a visit, this concept is in much wider use – and should be used even more. Sometimes called community health workers or (from the Spanish) promotoras (health promoters), these are lay people, not doctors or nurses or pharmacists, who have been trained to do basic health assessments, recommend treatment (usually in consultation with a nurse or doctor by phone) and help patients do a better job of taking care of their own health. They are most effective when they are from the community and culture of the patients they care for (see the discussion of community health workers in Camden and you: the cost of health care to communities, February 18, 2012). Why do I believe that they have more promise? Because they are recruited from the communities that they will serve, and in which they have roots and ties, they are going to continue to serve those communities. This model has worked for dental care in Alaskan Native communities, and in urban inner city communities like Camden. In the case of rural communities, the concept can also be used to increase the skills of nurses. Enhancing and expanding the training of a nurse in a rural community, someone who has family there, or training community health workers who live there, will improve access in those areas in a way that simply will not happen by producing more doctors and nurse practitioners who come from and train in major urban centers.

And self care? Sure, for the right things. These things include most of the diagnoses (notably excluding immunizations) that retail clinics provide care for. For colds, for minor injuries, people have should be able to care for themselves. Where it gets tricky is when the “self” has multiple chronic diseases (say diabetes, hypertension, congestive heart failure, chronic lung disease, arthritis, low thyroid, and high cholesterol – a very common combination in any primary care practice). These people can provide more of their own care, but need the guidance of a skilled health professional, most often a primary care physician. The NY Times article provides some examples of the use of self-care and it has great potential, particularly when coupled with “trusted health aides” who can help, and teach.

All of these ideas have merit, but the issue of geographic and socioeconomic diffusion is largely ignored by most of those who tout their profession as the solution. Of course, as Dr. McCanne concludes his comments on specialists not seeing poor people, “I'll say it once again. If we had an improved Medicare single payer system that treated everyone equitably, we would not have this problem.”

Yes, certainly there would still be problems, but that would be a great start.

Top Ten Reasons for Future Subspecialist Physicians To Be Concerned

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This guest piece, by Robert Bowman, MD, of the AT Still School of Osteopathic Medicine in Mesa, AZ, can be considered to be a sequel to his guest blog from January 15, 2009, Ten Biggest Myths Regarding Primary Care in the Future. In that piece, Dr. Bowman discussed how, of the five primary care training “forms” (General Pediatrics, General Internal Medicine, Family Medicine, Nurse Practitioners and Physician assistant) only family physician provided enough “Standard Primary Care Years” per graduate, and distributed to the areas in which people live, to provide sufficient primary care. In this piece, he presents information on how the change in the workforce is likely to have an even greater impact on subspecialists.
I think that this is very timely. The idea that family physicians, or primary care doctors in general, will be “replaced” by nurse practitioners and/or physician’s assistants keeps rearing its ugly head despite evidence to the contrary. Dr. Bowman demonstrates that reimbursement policies that pay far more for “partialism” encourage both physicians and non-physicians to enter subspecialist practice. We still do and will need more primary care and it is not going to happen by magic. It is going to happen by changing reimbursement policies. (See, for example, Mary Carmichael's "The Doctor Won't See You Now", in Newsweek, Feb 26, 2010).

The first two graphics demonstrate trends in the number of primary care providers by "form" if there were not movement into subspecialism, and what the real trend will be.
The final graphic compares the retention in primary care, over time, for the different "forms" based on whether they are more "permanent choice" primary care (e.g., family medicine) or "flexible choice" (e.g., internal medicine).

10. “Midlevel” Growth: Nursing leaders have promised to deliver health access where it was most needed and received numerous concessions to move beyond nursing but have largely left health access behind along with basic nursing. Nursing leaders continue to promise primary care while nurse practitioners steadily depart primary care to become specialty workforce and appear poised to become “nurse doctors” (DNPs). There is every reason to believe that DNPs will be no more – and probably less – likely to practice in underserved or rural areas at greater rates than current NPs. Physician assistant leaders are likely to follow the independent "successes" of nursing. Future subspecialist physicians will face competition no other physician subspecialists have ever had to face.

9. Increasing NP, IM, Ped entry into subspecialties. About 40% more nurse practitioner, 50% more internal medicine, and 60% more pediatric graduates are entering specialty workforce compared to a 10 - 15 years ago, and specialization rates have continued to increase. In addition, more internists and nurse practitioners convert from primary care to specialty care in the years after graduation.

8. Increasing PA production, also entering subspecialties. Over 220% more new physician assistant graduates are entering the sub-specialty workforce, increasing from fewer than 1500 in 1998 to over 4600 in 2008. The percentages in emergency care, orthopedic, and surgical subspecialties are now greater than those in primary care. Physician assistants also are converting from primary care to specialty care after graduation. Only 28% of 2008 graduates entered primary care in AAPA surveys.

7. Postive Cost-Benefit ratio for “midlevel subspecialists. Nurse practitioner and physician assistant graduates have lower employment costs than subspecialist physicians. It is possible for 2 or 3 NP or PA subspecialists to generate more revenue than one subspecialist physician for less cost of salary, benefits, and other physician perks.

6. Increased “midlevels” in subspecialties decrease need for more subspecialist physicians. More and better nurses, assistants, and other health care team members are recruited to subspecialty workforce because the higher reimbursement for subspecialty services as compared to primary care allows these subspecialists to pay them more. Physician assistants and nurse practitioners are on track to increase to 450,000 that are more than 70% subspecialty care. The US is moving to a specialty workforce that can deliver more specialty care with fewer specialty physicians.

5.Increasing US graduates likely will further increase subspecialist production. US graduates deliver twice the workforce of non-citizen international medical graduates due to delays in entry and departures from the US workforce after graduation. Expansions of US medical schools are likely to replace more non-citizens with US origin graduates. This replacement results in twice the specialty workforce for each position transitioned from a non-citizen to a US origin graduate.

4. Increasing subspecialist production of US Medical Schools. The United States produces 40 - 50% more subspecialist workforce from each type of medical school compared to a decade ago. Currently no one can estimate just how much specialty workforce will be produced as the annual graduates entering the workforce continue to increase with higher percentages found entering specialty care in physicians and in non-physicians.

3. Threats to very high subspecialist reimbursement. To the extent that there is any decrease in subspecialist reimbursement, these physicians will face the possibility of longer hours, more services, less vacation, and more years of work per subspecialist physician.

2.Supply, demand, and cost of care. All physicians will be blamed for continued health care cost increases as all levels of government and all businesses and all of the US people pick up the tab. There is potential for even more costs with subspecialists increasing services to compensate for an oversupply of subspecialists.

1. And, finally, when the United States finally invests in sufficient primary care substantially fewer visits will be needed in specialty offices.

Add to this
· the steadily increasing disconnect between subspecialist physicians separated from their patients by additional assistants
· the admission patterns of medical schools favoring upper-income students leading to subspecialists with ever more exclusive origins who are less and less like lower and middle income Americans .

In other words, our medical education leaders and medical association leaders and subspecialists...
...will probably never see it coming.

Robert C. Bowman, M.D., rcbowman@atsu.edu

Only those unable, those unaware, or those with another agenda fail to understand that solutions for basic health access have worked for over one hundred years.

http://www.basichealthaccess.org/ http://www.physicianworkforcestudies.org/ http://www.ruralmedicaleducation.org/

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