Health Policy Journal Club, May 2021
The Current State and Future of Primary Care

Readings

1. Willis J, Antono B, Bazemore A, Jetty A, Petterson S, George J, Rosario BL, Scheufele E, Rajmane A, Dankwa-Mullan I, Rhee K. The State of Primary Care in the United States: A Chartbook of Facts and Statistics. October 2020. 
2. McMahon LF, Rise K, Irby-Johnson N, Chopra V. Designed to fail? The future of primary care. J Gen Intern Med. 2020;36(2):515-7. 
3. Berwick D. Questions to guide the future of primary care. Institute for Healthcare Improvement. October 9, 2020. 
4. Fernandez A. What will primary care look like in 2040? 7 predictions from Dr. Lauren Hughes. MATTER. October 15, 2020

Key takeaways from the readings

All the articles are grounded in the proven and generally accepted premise that properly funded and staffed primary care is essential for high quality patient outcomes and cost control.

The proportion of the physician workforce in primary care is lower than recommended and in decline. 

• The Council on Graduate Medical Education recommends that 40% of the physician workforce be comprised of primary care physicians; currently primary care physicians are a little less than 33% of the workforce.
• One quarter of this primary care workforce is nearing retirement.
• The American Association of Medical Colleges estimates there will be a shortage of 21,100-55,200 primary care physicians by 2032.
• An estimated 42% of nurse practitioners are in primary care and 36% of physician assistants; similar to physicians, these numbers are also in decline.
• The distribution of primary care physicians varies significantly by state. Regionally, the highest proportions per population are in the Northeast, Northwest, and Northern Midwest.

Comments from discussion participants:

• COVID may also have a severe impact on the looming workforce shortage by driving early physician retirement.

Primary care physicians care for the broadest range of conditions and illnesses among specialties.

• Family medicine/general practitioners see patients with over 800 diagnosis codes, followed by internal medicine and pediatrics at a little over 400 diagnosis codes. For comparison, urologists and cardiovascular specialists see patients for just over 200 diagnosis codes.
• There are decreasing proportions of family physicians practicing inpatient medicine (from 34% in 2013 to 24% in 2018); similar trends have been observed for obstetrics and nursing home care. They are, however, increasingly likely to care for complex, multimorbid patients in outpatient and community settings.

Comments from discussion participants:

• Using diagnosis codes could actually underrepresent all that is taken care of in primary care.

While primary care comprises approximately 35% of all visits and about 50% of all outpatient visits, it receives about 5-7% of the total medical spending.

• The proportion of total spending going to primary care is lower in the U.S. than in other developed countries.
• Specialty care receives three times the amount of primary care.
• The median primary care physician income is $273,000 compared to $448,000 in other specialties. This gap decreased slightly between 2014-2018.

Comments from discussion participants:

• It is interesting to see that ER comprises only 3.7% of total spending, but is touted as a large driver of expensive care.

The demands of non face-to-face care have accelerated in primary care without sufficient increase in time to meet those demands.

• In the McMahon et al article, the authors noted primary care physicians spend about 20 hours a week on administrative tasks (largely in the electronic health record and other “paperwork”), whereas a common schedule for physicians reserves about 8 hours of week for administrative time.
• Value-based payment has also shifted responsibility to primary care to manage outcomes that it may not be able to directly impact.
• With workload not matching hours of practice, there are increasing shifts to part time work, pursuing hospitalist positions, direct primary care, or concierge practices. 

Comments from discussion participants:

• Eight or nine half days seeing patients in a week of primary care is not sustainable the way it is currently structured.
• Rebalancing work weeks with more time for administrative tasks would help providers in primary care be more balanced themselves.

The new normal for primary care will likely add a focus on innovation and technological advancements while maintaining a focus on human connection.

• In addition to increased use of phone and video visits, remote patient monitoring devices will be a large area of growth but need optimizing – currently they are not well integrated with electronic medical records
• As noted in the interview with Dr. Lauren Hughes, “it’s really important to maintain the focus on human connection and presence, and we need to continuously think about how to do that in light of these new technologies and solutions that will become increasingly online.”

Comments from discussion participants:

• Simply producing masses of new data is not helpful. User and practitioner-friendly monitoring will flag exceptions, recommended actions, and the like in ways that save time and help guide care. Experience with electronic health records in this regard to date does not make us optimistic.