The health care problem no one’s talking about

As the nation moves closer to a health reform bill designed to extend coverage to the vast majority of the uninsured, a key concern is being overlooked: Simply having health insurance—crucial as that is—is not enough. People also need access to care, particularly to primary care. Yet a growing body of evidence suggests that even among insured Americans, access to primary care is on the decline.

Consider the following:

• In 2005, more than 56 million Americans (nearly half of whom had some form of coverage) were “medically disenfranchised”—lacking sufficient access to primary care services. Two years later, that number had grown to 60 million.¹
• In a 2006 national survey, little more than 1 in 4 adults (ages 18 to 64) said they could easily reach their doctors by phone, get after-hours care, or schedule timely office visits.²
• The number of medical school graduates in the United States choosing careers in family medicine fell from 2340 in 1997 to 1132 in 2006; during that same period, the percentage of internal medicine residents entering primary care dropped from 54% to 20%.³
• In 2008, nearly 30% of Medicare beneficiaries seeking a new primary care physician (PCP) reported difficulty finding a doctor—a 17% increase since 2006.⁴

A shrinking pool of primary care physicians

Compared with other Western nations, the United States has a smaller proportion of its physician workforce engaged in primary care.⁵ Shortages of PCPs already exist in numerous states, with Alabama, Alaska, Florida, Kansas, Mississippi, Missouri, Oregon, South Carolina, and Utah among them.¹ In the decade ahead, the Council on Graduate Medical Education, among other professional groups, expects the shortages to become more widespread and more severe.

Recruiting PCPs is increasingly difficult—something that comes as no surprise to physician recruiters. Merritt Hawkins, a large physician recruitment firm, reports that in 2005 the number of searches for open positions for PCPs exceeded searches for specialists for the first time.⁶ And in 2006, nearly half of all primary care residents were contacted by recruiters more than 50 times. In a survey of physician groups that same year, 94% of respondents ranked either internists or family physicians as the most difficult to recruit.⁷

Nurse practitioners (NPs) and physician assistants (PAs) have been important contributors to the primary care workforce, but they, too, may soon be in shorter supply. That’s especially true of PAs, given that less than one third (31%) of them are choosing careers in adult primary care.⁸

Quality of care pays the price. Ironically, the shrinking pool of PCPs coincides with the growing recognition of the importance of the patient-centered medical home. There is increasing evidence, too, of the link between lack of access to primary care and higher mortality rates⁹ and poorer outcomes.¹⁰ Lack of access appears to have an adverse effect on health care spending, as well. While the administration searches for ways to lower the cost of care in order to pay for the expansion in coverage, directors of health plans and medical groups expect medical spending to rise as the looming PCP shortage leads to greater use of specialists and more emergency visits.¹¹

A broader look at inadequate access

The PCP shortage alone, however, is not the whole story. A number of other potent factors related to, but not the direct result of, the shortage contribute to the growing inability of insured Americans to have timely access to primary care. Chief among them are a mismatch between demand for appointments and physicians’ capacity to provide them, limited after-hours care, and organizational problems in primary care practices. We’ve identified the following barriers—and the policy changes and shifts in physician culture that are needed to overcome them.

BARRIER #1: Panel size

The average full-time primary care practitioner has an estimated panel of 2300 patients¹²—too many for a single physician to provide adequate patient care for, according to a recent study.^13,14 Some practices have excessively large panels because they’re located in areas with a shortage of primary care providers. (In an area with 25 PCPs per 100,000 population, for instance, the average panel size would be 4000.) Other practices accept too many patients in order to stay afloat financially. In either case, a situation in which the demand for appointments exceeds the available time slots impedes a patient’s ability to get timely care.

BARRIER #2: Capacity

The number of hours per week that a PCP sees patients and the number of patients scheduled per hour determine that physician’s visit capacity. Quality of care is also at stake. Although physicians who schedule 1 patient every 10 or 15 minutes can, of course, accommodate more patients than doctors who spend 20 or 30 minutes per visit, shorter appointments have been found to adversely affect quality.¹⁵

Further complicating things is the increasing number of physicians who are opting for part-time work.¹⁶ Added to the hospital and nursing home responsibilities many PCPs share, working fewer hours imposes further limits on the number of patients they can care for.

BARRIER #3: Distance

The uneven geographic distribution of PCPs makes access difficult for patients living at a distance from the nearest primary care practice, a particular problem for the homebound and those without transportation. Telemedicine could help mitigate this problem, but few primary care practices are equipped to practice “distance” medicine.

BARRIER #4: Medicaid/Medicare issues

Some primary care practices make decisions about which new patients to accept based on the kind of coverage held by the prospective patients. Medicaid patients have an especially difficult time finding a PCP—far harder than privately insured individuals. Also, in areas in which Medicare fees are below the market rates paid by private insurers, many practices limit the number of Medicare patients they accept.

The bottom line: Already stressed by the economy and low fees, some PCPs say they have little choice but to restrict the number of patients whose care costs them more than they’re paid to provide it.

BARRIER #5: After-hours care

Many patients try, unsuccessfully, to reach their PCP in the evening or on the weekend. The dearth of after-hours access has led to an explosion of “convenience clinics” in pharmacies and shopping malls—and to overuse of the emergency department (ED). In a 2007 national survey, 67% of adults said they had difficulty getting care at night or on weekends unless they went to the ED.¹⁷ In another survey, conducted in California in 2006, nearly half of those who sought care in the ED believed their condition could have been handled in a primary care setting, had it been available.¹⁸

BARRIER #6: Scheduling

Many patients call their PCP’s office for an appointment, only to find that the next available opening is 3 weeks away. While some groups have introduced open-access scheduling—also called same-day scheduling or advanced access—such a system can only be sustained if the demand for appointments is in balance with the practice’s capacity to see patients.

Part of the problem appears to be organizational. Some physicians routinely make monthly follow-up appointments for patients with chronic conditions, such as hypertension, diabetes, or arthritis. However, the return visit interval is often based on the habits of the individual physician or provider group, rather than on the medical needs of the patients. Indeed, 1 study found that prolonging the visit interval resulted in an improvement rather than a decline in quality of care.¹⁹

BARRIER #7: Virtual visits

Many chronic care and preventive care issues could be handled in brief patient encounters via telephone or e-mail. In addition to being convenient for many patients, such virtual visits would increase the practice’s capacity for patients who require in-person visits.²⁰ Here, too, the problem is financial: Insurers generally do not provide reimbursement for virtual visits.

BARRIER #8: Troubles with team care

At some medical groups, nonphysician providers, including registered nurses and pharmacists, use doctor-created protocols and standing orders to address routine chronic care issues and preventive measures for individuals with certain conditions—identified via patient registries. Similarly, medical assistants and community health workers may be trained as health coaches to work with patients on behavior change and adherence to medication regimens, thus freeing up physician time.²¹ Despite the benefits of team care, most insurers only reimburse the services of MDs, NPs and PAs, meaning that no incentives exist for primary care practices to hire other team members.

The solutions: Policy shifts and culture change

What will it take to improve access to primary care and tear down these barriers? First and foremost, we believe the following policy changes are needed:

• Increase reimbursement for primary care.
• Increase loan repayment programs for medical students who establish primary care practices in areas with established shortages.
• Standardize fees paid by private insurers, Medicare, and Medicaid plans.
• Provide financial incentives for PCPs to deliver after-hours care.
• Invest in a national program aimed at helping primary care practices implement same-day scheduling, team care, and other access improvements.²²
• Provide reimbursement for e-mail and telephone encounters and team care, including fees for all allied health professionals who assist PCPs in managing chronic disease and preventive care.

These reforms, if they were to truly come to pass, would ease much of the pressure on PCPs. No matter what policy changes are implemented to increase access to primary care, however, it is clear that a substantial culture change is required on the part of PCPs, as well. Physicians can begin to make changes on their own to increase patient access—expanding the interval between follow-up visits for stable patients, for instance, and reorganizing work schedules so that the practice can remain open for more hours.

It’s clear that providing health insurance to the uninsured without guaranteeing access to primary care can turn a potentially positive development into widespread patient frustration. Unless Americans have greater access to primary care, we fear, the US health care system will undergo significant change without substantial improvement.

CORRESPONDENCE
Thomas Bodenheimer MD, MPH, Department of Family and Community Medicine, University of California at San Francisco, Bldg 80-83, SF General Hospital, 995 Potrero Avenue, San Francisco, CA 94110; [email protected]

As the nation moves closer to a health reform bill designed to extend coverage to the vast majority of the uninsured, a key concern is being overlooked: Simply having health insurance—crucial as that is—is not enough. People also need access to care, particularly to primary care. Yet a growing body of evidence suggests that even among insured Americans, access to primary care is on the decline.

Consider the following:

• In 2005, more than 56 million Americans (nearly half of whom had some form of coverage) were “medically disenfranchised”—lacking sufficient access to primary care services. Two years later, that number had grown to 60 million.¹
• In a 2006 national survey, little more than 1 in 4 adults (ages 18 to 64) said they could easily reach their doctors by phone, get after-hours care, or schedule timely office visits.²
• The number of medical school graduates in the United States choosing careers in family medicine fell from 2340 in 1997 to 1132 in 2006; during that same period, the percentage of internal medicine residents entering primary care dropped from 54% to 20%.³
• In 2008, nearly 30% of Medicare beneficiaries seeking a new primary care physician (PCP) reported difficulty finding a doctor—a 17% increase since 2006.⁴

A shrinking pool of primary care physicians

Compared with other Western nations, the United States has a smaller proportion of its physician workforce engaged in primary care.⁵ Shortages of PCPs already exist in numerous states, with Alabama, Alaska, Florida, Kansas, Mississippi, Missouri, Oregon, South Carolina, and Utah among them.¹ In the decade ahead, the Council on Graduate Medical Education, among other professional groups, expects the shortages to become more widespread and more severe.

Recruiting PCPs is increasingly difficult—something that comes as no surprise to physician recruiters. Merritt Hawkins, a large physician recruitment firm, reports that in 2005 the number of searches for open positions for PCPs exceeded searches for specialists for the first time.⁶ And in 2006, nearly half of all primary care residents were contacted by recruiters more than 50 times. In a survey of physician groups that same year, 94% of respondents ranked either internists or family physicians as the most difficult to recruit.⁷

Nurse practitioners (NPs) and physician assistants (PAs) have been important contributors to the primary care workforce, but they, too, may soon be in shorter supply. That’s especially true of PAs, given that less than one third (31%) of them are choosing careers in adult primary care.⁸

Quality of care pays the price. Ironically, the shrinking pool of PCPs coincides with the growing recognition of the importance of the patient-centered medical home. There is increasing evidence, too, of the link between lack of access to primary care and higher mortality rates⁹ and poorer outcomes.¹⁰ Lack of access appears to have an adverse effect on health care spending, as well. While the administration searches for ways to lower the cost of care in order to pay for the expansion in coverage, directors of health plans and medical groups expect medical spending to rise as the looming PCP shortage leads to greater use of specialists and more emergency visits.¹¹

A broader look at inadequate access

The PCP shortage alone, however, is not the whole story. A number of other potent factors related to, but not the direct result of, the shortage contribute to the growing inability of insured Americans to have timely access to primary care. Chief among them are a mismatch between demand for appointments and physicians’ capacity to provide them, limited after-hours care, and organizational problems in primary care practices. We’ve identified the following barriers—and the policy changes and shifts in physician culture that are needed to overcome them.

BARRIER #1: Panel size

The average full-time primary care practitioner has an estimated panel of 2300 patients¹²—too many for a single physician to provide adequate patient care for, according to a recent study.^13,14 Some practices have excessively large panels because they’re located in areas with a shortage of primary care providers. (In an area with 25 PCPs per 100,000 population, for instance, the average panel size would be 4000.) Other practices accept too many patients in order to stay afloat financially. In either case, a situation in which the demand for appointments exceeds the available time slots impedes a patient’s ability to get timely care.

BARRIER #2: Capacity

The number of hours per week that a PCP sees patients and the number of patients scheduled per hour determine that physician’s visit capacity. Quality of care is also at stake. Although physicians who schedule 1 patient every 10 or 15 minutes can, of course, accommodate more patients than doctors who spend 20 or 30 minutes per visit, shorter appointments have been found to adversely affect quality.¹⁵

Further complicating things is the increasing number of physicians who are opting for part-time work.¹⁶ Added to the hospital and nursing home responsibilities many PCPs share, working fewer hours imposes further limits on the number of patients they can care for.

BARRIER #3: Distance

The uneven geographic distribution of PCPs makes access difficult for patients living at a distance from the nearest primary care practice, a particular problem for the homebound and those without transportation. Telemedicine could help mitigate this problem, but few primary care practices are equipped to practice “distance” medicine.

BARRIER #4: Medicaid/Medicare issues

Some primary care practices make decisions about which new patients to accept based on the kind of coverage held by the prospective patients. Medicaid patients have an especially difficult time finding a PCP—far harder than privately insured individuals. Also, in areas in which Medicare fees are below the market rates paid by private insurers, many practices limit the number of Medicare patients they accept.

The bottom line: Already stressed by the economy and low fees, some PCPs say they have little choice but to restrict the number of patients whose care costs them more than they’re paid to provide it.

BARRIER #5: After-hours care

Many patients try, unsuccessfully, to reach their PCP in the evening or on the weekend. The dearth of after-hours access has led to an explosion of “convenience clinics” in pharmacies and shopping malls—and to overuse of the emergency department (ED). In a 2007 national survey, 67% of adults said they had difficulty getting care at night or on weekends unless they went to the ED.¹⁷ In another survey, conducted in California in 2006, nearly half of those who sought care in the ED believed their condition could have been handled in a primary care setting, had it been available.¹⁸

BARRIER #6: Scheduling

Many patients call their PCP’s office for an appointment, only to find that the next available opening is 3 weeks away. While some groups have introduced open-access scheduling—also called same-day scheduling or advanced access—such a system can only be sustained if the demand for appointments is in balance with the practice’s capacity to see patients.

Part of the problem appears to be organizational. Some physicians routinely make monthly follow-up appointments for patients with chronic conditions, such as hypertension, diabetes, or arthritis. However, the return visit interval is often based on the habits of the individual physician or provider group, rather than on the medical needs of the patients. Indeed, 1 study found that prolonging the visit interval resulted in an improvement rather than a decline in quality of care.¹⁹

BARRIER #7: Virtual visits

Many chronic care and preventive care issues could be handled in brief patient encounters via telephone or e-mail. In addition to being convenient for many patients, such virtual visits would increase the practice’s capacity for patients who require in-person visits.²⁰ Here, too, the problem is financial: Insurers generally do not provide reimbursement for virtual visits.

BARRIER #8: Troubles with team care

At some medical groups, nonphysician providers, including registered nurses and pharmacists, use doctor-created protocols and standing orders to address routine chronic care issues and preventive measures for individuals with certain conditions—identified via patient registries. Similarly, medical assistants and community health workers may be trained as health coaches to work with patients on behavior change and adherence to medication regimens, thus freeing up physician time.²¹ Despite the benefits of team care, most insurers only reimburse the services of MDs, NPs and PAs, meaning that no incentives exist for primary care practices to hire other team members.

The solutions: Policy shifts and culture change

What will it take to improve access to primary care and tear down these barriers? First and foremost, we believe the following policy changes are needed:

• Increase reimbursement for primary care.
• Increase loan repayment programs for medical students who establish primary care practices in areas with established shortages.
• Standardize fees paid by private insurers, Medicare, and Medicaid plans.
• Provide financial incentives for PCPs to deliver after-hours care.
• Invest in a national program aimed at helping primary care practices implement same-day scheduling, team care, and other access improvements.²²
• Provide reimbursement for e-mail and telephone encounters and team care, including fees for all allied health professionals who assist PCPs in managing chronic disease and preventive care.

These reforms, if they were to truly come to pass, would ease much of the pressure on PCPs. No matter what policy changes are implemented to increase access to primary care, however, it is clear that a substantial culture change is required on the part of PCPs, as well. Physicians can begin to make changes on their own to increase patient access—expanding the interval between follow-up visits for stable patients, for instance, and reorganizing work schedules so that the practice can remain open for more hours.

It’s clear that providing health insurance to the uninsured without guaranteeing access to primary care can turn a potentially positive development into widespread patient frustration. Unless Americans have greater access to primary care, we fear, the US health care system will undergo significant change without substantial improvement.

CORRESPONDENCE
Thomas Bodenheimer MD, MPH, Department of Family and Community Medicine, University of California at San Francisco, Bldg 80-83, SF General Hospital, 995 Potrero Avenue, San Francisco, CA 94110; [email protected]

As the nation moves closer to a health reform bill designed to extend coverage to the vast majority of the uninsured, a key concern is being overlooked: Simply having health insurance—crucial as that is—is not enough. People also need access to care, particularly to primary care. Yet a growing body of evidence suggests that even among insured Americans, access to primary care is on the decline.

Consider the following:

• In 2005, more than 56 million Americans (nearly half of whom had some form of coverage) were “medically disenfranchised”—lacking sufficient access to primary care services. Two years later, that number had grown to 60 million.¹
• In a 2006 national survey, little more than 1 in 4 adults (ages 18 to 64) said they could easily reach their doctors by phone, get after-hours care, or schedule timely office visits.²
• The number of medical school graduates in the United States choosing careers in family medicine fell from 2340 in 1997 to 1132 in 2006; during that same period, the percentage of internal medicine residents entering primary care dropped from 54% to 20%.³
• In 2008, nearly 30% of Medicare beneficiaries seeking a new primary care physician (PCP) reported difficulty finding a doctor—a 17% increase since 2006.⁴

A shrinking pool of primary care physicians

Compared with other Western nations, the United States has a smaller proportion of its physician workforce engaged in primary care.⁵ Shortages of PCPs already exist in numerous states, with Alabama, Alaska, Florida, Kansas, Mississippi, Missouri, Oregon, South Carolina, and Utah among them.¹ In the decade ahead, the Council on Graduate Medical Education, among other professional groups, expects the shortages to become more widespread and more severe.

Recruiting PCPs is increasingly difficult—something that comes as no surprise to physician recruiters. Merritt Hawkins, a large physician recruitment firm, reports that in 2005 the number of searches for open positions for PCPs exceeded searches for specialists for the first time.⁶ And in 2006, nearly half of all primary care residents were contacted by recruiters more than 50 times. In a survey of physician groups that same year, 94% of respondents ranked either internists or family physicians as the most difficult to recruit.⁷

Nurse practitioners (NPs) and physician assistants (PAs) have been important contributors to the primary care workforce, but they, too, may soon be in shorter supply. That’s especially true of PAs, given that less than one third (31%) of them are choosing careers in adult primary care.⁸

Quality of care pays the price. Ironically, the shrinking pool of PCPs coincides with the growing recognition of the importance of the patient-centered medical home. There is increasing evidence, too, of the link between lack of access to primary care and higher mortality rates⁹ and poorer outcomes.¹⁰ Lack of access appears to have an adverse effect on health care spending, as well. While the administration searches for ways to lower the cost of care in order to pay for the expansion in coverage, directors of health plans and medical groups expect medical spending to rise as the looming PCP shortage leads to greater use of specialists and more emergency visits.¹¹

A broader look at inadequate access

The PCP shortage alone, however, is not the whole story. A number of other potent factors related to, but not the direct result of, the shortage contribute to the growing inability of insured Americans to have timely access to primary care. Chief among them are a mismatch between demand for appointments and physicians’ capacity to provide them, limited after-hours care, and organizational problems in primary care practices. We’ve identified the following barriers—and the policy changes and shifts in physician culture that are needed to overcome them.

BARRIER #1: Panel size

The average full-time primary care practitioner has an estimated panel of 2300 patients¹²—too many for a single physician to provide adequate patient care for, according to a recent study.^13,14 Some practices have excessively large panels because they’re located in areas with a shortage of primary care providers. (In an area with 25 PCPs per 100,000 population, for instance, the average panel size would be 4000.) Other practices accept too many patients in order to stay afloat financially. In either case, a situation in which the demand for appointments exceeds the available time slots impedes a patient’s ability to get timely care.

BARRIER #2: Capacity

The number of hours per week that a PCP sees patients and the number of patients scheduled per hour determine that physician’s visit capacity. Quality of care is also at stake. Although physicians who schedule 1 patient every 10 or 15 minutes can, of course, accommodate more patients than doctors who spend 20 or 30 minutes per visit, shorter appointments have been found to adversely affect quality.¹⁵

Further complicating things is the increasing number of physicians who are opting for part-time work.¹⁶ Added to the hospital and nursing home responsibilities many PCPs share, working fewer hours imposes further limits on the number of patients they can care for.

BARRIER #3: Distance

The uneven geographic distribution of PCPs makes access difficult for patients living at a distance from the nearest primary care practice, a particular problem for the homebound and those without transportation. Telemedicine could help mitigate this problem, but few primary care practices are equipped to practice “distance” medicine.

BARRIER #4: Medicaid/Medicare issues

Some primary care practices make decisions about which new patients to accept based on the kind of coverage held by the prospective patients. Medicaid patients have an especially difficult time finding a PCP—far harder than privately insured individuals. Also, in areas in which Medicare fees are below the market rates paid by private insurers, many practices limit the number of Medicare patients they accept.

The bottom line: Already stressed by the economy and low fees, some PCPs say they have little choice but to restrict the number of patients whose care costs them more than they’re paid to provide it.

BARRIER #5: After-hours care

Many patients try, unsuccessfully, to reach their PCP in the evening or on the weekend. The dearth of after-hours access has led to an explosion of “convenience clinics” in pharmacies and shopping malls—and to overuse of the emergency department (ED). In a 2007 national survey, 67% of adults said they had difficulty getting care at night or on weekends unless they went to the ED.¹⁷ In another survey, conducted in California in 2006, nearly half of those who sought care in the ED believed their condition could have been handled in a primary care setting, had it been available.¹⁸

BARRIER #6: Scheduling

Many patients call their PCP’s office for an appointment, only to find that the next available opening is 3 weeks away. While some groups have introduced open-access scheduling—also called same-day scheduling or advanced access—such a system can only be sustained if the demand for appointments is in balance with the practice’s capacity to see patients.

Part of the problem appears to be organizational. Some physicians routinely make monthly follow-up appointments for patients with chronic conditions, such as hypertension, diabetes, or arthritis. However, the return visit interval is often based on the habits of the individual physician or provider group, rather than on the medical needs of the patients. Indeed, 1 study found that prolonging the visit interval resulted in an improvement rather than a decline in quality of care.¹⁹

BARRIER #7: Virtual visits

Many chronic care and preventive care issues could be handled in brief patient encounters via telephone or e-mail. In addition to being convenient for many patients, such virtual visits would increase the practice’s capacity for patients who require in-person visits.²⁰ Here, too, the problem is financial: Insurers generally do not provide reimbursement for virtual visits.

BARRIER #8: Troubles with team care

At some medical groups, nonphysician providers, including registered nurses and pharmacists, use doctor-created protocols and standing orders to address routine chronic care issues and preventive measures for individuals with certain conditions—identified via patient registries. Similarly, medical assistants and community health workers may be trained as health coaches to work with patients on behavior change and adherence to medication regimens, thus freeing up physician time.²¹ Despite the benefits of team care, most insurers only reimburse the services of MDs, NPs and PAs, meaning that no incentives exist for primary care practices to hire other team members.

The solutions: Policy shifts and culture change

What will it take to improve access to primary care and tear down these barriers? First and foremost, we believe the following policy changes are needed:

• Increase reimbursement for primary care.
• Increase loan repayment programs for medical students who establish primary care practices in areas with established shortages.
• Standardize fees paid by private insurers, Medicare, and Medicaid plans.
• Provide financial incentives for PCPs to deliver after-hours care.
• Invest in a national program aimed at helping primary care practices implement same-day scheduling, team care, and other access improvements.²²
• Provide reimbursement for e-mail and telephone encounters and team care, including fees for all allied health professionals who assist PCPs in managing chronic disease and preventive care.

These reforms, if they were to truly come to pass, would ease much of the pressure on PCPs. No matter what policy changes are implemented to increase access to primary care, however, it is clear that a substantial culture change is required on the part of PCPs, as well. Physicians can begin to make changes on their own to increase patient access—expanding the interval between follow-up visits for stable patients, for instance, and reorganizing work schedules so that the practice can remain open for more hours.

It’s clear that providing health insurance to the uninsured without guaranteeing access to primary care can turn a potentially positive development into widespread patient frustration. Unless Americans have greater access to primary care, we fear, the US health care system will undergo significant change without substantial improvement.

CORRESPONDENCE
Thomas Bodenheimer MD, MPH, Department of Family and Community Medicine, University of California at San Francisco, Bldg 80-83, SF General Hospital, 995 Potrero Avenue, San Francisco, CA 94110; [email protected]