Who will provide primary care?

Being a primary care physician isn’t the most enticing job right now. The average salary is six figures below that of most specialists, according to Medical Economics® survey data, yet primary care physicians must treat everything from a sprained ankle to heart arrythmia. Time with patients is short, and the administrative burden is high, and with an increasing shortage of primary care physicians, patient needs are only going to add to the workload.

With too few physicians to go around, nurse practitioners (NPs) — and to a lesser extent physician associates (PAs) — are stepping in to fill the gaps. But physician groups such as Physicians for Patient Protection (PPP) and the American Medical Association are pointing out that NPs are not necessarily joining physician practices, but are using the physician shortage to attain full practice authority. This allows them to compete directly with physicians, adding one more headache to the primary care physician’s list of ailments.

PPP leaders decry this shift to non-physician led care, and worry that the lower cost of NPs combined with their less rigorous training requirements will lead to poor patient outcomes while threatening the jobs of primary care physicians. But NPs counter that when it comes to primary care, they are as effective as doctors, serve rural areas more often, and with so many patients needing care, the argument over jobs is moot.

So the primary care physician may be left wondering how they fit into a future of fewer physicians, rising numbers of non-physician providers and an aging population that will strain the health care system like never before. Will they be the quarterback of a growing primary care team, or be relegated to the bench in favor of cheaper, less-educated replacements?

The scope of the shortage and what it means for physicians

Any professional group representing primary care will tell you doctors are already feeling the strain of too many patients for too few physicians. And it is only going to get worse if something doesn’t change. The Association of American Medical Colleges (AAMC) is projecting that by 2034 there will be a shortage of primary care physicians of between 18,000 and 48,000 — and if equitable care for all individuals is the goal, then another 35,000 to 50,000 physicians are required.

The Association for Advancing Physician and Provider Recruitment reported that in 2021, the percentage of physician searches filled decreased for the fourth straight year, with primary care being one of the most difficult to fill. In addition, the percentage of physician searches still open at year-end increased to 47%.

These numbers spell trouble for many patients.

“As the shortage grows, access is going to decrease in an inequitable way,” says Michael Dill director of workforce studies at AAMC, “as so many things do when supply of something gets scarce. Then the people with the most resources are more likely to continue to be able to access whatever that is, and everybody else, not so much, which means those inequities will grow as the shortage gets worse.”

The U.S. populationis growing and aging, and the older the population, the more health care it will require. But the physician workforce is aging along with it.

“Within the next 10 years, tops, we will get to a point where two out of every five practicing physicians in the nation are 65 years of age and over,” says Dill. “That’s not sustainable in terms of meeting the health care needs of a nation. We really need to step up and start training more, but we have to start doing it now, because it takes (about) a decade to train a new cadre of physicians.”

Dill says there’s not much more productivity that can be squeezed out of the current primary care physicians. Team-based care that brings in more non-physicians is an option, but it requires management and coordination as well, which also takes up physician time.

“In the end, we really just need more physicians,” notes Dill.

Experts say it is in this context of unmet care needs that NPs are gaining full practice authority as states scramble to make sure residents have access to care, and the American Association of Nurse Practitioners (AANP) says this is a benefit to patients.
“Time and again, we see that when states adopt full practice authority, the ranks of nurse practitioners grow,” says April N. Kapu, D.N.P., APRN, ACNP-BC, FAANP, FCCM, FAAN, president of AANP. “According to a 2018 report produced by UnitedHealth Group, authorizing full practice authority for NPs nationwide would increase health care access for approximately 31 million people living in primary care health professional shortage areas. The National Academies of Sciences, Engineering, and Medicine Future of Nursing report further reinforces that NPs must be granted autonomy and institutional authority to achieve the goals of strengthening health access and equity. NPs and other APRNs (advanced practice registered nurses) are more likely to treat Medicaid and uninsured patients, and to travel to areas where the need for care is greatest.”

David Blumenthal, M.D., M.P.P., president of the Commonwealth Fund, agrees that NPs may be a partial solution.

“There is some hope that non-physician primary care clinicians –– nurse practitioners and physicians assistants –– can fill some of the gaps,” says Blumenthal. “And if we had robust, community-based health workers to provide some of the very basic primary care services that we lacked, such as monitoring health in the home and providing immunization and providing basic health services, which has been successful in many other countries, that could partially ameliorate the problem.”

Relying on NPs and PAs may be especially necessary in rural areas where finding a primary care physician is more difficult than in an urban area. “I think for some small places, having NPs and PAs might be just fine,” says Davis Patterson, Ph.D., director of the Washington, Wyoming, Alaska, Montana, Idaho Rural Health Research Center at the University of Washington School of Medicine in Seattle. “There are places where NPs and PAs staff emergency departments after hours and those kinds of things. We just have to be realistic about what the right solution is in using our workforces flexibly in ways that can help. If it’s a difference between not having someone in that community versus having someone, it doesn’t matter if it’s a physician, because if you have no one, your quality of care in that community is really going to suffer.

“We need more robust primary care, and there is plenty of room for more primary care if we look at the big picture, because we don’t have enough of it. I think primary care physicians in particular should be more worried about the decline in primary care overall.”

Boosting the number of primary care physicians

Adding more primary care physicians is easier said than done. Becoming a physician in the United States requires graduate medical education (GME) in the form of a residency, but congress put a cap on Medicare support for GME in the late 1990s, and only 1,000 new slots have been authorized since then and that happened last year.

“We are turning out as many new physicians as we can with the GME we have, but we need more,” says Dill. “There’s no way around that. If they would raise the cap another 4,000 or 5,000 slots, that would be immensely helpful.”

There is some growth in slots funded outside of Medicare, but it is slow, says Dill.

Overall, the U.S. has over 36,000 GME slots available each year, which are filled with a combination of both domestic and international medical students. But experts point out that these are for all specialties, and with primary care being at or near the bottom of the pay scale, it isn’t always the most desirable for students who may incur substantial debt while attending medical school.

“Physicians taking care of their patients cost less than nurse practitioners,” says Christopher Garofalo, M.D., a family medicine physician and member of PPP. “If congress really wants better care access for patients, with better access to their physicians and lower costs, we should be fighting to have more physicians available to patients.”

But short of congressional action, experts don’t see much changing in the number of GME slots, meaning physicians will continue to be in high demand and some portions of the country will not have a doctor within a reasonable distance. This continued shortage also likely means that NPs will retain their full practice authority in 26 states and both they and PAs are likely to expand their ability to practice independently as patients in rural areas struggle to find doctors.

“That’s going to definitely be difficult,” says Garofalo, referring to revoking full practice authority in states. “It’s hard to put the toothpaste back in the tube, and it will be difficult to roll those back.”

Only a team can win

In the end, there are just more patients in need of primary care than there are providers of any education level to provide it, according to experts. The only way to help patients is to think about primary care in new ways.

“Everybody needs to work collaboratively if we want to change health care in this country,” says Jennifer M. Orozco, D.M.Sc., PA-C, DFAAPA, president of the American Academy of Physician Associates. “There is absolutely no reason why 95 million Americans should be without access to primary care, and that’s only going to grow with our aging population. Looking down the road, we will never have enough physicians, PAs or NPs. I don’t care how many training programs opened in the next year, we will not get enough people off the ground to take care of people.”

She says that only by innovating and forming teams made up of all caregivers can primary care be maximized, a concept Patterson agrees with.

“We need to be thinking about care teams, because it is not just one person going it alone,” says Patterson. “Teams may look a little different in rural areas. It’s not physicians versus NPs versus PAs; none of them practice in isolation. We need to put our attention on how we can create more robust teams, and that means NPs and physicians and PAs working together as well as working with other types of providers and health care support people.”

Patterson says that the best way to get there is to train all providers side by side so there are no silos and each clinician learns to work with other types of professionals. “I think this might really alleviate some of the concerns and lead to more collaborative approaches to things rather than sort of just protecting turf,” he says.

“All that matters at the end of the day is patients; it’s not about money or this or that,” says Orozco. “It’s about how we are going to start getting patients better, and that is going to be through preventive services and decreasing those chronic conditions. And there is just no way that physicians alone can get it done.”

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Getting primary care to rural America

Rural America is struggling when it comes to primary care, because as physicians retire from these areas, it is becoming increasingly difficult to find replacements who are willing to live in these more remote parts of the country.

Although findings from studies show that doctors who grew up in rural areas are more likely to return there to provide care, there just aren’t enough of them to cover patient needs. As a result, more non-physician providers are stepping in to fill the gaps — not because they necessarily go to rural areas at a much greater rate than physicians, but because there are simply more of them overall, experts say.

“Our health professions training is very urban centric,” says Davis Patterson, Ph.D., a researcher from the University of Washington who studies patterns of care in rural areas. “We probably need to double the number of training slots in rural residencies to start to get parity, and possibly even more than that.”

Patterson says that new research shows that medical colleges do not necessarily have to recruit from rural areas to boost the number of doctors serving those communities. “While rural background was a positive predictor, rural training was also a separate, independent predictor of going to a rural area to practice,” Patterson says.

The same pattern held true for physician associates as well (Patterson said enough data is not available on NPs to draw any conclusions, but he suspects they would follow similar patterns).

According to Patterson, to help boost the number of physicians in rural areas, research indicates that medical residents just need more exposure to rural rotations to increase interest in serving rural America.