Will Feds put final nail in coffin of physician-led primary care?

Rebekah Bernard, MD

It seems like the U.S. government has officially given up on the idea of physician-led primary care, and according to a quote from Senator Bernie Sanders, Americans had better just get used to it. Instead, legislators like Sanders aim to have patients receive primary care from community health centers by nurses and physician assistants practicing without physician oversight.

This idea is nothing new. Federal policy to replace physicians has been around for decades, beginning with the Rural Health Clinic Act of 1977, which tied funding to rural healthcare centers to the mandate that at least 50% of all services be provided by nurse practitioners or physician assistants. Beginning in the 1980s, the government enacted policies to restrict physician growth, including a 1997 cap on funding for residency training, the mandatory 1-3 years that medical school graduates must complete to become licensed physicians. Despite a documented physician shortage, bills introduced nearly every year since 2007 to reverse the freeze on residency training have failed to pass Congress.

Government policies incentivize physician replacements

As policies were instituted to decrease the number of physician graduates, government agencies took active steps to increase nurse practitioners and physician assistants. For example, at the same time as his administration was paying hospitals to stop training physicians, President Bill Clinton proposed that $200 million be allocated to fund nurse practitioner training. Fifteen years later, President Barack Obama signed the Affordable Care Act (2010), which expanded funding to nurse practitioner and physician assistant training programs, without increasing residency training for physicians. In 2016, the Veteran’s Administration elected to allow nurse practitioners to fill the role traditionally provided by physicians, treating servicemen and women independently.

Policies to replace physicians with nonphysician practitioners continue, and in 2019 the U.S. Government Accountability Office recommended diverting physician residency funds toward funding nurse practitioner and physician assistant ‘residency’ programs, stating, “while increasing physician supply is one way to reduce physician shortages, some experts have also suggested increasing the number of non-physician providers.” The current administration has taken this messaging to heart, allocating $100 million specifically to train nurse practitioners to own and operate primary care practices, a plan that, according to Health and Human Services Secretary Xavier Becerra, came straight from the Oval.

But will this plan work?

Probably not. First of all, nurse practitioners (and physician assistants) are exiting primary care for the exact same reasons as physicians—too much aggravation for too little pay. It is estimated that just 30% of physicians and one-third of physician assistants choose primary care. While nurse practitioners are promised to ‘fill the primary care gap,’ workforce data found that just 48% worked in the field in 2012. A $179 million pilot project intended to encourage nurse practitioners to choose primary care failed to produce results. After five years, just 12% of nurse practitioner program graduates entered the primary care workforce.

Why are clinicians leaving the primary care workforce?

As a primary care physician myself, the reasons are obvious: Patients are sicker and more complicated than ever, and yet clinicians are being asked to do more in less time, sometimes being given minutes to address multiple health conditions while achieving high patient satisfaction scores. In addition, they are tasked with multiple administrative burdens, with studies showing that for every hour spent face-to-face with a patient, primary care doctors spend two hours on computer documentation.

High anxiety levels and patient demand for reassurance for minor, self-limited problems compound the problem. A Politico article seems to have unintentionally hit the nail on the head: “Most Americans share a common frustration when they get sick—by the time they can get an appointment with their doctor, they’re feeling better.” In other words, these patients didn’t need to see a doctor in the first place. Further, treatments received for such conditions (such as unnecessary antibiotics for viral infections) are more likely to hurt patients than to help them. This is likely one of the reasons that more patients die worldwide due to poor quality care than die due to lack of access to any care at all.

What policymakers and analysts fail to understand is that primary care is essential for Americans not because of the treatment of minor, self-limited conditions like colds, cuts, or scrapes, but because of interventions that reduce overall mortality. This happens in two main ways: through the routine management of risk factors that lead to death from heart attacks and strokes (such as controlling blood pressure, cholesterol, and diabetes), and by performing evidence-based screening tests to detect and treat cancer in the earliest stages. Seeing the same physician over time has been shown to decrease mortality, in part because primary care physicians are trained to provide these essential services at every visit, even when patients are presenting for a minor ailment.

Studies show that non-physicians may cost the system more

While policymakers are betting big that nonphysicians with a fraction of the training and education can provide this same care as primary care doctors, studies indicate otherwise. A 2022 report published by the Hattiesburg Clinic, one of the largest accountable care organizations in the country, found that despite carrying panels of lower-risk patients, nurse practitioners and physician assistants working independently had poorer outcomes and higher costs of care than primary care physicians. Doctors performed better on 9 out of 10 quality measures, with areas like influenza vaccination rates showing double-digit differences. Nonphysician practitioners had higher emergency room referrals and specialty referrals, translating into an additional $28.5 million annually.

Government policies to replace physicians with nonphysicians have failed to show promised improvements in care or cost savings. It’s time to rethink this strategy by increasing our miserly funding of primary care (estimated at just 5% of healthcare spending) and producing physicians with the right training to provide high-quality care for patients. Incentivize students to choose primary care by lowering the cost of medical education, paying doctors fairly, and removing the administrative burdens that make it so difficult to practice medicine today.

If policymakers refuse to listen, physicians and patients can either ‘get used to it,’ or they may choose to take matters into their own hands. This might not be such a bad thing, as has been shown by the growth of direct primary care (DPC), an affordable alternative to concierge care. The model, which is exploding across the country, allows physicians to spend more time with patients by limiting panel size to about 600 (compared to the usual 2,500). Patients have virtual access to their physician, and by eliminating administrative costs associated with third-party payers, most DPC practices charge reasonable rates, averaging $77 per month.Leaders in the DPC movement have shown data associating the model with lower overall healthcare costs and improved quality of care, and my own experience has shown DPC to be a game-changer in terms of physician burnout.

When it comes to ensuring high-quality healthcare, my message to patients is this—don’t accept the status quo. Demand that your representatives address the healthcare crisis by slashing high administrative costs, eliminating drug manufacturer kickbacks, and decreasing consolidation in healthcare, not by replacing your doctor with a seemingly cheaper alternative.

Rebekah Bernard, MD is a Family physician in Fort Myers, Florida and the author of Imposter Doctors: Patients at Risk. She is the president of Physicians for Patient Protection, a grassroots organization that advocates for physician-led care for all patients and truth and transparency among healthcare practitioners.