The Impending Shortfall of Primary Care Providers

With the passage of the Affordable Care Act (ACA) will be a projected shortfall of primary care providers of about 20,400. Who will fill this void? Will it primarily be physicians, nurse practitioners (NPs), or both? There is a push to increase the training of both NPs and physicians to fill this shortfall, but creating positions to train more primary care providers will not be successful if there are not enough people to fill them.

This article shares the results of a mailed survey of primary care physicians (PCPs) and primary care NPs (PCNPs). It delves into job and career satisfaction as well as how likely PCPs and PCNPs are to recommend their careers to others.

Almost 1000 clinicians (half PCPs and half PCNPs) returned surveys. When asked whether they believed that there was a national shortage of primary care providers, PCPs were less likely than PCNPs to agree that there is a national shortage of primary care providers (52% of PCPs vs 78% of PCNPs). In answer to the question, “Given what you know about the state of healthcare, would you advise a qualified high school or college student to pursue a career as a PCP or PCNP?” 56% of PCPs and 88% of PCNPs would do so. Of interest, even more PCPs (66%) recommended a career as a PCNP.

Current job satisfaction was high among both groups (88% for PCNPs and 83% for PCPs). Career satisfaction (defined as satisfaction beyond the current job) was lower than current job satisfaction but was much higher among PCNPs (73%), whereas only 46% of PCPs reported that they were very satisfied with their careers.

Participants were asked about their level of influence on decisions made in the workplace. In response, 54% of PCPs perceived opportunities to influence their organizations or workplaces, whereas PCNPs expressed less influence. Only 29% of PCNPs acknowledged these opportunities.

The impact of an increasing supply of PCNPs was also evaluated. Slightly more than half of PCPs (57%) believed that their income would decline should more PCNPs enter the workforce, whereas only 22% of PCNPs believed the same. In a similar vein, 74% of PCPs believed that an increase of PCNPs in the workforce would lead to replacement of PCPs by PCNPs. Only 50% of PCNPs believed this to be true.

Viewpoint

Primary care is changing. A shortage of primary care clinicians is predicted and the demand for primary care clinicians is rising. Increasing the training slots for physicians or NPs will not necessarily resolve primary care provider shortage if the current workforce is dissatisfied with their careers. Redesigning the work through new models of care to increase efficiency, quality, and career satisfaction may be a more effective strategy than simply turning out more primary care clinicians of any type.

The changes in primary care will present challenges, but they will also bring opportunities. The roles of primary care providers will change in keeping with the increasing demands on the practice of primary care. Meaningful use of electronic health records (EHRs), patient-centered medical homes, accountable care organizations, and other quality-of-care initiatives will result in changes to the primary care visit. The focus of the patient visit now is different from in the past, with an increased emphasis on meeting and documenting various measures and data.

How will the predicted shortage of primary care providers be filled? The number of NPs in the United States has been increasing, whereas the number of PCPs has been declining. In March 2014, the American Academy of Family Physicians released a policy paper recommending increasing family practice residency positions from 3500 to 4475 by 2025 as a solution to this crisis.[1] Will increasing these residency positions create more primary care providers? Only 56% of the PCPs who completed the survey would recommend their careers to others, and less than half reported being very satisfied with their career. Could there be other reasons that these PCPs express pessimism about the role of the PCP? Filling the anticipated (and real, in many parts of the country) shortage of primary care providers may take more than increasing training slots and funding. It may require a culture change in the way primary care is practiced in the United States.

Primary care has become more difficult as a consequence of pressure to see increasingly more patients more quickly. At the same time, the pressure to track and document proscribed measures is increasing. Relationships with patients are changing, resulting in less total time spent with patients. Less time with patients and pressure to see more patients have been associated with job dissatisfaction among PCPs.[2]

EHRs, in and of themselves, have changed the way an office visit is conducted. In most cases, a computer or electronic device is involved in the primary care visit. There can be both advantages and disadvantages to this electronic addition, but it has undoubtedly changed the relationship and the workflow for both patient and primary care clinician. The clinician now spends much of the office visit interacting with the computer, which can lead to reduced satisfaction for both clinician and patient.

Increasingly, patient care medical homes and other initiatives are not evaluated by such outcomes as patients living longer and healthier lives; rather, they are judged by process measures, cost reduction, and increased visit volume. Do these initiatives meet the needs of patients, clinicians, payers, or EHRs? Do the reports of “quality” measure the “value” of care?

PCNPs expressed higher job satisfaction, career satisfaction, and likelihood of recommending their careers compared with PCPs, but simply replacing PCPs with PCNPs may not solve the primary care shortage. PCNPs are capable of filling these roles, but as they do, they may find the current system challenging, eroding their career satisfaction over time. Traditionally, PCNPs have been required to see fewer patients, a fact that may have contributed to higher job satisfaction, but continued forces that detract from what nurses value—their relationships with patients—could change the relationship or lead to burnout of the nurses.

Healthcare will continue to evolve for the many players in the process—clinicians, payers, and patients. We must actively participate in this evolution, looking outside the box, beyond the way things have always been done or the way we have been paid to do things and beyond simply minimizing cost. Instead, we must focus on maximizing the value (the outcomes that matter most to the patient) of care over the lifetime of the patient. It is possible to make primary care a place where clinicians will want to work and will recommend to others as well. The opportunity is ours. 2014. http://www.aafp.org/media-center/releases-statements/all/2014/familiy-physician-shortage-end-value-primary-care.html Accessed February 28, 2015. http://medicaleconomics.modernmedicine.com/medical-economics/news/user-defined-tags/deloitte/pcps-among-least-satisfied-medical-profession?page=full Accessed February 28, 2015.

References

  1. American Association of Family Physicians. Family physician shortage

    could end with targeted policies that value primary care. Marc 13,

  2. Zimlich R. PCPs among least satisfied in the medical profession.

    Medical Economics. March 28, 2013.

From Medscape, by Tom G. Bartol, NP, March 18, 2015