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Podcast Library > NextGen Advisors Podcasts > Primary Care Takes Center Stage in the Evolution of Care

November 9, 2021

Primary Care Takes Center Stage in the Evolution of Care

The Affordable Care Act reaffirmed the centrality of primary care as the foundation supporting the entire American health care system. In today’s podcast, the NextGen Advisors discuss a report written in collaboration between the Robert Graham Center, the American Board of Family Medicine, and IBM Watson Health titled, "Primary care in the United States a Chartbook of Facts and Statistics". The Advisors provide their views on this interesting, updated snapshot of the state of primary care in the United States.

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Transcript

Dr. Betty Rabinowitz:

Hello, this is Dr. Betty Rabinowitz, NextGen Healthcare's chief medical officer and principal with NextGen Advisors. I'm joined today by Graham Brown and Dr. Martin Lustick, my colleagues in the NextGen Advisors. Welcome, Graham.

Graham Brown:

Good Morning.

Dr. Betty Rabinowitz:

And good morning, Martin.

Dr. Martin Lustick:

Thank you, hi.

Dr. Betty Rabinowitz:

The Affordable Care Act reaffirms the centrality of primary care as the foundation supporting the entire American healthcare system. Strong primary care is associated with improvements in overall health outcomes for both persons and populations, including but not limited to broader access, lower costs, greater health equity, and higher quality. I recently came across a report written in collaboration between the Robert Graham Center, the American Board of Family Medicine, and IBM Watson Health, titled primary care in the United States, a chartbook of facts and statistics, which I found fascinating. It provides a current updated snapshot of the state of primary care in this country.

Dr. Betty Rabinowitz:

Our conversation today will center on some of the information in this report. So let's get started. For every 1000 citizens of the US, numbers support the fact that 800 of those people report some symptoms during the year, 327 consider seeking medical care, 217 of them visit a physician's office of which 113 visit a primary care physician, 104 visit a specialist, 65 visit a complementary or alternative medical care provider, 21 visit a hospital-based outpatient clinic. 14 of those people receive health services at home, 13 visit an emergency department, eight are hospitalized and less than one person is hospitalized in an academic medical center. So Graham, what comes to mind hearing these statistics?

Graham Brown:

Well, first of all, I think it's a really fascinating way to kind of break down the numbers and look at how the US population is really accessing care. The fact that more people seek primary care than any other health, type of health service, I think is really indicative of the role that primary care plays. There's a surprising number of individuals who experience symptoms, but really only a portion of those individuals then consider seeking care. And then of those amounts that go to seek care really only a third of them are ending up with a primary care provider. What was also a little surprising for me is that 65 of the 1000 are visiting some kind of complimentary provider or alternative medical care provider.

Graham Brown:

So that kind of suggests there's maybe not a strong understanding within the public of the role that primary care plays in both preventive care and chronic condition management. I guess one other thought that was a little surprising related to this is given how large academic medical centers are really considered very powerful entities and have a significant role in terms of healthcare policy, training and how the medical community is prepared that really a very limited amount of care is being provided in those environments. And that was surprising to me. I would've thought it was more.

Dr. Martin Lustick:

A couple of other thoughts I have on this, what as far as the academic medical centers, this only refers to hospitalizations. And so I do think academic medical centers having been in practice around them. They have long tentacles, as a practicing pediatrician out in the community, I would count on the expertise of those specialists that the academic medical center, sometimes not even to see my patients, but just to give me advice on how to take care of them. So I do think that they have a large impact, even though they may only represent a small percentage of visits.

Dr. Martin Lustick:

The other thing for me is these statistics really reinforce the concept of the pyramid of care that [inaudible 00:04:21] the overwhelming majority of care in is self-care, which are the people who have symptoms but don't even seek any healthcare services at all. And that then primary care within the delivery system is really at the foundation. You see as you go up that pyramid, it narrows to fewer and fewer people making their way up. And ultimately we want people to stay at the low end of the pyramid to be able to live their lives and not have to spend a lot of time and resources in the healthcare system. That's the best outcome they could hope for. So if we can keep that foundation strong, then that provides the most value.

Dr. Betty Rabinowitz:

Graham, you made an observation about the complimentary visits, and this is a trend we've been seen consistently. I wasn't surprised by its striking, but it has been coming for a while. And I think it has a lot to do with some of the struggles of primary care, to keep access convenient, to have flexible hours, to have less barriers to entry into primary care to have providers, complimentary providers, open, wide open, and willing to see people versus the struggle in some urban settings to actually find a primary care physician who's taking patients.

Dr. Betty Rabinowitz:

So I think this number is a bit of a wake-up for primary care as a system and as a specialty and I'm glad you emphasize it because it is quite striking that full half of the people who seek primary care seek complementary care as well. Now, what we don't know is how overlapping these circles are. Do these people see an alternative clinician and a family physician? We also don't know, Martin, to your point, what symptoms people are experiencing? Is it a headache? Is it a... But I think your point is well taken. So, Martin, the report focused quite a bit on the compositions of the primary care workforce, what were your key takeaways as it pertains to the size of the primary care workforce in the US?

Dr. Martin Lustick:

Yeah. So if you look at the absolute numbers they reported just under 230,000 primary care physicians, but I think the... Maybe the more important thing is that only represents about a third of the overall physician workforce in the United States and that falls short of the 40% that's recommended by the Council on Graduate Medical Education. So there is a gap there in terms of those who are choosing versus those that are actually going in. And some of the statistics, certainly from the beginning of this century suggests that there have been drops in medical graduates, choosing family medicine. And that's disturbing. Although I think some of the more, most recent data suggests that there's been some significant uptick in the last five years or so. So maybe there's a silver lining in that cloud.

Dr. Betty Rabinowitz:

And interestingly, these numbers also did not reflect on foreign grads. These numbers were for US-trained physicians and obviously, much of the workforce is being supported by foreign grads, selecting primary care and doing so quite successfully. So are you worried about these numbers?

Dr. Martin Lustick:

Yeah. It's certainly.... It's an interesting question because if you actually just look at the raw numbers and you particularly if you combine these with NPs and PAs where we are seeing that less than half of nurse practitioners are going into primary care and only a little over a third of physicians assistants are, but when you combine all those numbers together, we have one primary care provider for every close to eight or 900 people in the United States, which says a ratio on the face of it appears would not be concerning. But we know that not all of these people practice full time and that a lot of primary care trained physicians and others don't actually practice primary care, they may be working in urgent care centers. They may be working as hospitalists and in other non-direct primary care service roles. So when you take all those things into account, you can conclude that we really do face a significant challenge in having adequate primary care coverage.

Dr. Betty Rabinowitz:

Absolutely. And Graham much has been said about the graying of the primary care workforce. How impactful do you think this factor is and is going to be in the upcoming years?

Graham Brown:

Certainly, I think it's an important factor. We've been watching for 20 years, the kind of the aging of the primary care workforce and the demographics certainly are supporting that trend. Most primary care physicians start practice kind of in their late twenties when they finish their residency and their medical education. And they remain in the workforce for about a 40 year period. So they're retiring in their sixties, mid-sixties. I think the increase interest that was demonstrated in the early nineties shows us 30 years later where we are in terms of that peak of physicians that are in practice. But, now we're at this point where nearly a quarter of primary care physicians are 60 years and older. So there really is a pending boom of retirements here that I think's been on the radar of healthcare organizations for a number of years.

Graham Brown:

And to me, part of what Martin was just speaking to around how the workforce is then adapting and how provider organizations are looking at the role of physician assistants and nurse practitioners to extend the clinical team to really supplement the graying of the physician cohort is trying to address some of those concerns, at the same time really working to encourage providers that are going into medical school to continue to pursue primary care. But there's a number of factors that are preventing that from occurring in terms of the actual work and the practice itself, along with compensation and other challenges in terms of where that care is needed between urban and rural settings and where people want to live.

Dr. Martin Lustick:

Yeah. Along those lines of the changing model of care, there is an interesting study at the University of California that modeled, what physician practicing primary care on average if they worked 43 hours a week seeing patients and 48 weeks a year, that they could see that they could take care of about 900 patients. But if they delegated to other levels of care, those functions that didn't have to be done by them as a physician, they could take care of 2000 people. So this whole idea of really maximizing the value of the team and figure is imperative for us given where we stand in terms of the aging of the physician population.

Dr. Betty Rabinowitz:

So Martin, in my mind, what you said is exactly what has been one of the downfalls of the challenges for primary care is that we have expected primary care physicians to take care of 2000 patients without delegating anything.

Dr. Martin Lustick:

Right.

Dr. Betty Rabinowitz:

So no wonder people are burnt out, challenged, very tired, stretched very thin. Because we haven't materially created high functioning care team model that allows people. And it's very cliche and I'm going to say it anyway to work to the top of their license. And there's, we still have a grand opportunity there. So Martin, what does the report reveal about the gender distribution of primary care physicians?

Dr. Martin Lustick:

Right. So we've seen and I think this has been a pattern based on the report across all industrialized nations that women are increasingly in the primary care physician workforce. And in recent decades, the proportion of primary care who are women is doubled or close to doubled at least. And certainly is outpacing what we're seeing in non-primary care specialties. I know in my own specialty of pediatrics, women far outnumber men at this point. And I do think, my earlier comment about people working part-time and not being full-time is partly related to women increasingly joining this workforce, although it's not just [inaudible 00:13:41] of women, I think the younger generation of physicians is more likely to work less than full-time in their clinical role.

Dr. Betty Rabinowitz:

Absolutely. It's interesting the University of Rochester's primary care residency programs, a majority women have been for the last few years, there have been a couple of classes that really are overwhelming majority women in primary care. And if we adapt and adjust and allow women to both parents and have a balance between work and life, there is such an opportunity because in many ways I think the style that women practice in is highly suited for primary care. So I, on many levels welcome this trend. Graham, what do we know about the geographic distribution of primary care physicians in this country?

Graham Brown:

The data presented here in this report, it's interesting. It's from 2019. So it's pretty current. And what we see is that primary care physicians are better represented in rural areas than specialist physicians. So one kind of element to consider there. And then within the primary care physician groups, family physicians, and general practice physicians are more highly concentrated in the rural areas compared to geriatricians internists, or pediatricians. And so we're seeing more of those practices, geriatricians, internists, pediatricians in highly concentrated urban areas to a similar extent that we see specialists. So this broader dynamic of the need within rural communities and the types of providers that they're able to actually attract into those communities and to practice there. I think this report really substantiates what we see are the trends and it provides some data to kind of recognize that what we feel and what we hear from clients and different provider organizations that we work with around their recruitment challenges are indeed backed up by some of the numbers.

Dr. Betty Rabinowitz:

Absolutely. Do you have a sense what some of the implications of this pattern of distribution could be?

Graham Brown:

Well, I think there's the potential for a contribution to some health disparities when you think about access to different types of providers and needing a geriatrician to really work with an elderly patient on their complex medication regimen or some of their needs as their overall health declines. Being able to access that individual in a rapid and meaningful way or for long-term continuity of care, if that care isn't available, it may indeed create some health disparities. When we think from a policy perspective, it's important then to create incentives to ensure that as graduates are coming out of medical school, and there is an incentive to support rural primary care and there's specific initiatives and plan to really drive that growth within the rural populations to serve folks that are living in rural environment. The pandemic has interestingly cast a bit more of a spotlight on this as we see the movement of individuals sometimes out of cities and into the surrounding communities. And the workforce hasn't necessarily kept up with the trend of the last several years and the last year in itself, maybe just putting a little bit more pressure in that domain.

Dr. Martin Lustick:

One other thing, I think when we talk about this geographic pattern and disparities, there's a risk here of missing the issues within an urban setting, because although there are high concentrations of the various primary care specialists in urban settings, they are not evenly distributed throughout those settings. And so it's common in urban settings that the wealthier non-minority areas of the urban area have plentiful primary care, whereas the minority disadvantaged communities really struggle to get access to primary care. And that is a huge challenge is that we don't match our service capacity to the needs of the community.

Dr. Betty Rabinowitz:

Yeah. And I must say that something that comes to mind and a while back, I had written a blog about rural medicine and the numbers, the disparate numbers in terms of mortality rates, time to get into the emergency room, even some of the disparate deaths from overdoses had to do with the scarcity of some of these primary resources, the plight of community hospitals in rural areas that have closed at an unbelievable rate. All of this is important and pertinent what comes to mind is virtual care of virtual care of virtual care might end up being the biggest remedy. The biggest sav for this wound that both availability of subspecialties that are not likely to migrate to the rural areas will be increased with virtual care. And even primary care can be now provided much more effectively in rural areas where there's low population density and large geographical distances.

Dr. Betty Rabinowitz:

So this is actually one of the factors that I think a company like NextGen with our technology has been part of the solution and helped significantly with mitigating this element. And then obviously lots of additional fascinating information and data would love to keep going. We had some interesting thoughts on practice ownership and the structures around that. We may do that in a future podcast. So definitely stay tuned. I'd like to thank our listeners for joining us today, and obviously thank my colleagues, Dr. Martin Lustick and Graham Brown for sharing their insights and perspectives. If you've enjoyed today's topic, consider subscribing to our podcast. This is Dr. Betty Rabinowitz, NextGen healthcare. Have a great day.