Primary Care Shortage Reshaping How Patients Seek Care

Continued Shortages of PCPs

“We know there’s a documented pajama time,” Ms. Greiner said. For every 1 hour spent with a patient, primary care must spend nearly 2 additional hours on electronic health records and desk work, according to a study by the American Medical Association. Even with all those additional hours devoted to getting paid, primary care doctors make an average of $103,000 less annually compared with their counterparts in surgery and oncology.

It’s not an attractive combination for a new doctor with medical debt. This year, Ms. Greiner said that residency positions in internal medicine and pediatrics went unfilled. Of those trainees who do go into a primary care specialty, many won’t last. Only half of primary care residents practice in primary care 3-5 years later. The rest choose to subspecialize or become hospitalists.

These untenable demands on a primary care provider don’t go unnoticed by patients. In Ella’s attempts to invest in a new primary care relationship, she often doesn’t feel heard and can tell the doctor is rushed. “[Urgent care is] probably not the best care because they don’t know me, but it does seem like they are able to listen to me better,” Ella said.
 

Patients Want to Invest in Primary Care

Primary care should work like putting money in a bank account, Dr. Rotenstein said. Young patients invest in the relationship and reap the benefits of a doctor who knows them later in life when they need more complex care. But if seeing a doctor is so difficult, many young people may stop investing in their PCP relationship.

“One thing ... that I worry about in this kind of situation where patients really have to put in a lot of work to get the care they need is in inequities of care,” Dr. Rotenstein said. “We know some of our patients are more able to undertake that work.”

Alternatively, the primary care shortage could be reshaping how patients seek care. A 2023 study showed the proportion of primary care preventative visits increased over 20 years. Policies under the Affordable Care Act were the driving force. But it’s also true that sick visits are being diverted to urgent care.

Ella told this news organization she doesn’t even consider primary care for sick visits at this point. “I can’t wait 5 days or a week and a half. Unless I have bigger issues, like I need tests, I’m not even going to go to primary care.” It’s possible that other patients also see primary care as a place for testing and wellness checks and leave sick visits to retail and urgent care.
 

The Road Ahead

There’s no single fix for primary care, but experts agree that the fee-for-service model is a core issue for the specialty. In a 2021 report, the National Association of Engineering and Medicine said that primary care reform needs to include higher reimbursement rates for primary care and that US primary care should be restructured so that payers “pay primary care teams to care for people, not doctors to deliver services.”

In the current model, the doctor-patient clinic time is the only income-generating part of a primary care practice. A better model would consider the communication, administration, teams, and support doctors have to fund to provide the best primary care.

“We need to change how we pay and how much we pay, so [primary care doctors] are properly incentivized to build out a team to provide the comprehensive care you need,” Ms. Greiner said.

In the meantime, primary care doctors are adapting. Some drop down to part-time to account for the additional administrative workload. Others are transitioning to concierge services to offer the quality of care they want while getting the income they need. Still, others specialize their practice, offering primary care to a subset of the population, like older adults.

Employers are also looking to improve care access for their employees, hiring in-house doctors to provide primary care on site. Ms. Greiner recently met with a group of chief medical officers from major companies to discuss expanding primary care access via the workplace.

The efforts to adapt amid a broken system are admirable, Dr. Rotenstein said. And whatever a PCP has to do to keep practicing in primary care is laudable. The only problem with these adaptations is they largely limit a doctor’s patient pool and, therefore, limit access, she said. More significant reforms that adequately reimburse primary care and incentivize new doctors are still needed.

As for Ella, she got married. Her wife is in the military, so now she has Tricare, which comes with a more streamlined process to access primary care. However, doctor shortages are just as evident in that system. The couple called to schedule new patient appointments after their recent move to Virginia. The first available ones were 6 weeks out.
 

A version of this article appeared on Medscape.com.