Direct Primary Care Physician | Advocate for free-market healthcare & patient-centered reforms | Entrepreneur | Writer
Originally written SEPTEMBER 3, 2015 – We’ve all heard it by now. There is physician shortage. It is mainly in primary care, and the shortage will worsen drastically as physicians retire and aren’t not replaced by more primary care docs. Not a week goes by that a major new outlet doesn’t run a story or at least mention this in a health-related article. Charts and graphs are displayed with the projections of shortage, giving credence to the narrative.
What is driving it? New medical graduates are opting for specialties that offer better lifestyle, few patients to manage and a more controlled professional focus; not to mention higher incomes. This is true. Primary care, like any specialty, is challenging to say the least. And the stress to reward ratio is probably a little higher in primary care than some other specialties; but enough whining.
Here is a quote from an article in The Annals of Family Medicine from 2012:
“Estimates suggest that a primary care physician would spend 21.7 hours per day to provide all recommended acute, chronic, and preventive care for a panel of 2,500 patients. The average US panel size is about 2,300.
Data on quality of care illustrate the results of this predicament. Patients receive only 55% of recommended chronic and preventive services. About one-half of US adults have at least 1 chronic condition. Fifty percent of people with hypertension have uncontrolled blood pressures, more than 80% of people with hyperlipidemia have not attained cholesterol control, and 43% of people with diagnosed diabetes have not achieved glycemic control.”
Pay close attention to the bolded line in the quote above. Remember the 2,300 figure as we work through this.
So it is obvious that PCPs don’t have enough hours in the day to provide quality care for chronic diseases and give prevention the time it deserves with these panel sizes. There are roughly 320,000 thousand primary care physicians between Family Practice, Internal medicine, and Gyn’s that provide primary care to women. (Not counting pediatrics in this first round; I will break it down precisely below and break it out by gender, but for this back-of-the-napkin calculation this will do). There are approximately 240 million people age 15 – 80. Do the math and that comes to about 750 patients per primary care doc. Now they are split up unevenly of course, but these numbers should raise some questions; other than the fact that we have a lot of underserved areas, but there are indeed some other factors going on that we need to explore further.
Data from KFF.org indicates the following breakdown for the number of physicians in the primary care “specialties” as follows.
- Internal Medicine 176,893
- Family Med/General 126,258
- Pediatrics 77,474
- OB-Gyn 48,402
- Geriatrics 1,123
The population figures I use in my calculations come from 2012 census data. I’ve also made some assumptions about distribution of patients between the various primary care disciplines based on my observations over 25 years of practice. They are indeed estimates, but I think pretty close to reality. Feel free to move the percentages up or down a few points if you disagree.
Briefly, I am assuming Pediatricians see 70% of those 14 and under (61.1 million), with the remainder split between FP and IM-Ped (dual boarded). Next, assuming the woman age 20 – 64 (94.2 million) split evenly between IM, FP/GP and Gyn for their primary care (some will have more than one doctor but I’m leaving that out of calculation). For those over age 70 (27.8 million), I am assuming that 5% see a designated Geriatrician and the remainder are split between IM and GP/FP. Last, for the males between 18 – 69 (108.1 million) , I am assuming a 70/30 split between FP/GP and IM.
For the sake of brevity, I am not going to show my math. Trust me, I’m a doctor! Here are the average panel sizes based on the assumptions above using 2012 census data.
- FP/GP = 1,041 patients per doc
- IM/IM-Peds = 464 patients per doc
- Pediatrics = 552 patients per doc
- Ob-Gyn = 642 patients per doc
- Geriatrics = 1,237 patients per doc (this was tough to estimate, maybe way off)
Take a close look at the patient panel sizes. Yes, they are derived from raw data and don’t represent actual practices, but they do represent every single individual via census data that were represented in the categories that I used.
Why are they so much lower than the “average” U.S. primary care doctor patient panel numbers we see quoted so often? The panel sizes would be larger if we count those with more than one doctor, but that would be a wild guess. But, that effect is dwarfed by the fact that I assumed every single American in the age/gender categories that I used has a personal physician, which we know is not the case. There is the issue of uneven distribution of doctors, with more in urban/suburban area compared to rural areas, tending to skew sampling surveys to higher panel sizes. The other sampling bias of surveys may be web presence of the practice. Again, these practices are easier to locate and contact; which might also account for why they have larger patient populations.
So it the physician shortage real? I don’t know. I do know access to supply is out of balance and we can do much better with some efficiency enhancers.
So how do we reconcile these numbers with the alleged physician shortage and what do we make of reports that the average U.S. primary care patient panel is about 2,300 (sources vary between about 1,700 – 2,500)? All I can assume is that they must not be sampling the smaller practices in underserved areas. If my numbers are even in the ballpark, and the “typical” urban practice has 2,300 patients, it would mean that there are thousands of practices with much lower panel sizes in order for average to be 1,041 for a FP/GP.
There is another issue that I believe is driving the predictions (and perceptions) of a physician shortage, which is intrinsic to the way we access and pay for care that causes it to be highly inefficient. There is an embedded catalyst resulting in a tendency to over-utilize based on the way we are forced to access care via network health plans. Over utilization in our current system is driven by perverse incentives on both the provider side and the patient side – and rarely results in better health or better outcomes. On the care side, “we eat what we code”, so to speak. You can’t get revenue if you can’t code a billable encounter and you can’t code a billable encounter without seeing the patient. On the patient’s side, there is a tendency to drop in more than necessary due to small office co-pays for in-network primary care visits. And, there usually is no other pathway available to patients by which to access their doctor, other than an office visit. Substantive phone conversations with physicians are not common for the average network plan subscriber.
So, now we know a panel size of 2,300 is too large, negatively impacting care outcome. We know there are unnecessary visits driven by CPT billing protocols mandated by network insurance contracts resulting in pressures/habits to over-utilize for doctors and patients. And based on other successful alternative practice models, we know these visits could be handled by more efficient means such as secure texting, healthcare communications platforms with automated workflows for improved efficiency and patient outcomes.
We also know that Direct Primary Care is ideally suited to be solution for dilemma described in the paragraph above. Panel sizes range from 400 on the low side to about 1000 depending on how the practice is structured, whether they have extended hours, specific services offered and the health characteristics of the patient population. In a DPC practice, many routine, uncomplicated issues can be handled by phone or secure text. Patients don’t always have to be seen for routine medication refills. There is no arbitrary rule that says they have to come in every so many months. Office visits, when needed, are unrushed resulting in more time to delve into real problems and come up with solutions without having to refer everything to a specialist. Communication is lifestyle friendly with online messaging, cell phones and texting. There is no financial incentive to over-book and the moral hazard of fee-for-coding goes away completely.
The DPC model is attracting a lot of interest from medical students, as evidenced by the conversation that I had with several delightful, energetic medical students that were part of the coalition from the Benjamin Rush Institute that attended the 2nd annual Free Market Medical Association meeting in Oklahoma City in August.
We are seeing a revival of interest in primary care as students and medical residents discover that there is a better way to care for patients that doesn’t involve any mandates or government coercion; simply a mutually beneficial exchange of value between two parties that is gratifying to both. My courageous DPC colleague from Massachusetts, Dr. Jeff Gold, wrote a fantastic post about this last week. Could these new disciples like the ones Dr. Gold is mentoring become recruits for DPC and fill the void? We are counting on it, as I don’t see our public policy initiatives getting it done.
So the next time you hear someone lamenting the primary care physician shortage, suggest to them that the solution is for doctors to reduce their panel size and stop taking insurance. Then enjoy the look of bewilderment on their face as they ask you to repeat what you just said.