The Primary Care Shortage

Diagnosing the problems and confronting the challenges. 

By Pete Mercer

November 2023- The Journal of Healthcare Contracting

Consistent visits to your primary care physician are the foundation of a preventive care regime, but what happens if there are no primary care physicians? Though the COVID-19 has mostly subsided in the last year or so, resources and personnel are still dwindling for the primary care space.

A study conducted earlier this year by Axios found that graduating medical students are not moving towards primary care, even with an increase in applicants to schools and further congressional efforts to increase residency slots. According to this data, many residents are moving towards higher-paying specialties in lieu of primary care, which could leave gaps in care for patients across the country.

This is a trend that experts have seen coming for a number of years, especially in the wake of COVID-19. A smaller percentage of physicians are entering the field than are currently practicing, and after seeing how healthcare took the brunt of a lot of challenges on the chin throughout the height of the pandemic, it’s no wonder that fewer people are entering the workforce.

As primary care continues to shrink across the country, healthcare organizations are looking at ways to better invest in primary care to ensure that there is no lapse in the healthcare continuum. First and foremost, these organizations need to understand the challenges facing patients and providers in the primary care setting.

Diagnosing the problem

According to the National Association of Community Health Centers, over 100 million Americans are facing barriers to access primary care. That gap in access to primary care can result in serious health issues for those affected, and potentially even greater public health threats. The pandemic revealed flaws and holes in the healthcare system that always existed but might not have been evident without a significant disruption. Because of that disruption, the healthcare industry faltered and stumbled through a challenging period where the patients far outnumbered the healthcare staff.

Additionally, the pandemic highlighted the need for preventive care – another big pressure point, many patients opted out of their typical primary care visits due to office closures or fear of getting sick from visiting the doctor. Primary care providers are typically the first line of defense for diagnosing and treating infectious diseases in vulnerable populations. Primary care physicians have only increased in value and scarcity since the onset of COVID-19.

With fewer residents going to primary care settings (and perpetual burnout and staffing shortages that the whole industry is dealing with), it exposes this greater threat of a lapse in patient care and creating bigger holes in a workforce that is already struggling. The report from Axios says that in 2022, “930 family medicine and internal medicine residency positions went unfilled.” The Milbank Memorial Fund found further evidence that from 2012 to 2020, “only one in five physicians who completed a residency were practicing primary care two years later.”

Fewer primary care physicians could mean a greater disparity in health equity in rural or medically underserved areas. When physicians do enter primary care, they aren’t always going where they are needed most. In these medically underserved areas, the report says that “the number of primary care doctors has been stagnant for last eight years.”

Graduating medical school students are showing a preference towards specialty residency programs over primary care positions. Donna Lamb, director of the National Resident Matching Program, said to Axios, “We’re seeing the same thing year over year, which is that the more specialized areas of medicine are not seeing a decline in applications or interest, but the primary care applications continue to see declines year over year.”

Efforts to improve primary care access

As doctors continue to push towards areas other than primary care, gaps are created in the healthcare continuum. Primary care is an essential piece of the puzzle in the healthcare system, and without it people could lose access to receiving the care that they need.

In an effort to meet the growing need in the state of Arizona, the University of Arizona Health Sciences is working to develop a new generation of primary care physicians through the Primary Care Physician Scholarship program. In this program, medical students at the University of Arizona College of Medicine – Tucson, and the University of Arizona College of Medicine – Phoenix, are awarded annual scholarships that will allow future physicians to pursue careers in primary care, without having to worry about repaying medical school debt.

For this program, scholarships are available to students who intend to pursue residency training in family medicine, general internal medicine, geriatric medicine, general pediatrics, psychiatry, obstetrics and gynecology, and general surgery. Recipients of this scholarship are committed to a minimum of two years of service in primary care. In the description of the program, applicants are also encouraged to have a “strong interest in practicing a primary care specialty in a rural or underserved region of Arizona.”

Similarly, the VA Central Iowa Healthcare System is offering a nurse practitioner residency program that offers newly licensed nurse practitioners a 12-month window to master clinical skills, enhance competence, and improve professional confidence. In this program, individual development plans will allow each resident to address specific needs and explore areas of interest. Essentially, it’s designed to bridge the early, nerve-wracking days of working as a nurse practitioner to developing into competent, confident, and independent primary care providers.

In June, CMS announced a value-based primary care model to serve rural and underserved populations that will be launched in Colorado, Massachusetts, Minnesota, New Jersey, New Mexico, New York, North Carolina, and the state of Washington.

The CMS model includes a three-track approach based on participants’ experience level with alternative payment models, though participants in all three tracks will receive enhanced payments. Track one participants will focus on building the infrastructure needed to support care transformation, while tracks two and three will include advance payments and more opportunities for bonus payments based on participant performance.

In a media release concerning the model, CMS said it will work with participants, which will include federally qualified health centers, Indian Health Service facilities and Tribal clinics, to address needs specific to their communities, including care management for chronic conditions, behavioral health services, and healthcare access for rural residents. The agency is also working with state Medicaid programs in the eight states and plans to involve commercial payers soon.

The NACHC is attempting to address the primary care problem by providing access to affordable healthcare through community health centers. These health centers provide patients with services like primary medical care, dental, behavioral health, access to a pharmacy and other preventative services. In fact, these health centers are the largest primary care network in the country, according to the NACHC.

While efforts are being made to address the challenges facing primary care head on, it’s evident this is a vestige of the American healthcare system that needs a course correction. There are plenty of ways for organizations to continue to carry the torch, and primary care will never go away completely. But the landscape of healthcare is constantly in a state of change, and primary care is in an increasingly vulnerable position as a viable avenue for patient care.

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