Projecting US Primary Care Physician Workforce Needs: 2010-2025

Petterson et al. have provided a sobering portrayal of the upcoming primary care workforce needs in the United States. Although the writers project an additional 52,000 primary care providers needed by 2025, they mention a large proportion of these providers will be needed in the years 2014 and 2015, when the Affordable Care Act (ACA) is enacted (1). Given the fast approaching increase in patients, and corresponding need for providers, we will benefit from turning our attention to team based practice and primary care extension services to maintain any chance of meeting our countries primary care needs.

The notion of physicians as figureheads of all healthcare teams must be abandoned. This is important in order for true collaboration, communication and division of labor to emerge in team-based care. This may also allow leaders in many disciplines to surface, will let team-members work to the level of their training, and may allow for expansion of professional skill sets (2). Examples include: nurse led clinics, medical assistant administered questionnaires, and community health workers home visits. These efforts will likely increase efficiency, decrease wait times for medical services, and increase provider job satisfaction.

As mentioned in the article as part of the ACA, another approach that may be successfully implemented with few medical providers is that of a health extension program. Originally modeled in New Mexico, health extensions have brought needed health education, funding initiatives, health professional pipeline development, and academic health center resources to rural communities (3). Extensions are models of prevention, and may be invaluable when considering the geographic inequities inherent in our physician workforce.

Between now and 2025, Family Physicians must take all opportunities to increase the numbers of students who choose primary care. We must all provide mentorship to students and residents so they see their bright future in primary care. Further, we should continue strong support for expanded federal funding for primary care education such as Title VII, support proposed increases in primary care residency slots such as in U.S. Senate Bill 1627, and back loan repayment initiatives so that primary care remains an option for all students (4,5). Petterson et al. reminds us there will soon be an increase in patients seeking primary care (1). In the short run, utilizing creative ways to reach patients must be employed. Long-term goals of increasing student commitment to primary care must also garner widespread support in order to meet our nation's primary care needs.

1. Petterson SM, Liaw WR, Phillips RL, Rabin DL, Meyers DS, Bazemore AW. Projecting US Primary Care Physician Workforce Needs: 2010-2025. Ann Fam Med. 2012; 10(6):503-509.
2. Grumbach K, Bodenheimer T. Can Health Care Teams Improve Primary Care Practice? JAMA. 2004;291(10):1246-1251.
3. Kaufman A, Powell W, Alfero C, Pacheco M, Silverblatt H et al. Health Extention in New Mexico: An Academic Health Center and the Social Determinants of Disease. Ann Fam Med. 2010;8(1):73-81.
4. Meyers D, Fryer GE, Krol D, Phillips RL, Green LA et al. Title VII funding is associated with more family physicians and more physicians serving the underserved. Am Fam Physican. 2002;66:554.
5. Legislative Detail: US Senate Bill 1627 - 112th Congress. LegiScan. http://legiscan.com/gaits/view/341721. Accessed 12/14/12.

Competing interests:   None declared

These evidence-based estimates are another example of "statistical compassion," via empirically-based arithmetic. The conservative assumptions made are prudent and align with/improve prior work. In short, this is a serious contribution that merits national attention in the cacaphony of calls for MORE physicians and just about every other type of clinician.

In addition to answering the questions posed for the analysis, this manuscript is filled with nuggets that also should provoke immediate national debate on a broader scale, such as could be had with implementation of the ACA authorized National Health Care Workforce Commission.

1. Declining visits to primary care physicians, below 50% by either NAMCS or MEPS is a wake-up call for anyone serious about inproving quality while containing expenditures.

2. Jutifified inflation of estimated needs to 8000 to obtain 6000 FTE's service is another wake-up call about current practice patterns of physicians working part time, while requiring full investments in education and training.

3. Discriminating where increased demand will lie places considerable pressure on discriminating between pediatricians and general internists and family physicians in workforce policy.

4. The immediacy of 2014-2015 expanded demand does not seem accommpanied by sensible urgency on the part of the health professions and policy makers.

5. The lack of accounting for geographic distributional deficiencies is not because we know it is irrelevant, and the maps of where pediatricians are not practicing and the counties that already dwell in shortage constitute something that could be labeled a "policy emergency."

6. The commentary posted for this article again calls out prior calls for interprofessional workforce planning, yet another reason to establish the National Workforceforce Commission.

As noted in commentary, the wild card is what the country needs from its health care workforce, particularly its primary physicians, and what they are going to actually do. If it is great personal doctoring, these estimates are a good start for defining the target.

To state the obvious, continung to expand the number of physicians without attention to accountability to public need is not a prudent course of action. If billions are to be spent for the purpose of meeting the needs of the population, rather than the needs of hosptitals and training centers, the money should have a chance at solving the problem.

Competing interests:   I have participated in workforce studies conducted by the Robert Graham Center

Petterson et al's article is an excellent addition to the literature assessing future primarycare workforce needs. Using the MEPS visit rates and parsing out growing demand for physician care into the bins of population growth, aging, and the ACA is a useful contribution to the literature, as is the careful description and accounting of the current primary care physician workforce. With regards to the latter, work using Medicare claims data has suggested that the number of primary care physicians truly performing the work of primary care is even lower than the authors find - which could help reconcile the apparently low amount of visits and numbers of patients per physician that Petterson et al find.

The estimate of the increased demand for primary care resulting from new coverage under the ACA (3%) is lower than others, and appears reasonable. The RAND health insurance experiment and work by CBO (Congressional Budget Office, 2008) and others have suggested that when the uninsured obtain coverage, they do use more care than they did previously, but not as much as similar people who were insured already (unlike the assumption made by Petterson et al). Thus, their assumed increase due to the ACA could be an overestimate still. On the other hand, as noted, the ACA, with its focus on medical homes and ACOs, may particularly increase the demand for primary care more than for all care overall.

The real wildcard, also noted by the authors, is the possibility of profound change in the technology of delivery of primary care. Not only is the number of Nurse Practitioners expected to increase markedly (Auerbach, 2012), but improved technology and movement away from fee for service should lead to more email and phone 'visits'. Improved delegation of tasks to medical assistants and reduction of unnecessary care can also ease demand for more primary care physicians.

Auerbach DI. Will the NP Workforce Grow in the Future?: New Forecasts and Implications for Healthcare Delivery. Medical care. 2012;50(7):606-10.

Congressional Budget Office, "Key Issues in Analyzing Major Health Insurance proposals," Dec 2008, p.71+; http://www.cbo.gov/publication/41746

Competing interests:   None declared

Hi Dr. Kelly, In response to your other comment about the type of provider seen by the patient, we used this question to identify the specialty of the physician. It is from the medical visit section of the questionnaire (for 2008: http://meps.ahrq.gov/survey_comp/hc_survey/2008/MV1201.pdf)

The question (MV03A) is "What was the doctor's specialty?" We considered primary care visits as visits to general practitioners, family physicians, pediatricians, geriatricians, or internists. MV04 asks whether the patient saw a different provider (such as a nurse practitioner or physician's assistant).

The question you referenced (which we did not use) is from the "Adult Self-Administered Questionnaire". As you mentioned, in this survey, the type of provider is not specified (http://meps.ahrq.gov/survey_comp/survey.jsp).

Thanks again for your comment. Winston

Competing interests: None declared

Dr. Kelly, Thanks for your response. We agree that NPs and PAs play an important role in delivering primary care. We also agree that projecting their utilization is an important aspect of answering our study's question.

We actually had a paragraph in the original discussion section about NPs and PAs (and about how we were unable to directly project their utilization using the AMA Masterfile which only tracks physicians). However in an attempt to focus our discussion and be responsive to peer-reviewers, we ultimately removed that paragraph.

As I mentioned, you bring up an important question, which would be an essential contribution to the existing literature on workforce projections.

Winston

Competing interests: None declared

As an addendum to my first comment, the patient self-identification of a primary care visit in the MEPS survey occurs by answering the following question:

"In the last 12 months, not counting the times you went to an emergency room, how many times did you go to a doctor's office or clinic to get health care for yourself?"

The type of provider seen is not specified. Especially in Federally Qualified Health Centers and Community Clinics, NPPs frequently outnumber physicians.

The numbers of NPPs practicing primary care have been estimated as of 2010 at:

http://www.ahrq.gov/research/pcwork2.htm

Current numbers are increased.

An excellent review of the difficulties calculating the number of needed providers is covered in the following manuscript:

Health Serv Res. 2007 October; 42(5): 2022-2037. doi: 10.1111/j.1475-6773.2007.00700.x PMCID: PMC2254567 Missing in Action: Care by Physician Assistants and Nurse Practitioners in National Health Surveys Perri A Morgan, Justine Strand, Truls Stbye, and Mark A Albanese

Competing interests:   None declared