A key concern in reforming our healthcare system to better manage care will be finding enough primary-care physicians to make the system work.
With few exceptions, hospitals and large medical group practices have made enhancing and expanding the care provided through primary-care physicians one of their most prominent strategies.
The form that these strategies take may vary, but typically they include recruiting family practitioners, general internists, pediatricians and obstetricians/gynecologists and developing stronger relationships with existing primary-care physicians.
The net impact of this courting ritual is that demand for primary-care physicians is skyrocketing while the supply is rising slowly. A national market has developed for new graduates of residency programs in primary-care specialties.
One outcome of these market dynamics is escalating salary levels for primary-care physicians. Meanwhile, smaller, rural and less financially strong providers are unable to offer competitive salaries and incentives, further intensifying physician shortages that are already acute.
The only proposed solution that has received significant attention is restructuring graduate medical education funding or residency approvals to channel medical students into primary-care specialty training programs. But this approach is slow; it's only a long-term remedy that won't immediately address a physician shortage that's reached crisis proportions in many underserved areas.
If the correct target is for approximately 50% of all physicians to be generalists-a level that's been suggested by the Council on Graduate Medical Education and others-market forces may be the best and quickest way to solve the lack of equilibrium in medical manpower.
Studies of the national market for physicians indicate that, in an all-managed-care system:
The number of physicians needed drops to 130 physicians per 100,000 population from the current supply of 175 physicians per 100,000. Though the need will drop dramatically, it will take longer for supply to adjust to the new market dynamics. While some physicians will pursue early retirement and career changes, there still may be a 15% oversupply of physicians in the next decade.
Fewer physicians will be needed in subspecialties, especially hospital-based specialties. Also, physician productivity is expected to rise because of the increased use of physician extenders and because subspecialists will work longer hours to maintain their level of pay.
The current complement of primary-care physicians is about right for future needs, assuming that there's growth in supply to replace retiring physicians and offset population growth. While this view may be seen as controversial, it's supported by the current rate of use of generalists in large, diverse managed-care plans. Also, the productivity of primary-care physicians can be expected to rise as they move into group practices and take advantage of the services of physician extenders.
The short-term solution to the primary-care shortage is to allow market dynamics to continue to work. With rising compensation for primary-care physicians and declining compensation for subspecialists, based on supply and demand factors, some subspecialists can be expected to seek additional training as primary-care physicians and convert their practices.
The significant oversupply of specialists will not only help alleviate primary-care shortages in the short run, but will result in eliminating nearly all physician shortages in the next decade. The extent of specialist surpluses is so great that, without massive retirements or career changes, many of these physicians will have little choice but to seek practice opportunities in communities that have shortages in a specialty, or be retrained as primary-care physicians.
These additional primary-care providers will aid the movement toward an all-managed-care system and help ease current spot shortages.
Until market dynamics have these effects, however, there are four actions that community hospitals and regional health systems can take to deal with the supply-demand imbalance.
Support the formation of primary-care groups that are formally aligned with the hospital or system. Group practices can operate more economically, achieve higher levels of productivity and reduce some of the burnout many primary-care physicians experience sometime in their careers.
Develop more coordinated recruiting efforts. Medical groups by themselves or, preferably, in conjunction with hospitals, likely will be more effective in recruiting generalists in the national market, where the players are other large entities.
Promote the use of physician extenders in primary-care practices. Using physician assistants and nurse practitioners can expand the capacity of generalists and is more cost effective.
Begin to encourage subspecialists to consider converting to primary-care practice. While this can be a difficult topic to pursue, it's most appropriate with medical subspecialists who have a blend of primary-care and subspecialty-care patients in their practices.