As interest in on-site clinics has ramped up, so has competition for physician talent, with new healthcare companies competing with traditional providers stretching the market to a breaking point, said Tom Florence, executive vice president of staffing firm Merritt Hawkins. By 2032, the nation could face a shortage of up to 55,200 primary-care doctors. As a way to bridge this gap, startups have increasingly been turning to nurse practitioners and physician assistants to work at these clinics, Florence said, particularly those in the virtual care space. Last summer, for example, Merritt Hawkins helped insurtech startup Oscar Health hire clinicians for its virtual-first care division and "it was interesting, because what they were looking for was nurse practitioners and physicians assistants," Florence said.
The New York City-based company credits these digital advanced practice providers with driving members to fill 80% of their prescription medications and complete more than 60% of labs ordered. The company said members with chronic conditions have higher adoption rates of its virtual-first plan, compared with healthy members. Additionally, 85% of Oscar Medical Group patients said they plan to only use virtual care when issues arise.
"If we didn't have (advanced practice providers), we would be in a really, really significant primary-care shortage," Florence said. "It has impacted that demand and it's really stretched the market. Some of the bigger cities even have challenges finding physicians."
A decade ago, the majority of Merritt Hawkins' physician searches were for communities of 100,000 people or fewer, Florence said. Today, 60% of the company's searches are for physicians to work in cities of that size or greater. The primary-care startup boom has exacerbated staffing shortages at traditional hospitals, with companies new and old looking to nurse practitioners and physician assistants as a lower-cost point of access. A 2021 survey by the National Association of Worksite Health Centers found that 20% of on-site clinics were staffed solely by registered nurses, or by other caregivers who did not identify as a doctor, nurse practitioner or physicians assistant. While skilled, these individuals are no substitute for a doctor, said Dr. Andrea DeSantis, a North Carolina-based family physician.
"The trend in medicine is to employ the cheapest possible staff and advertise it as if it's the same as going to see a doctor and it just isn't," she said. "You don't know what you're going to get when you're dealing with somebody who has not gone through the training a physician has gone through."
The quality of training programs for nurse practitioners and physician assistants can vary wildly, DeSantis said, with some graduating from comprehensive programs and others coming from "very flimsy online training programs where they are guaranteed to graduate and they have almost little to no experience with patient care," which can lead to increased costs for companies over the long term, she said.
Some reports have shown that advanced practice practitioners are more likely to refer patients to sub-specialists than primary-care physicians, and may have more expensive prescribing habits. A recent study from the University of Michigan also found that telehealth visits can increase downstream care.
"I just worry about how employer clinics are being staffed, who is profiting off of that, and is it the quality that the patient and employer is expecting?" DeSantis said.
Rosen knows that there is a tricky balance to finding the right staff and services. After getting burned by a large pharmacy benefit manager, Rosen also opened an in-house pharmacy in its medical center, where today employees can receive 90% of their medications for free. The company also employs a nutritionist, podiatrist, provides radiology services and offers Zumba and Tai Chi courses. Rosen also prohibits smoking among his 6,000 employees, and schedules frequent, and random, drug tests.
"Does it take a little courage? Yes. Why? Because it's doing something radically different," Rosen said. "People don't like to change. But if they look at the potential results, it's worth giving it a try. Everything else is skyrocketing out of control. This saves money and offers our associates a healthcare plan that they really love."