Primary-care shortage is a symptom of a broken delivery system.
Let’s look at “Mary” (she’s a composite, but closer to reality than most would like to think). Mary went to the emergency room 68 times in 2013 despite the fact that she didn’t have 68 emergencies. She also had four hospitalizations, most of which could have been prevented. She suffers from insulin-dependent diabetes, chronic pain, depression, and PTSD. Mary is 34 years old and has health insurance, but the system is clearly not working for her.
As a medical student interested in primary care, I’ve met a few people like Mary. She suffers from multiple chronic diseases and faces several social barriers to proper health care. The heartbreaking reality is that she does not fit into the traditional paradigm of clinical care in the United States. And Mary is not alone.
According to the Agency for Healthcare Research and Quality, 1% of the population accounted for 22% of overall health-care spending in 2008. In Minnesota, this would represent roughly 53,000 individuals accounting for $5.7 billion in health-care expenditures in 2013 (or about $107,000 per patient per year).
People like Mary shine a light on the shortage of primary-care physicians and the dysfunction of our current system. Mary and her physician require time together to build their relationship and determine the best plan for Mary’s health. But because of her multiple chronic conditions Mary also needs more convenient transportation, a care coordinator, a social worker, a mental health team, and health educators. As baby boomers age and the Affordable Care Act expands coverage, others will need the same services. As a result, we will all start to feel the impact of this shortage immediately.
In its current state, our primary-care system is not only dysfunctional for patients but also unappealing for most medical students trying to decide on a specialty.
A 2010 national report recommended that at least 40 percent of graduating medical students enter primary care in order to improve in our provider shortage. Unfortunately, the rate of students entering primary care has been stuck at a shocking 12 percent for the past five years. Students considering primary care are concerned about the infuriatingly short visits with patients, the burdensome paperwork and insurance regulations, payment systems that heavily favor specialists, and the extremely high rates of burnout for primary-care physicians.
More hands bailing water
A current and central strategy to alleviate this shortage has been to incentivize primary-care training programs with targeted student loan forgiveness. While commendable, this strategy essentially amounts to more hands bailing water from the sinking Titanic.
If we want to address this workforce shortage, we need to redesign the entire delivery system. (A “delivery system” is the combination of insurance companies, employer groups, providers, and agencies that work together to provide health care.)
We have the best-trained health-care workforce in the world, but many Minnesotans experience a Third World delivery system. They pay for their medical care out-of-pocket or refuse to see a provider because it is unaffordable. The basics for real reform must include aggressive dedication to preventive medicine and patient empowerment, affordable access for patients, team-based coordination, community engagement, and, perhaps most important, more time for provider-patient visits.
A bleak scenario
I want to be a primary-care doctor in Minnesota. My family is here, my wife’s family is here, and we’re excited about a future in Minnesota (despite this legendary winter). But my current career landscape includes a mountain of debt and a future of stress associated with cramming in an endless number of short patient visits to keep up with insurance company regulations.
Currently, primary care resembles a demanding assembly line, underutilizing the training of health-care professionals. This results in dissatisfaction, burnout or resentment toward coworkers and patients. I don’t want to be associated with a field like that. I want to be able to talk to patients for longer than 10 minutes, to work in a team-based environment that prioritizes preventive medicine, to offer my skills to help improve people’s health, and to connect with my community to contribute to a healthy neighborhood and society. Studies have shown that patients of satisfied doctors are more likely to adhere to treatment protocols, while dissatisfied physicians report more difficulty caring for patients.
What’s the cure?
In order to make transformative change, I urge passage of pending legislation to create a Minnesota Legislative Health Care Workforce Commission, and urge its would-be members to study models of care around the country that prioritize comprehensive, team-based medicine that keeps patients truly at the center.
Two examples of successful care models currently operating are the Nuka model for care in Alaska and the CareMore project in California. The hoped-for commission should consider incentivizing pilot projects in Minnesota that emulate these transformative practices.
If you design the delivery system to give providers enough time with patients and incentives to do their job well, more students will choose primary care and the shortage will disappear.
Peter Meyers is a fourth-year MD-MPH student at the University of Minnesota, and is planning to enter primary care.
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