What are the root causes of the primary care shortage

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Kevin Pho (aka KevinMD) exposes the irrational thinking behind blanket expansion of residency or medical school slots as a solution to the primary care shortage.

The root causes have been described in studies and are blatant in the every day lives of those working in primary care practices:

Primary care has been thrust into the untenable position of delivering care below an ethical standard. Their employers - whatever their intent or motivation - have created an environment in which it is not possible to deliver the kind of care our patients need.

Without the time to build trusting relationships, lacking the resources to engage in the full scope of services our patients need, without the funding to do even the most rudimentary care coordination we have been forced to abdicate the very core of our work.

We have been eviscerated by the exigencies of the marketplace. A hobbled specialty unable to live up to reasonable standards of professionalism or ethics is not a magnet for eager medical students.

PCPs are exploring any means possible to exit this toxic environment. Right now some consumers are willing and able to pay for the full scope of exemplary primary care.  Practices that have figured out how to work in this space are creating micro environments that support excellence.  In those environments primary care is a vital and exciting career choice exploring the full potential of our specialty.

The current slate of intermediaries between purchasers and exemplary care appear to be invested in maintaining the status quo.  I'm no longer willing to wait for them to come around and I'm not going to play the game of "let's study this forever and do nothing substantive."

Employers can expand access to exemplary primary care if they partner with it in their local markets. There are good markers for exemplary practices that may be use to hold them accountable (and by the way, the NCQA's PPC-PCMH ain't it by a long shot).  This will be the next step in front line innovation that needn't wait for Congressional blessing or insurers to wake up to a new reality.

Comments

[L Gordon Moore]

It is great to hear about primary care figuring out how to make it work in circumstances written off by other, kudos to you and your team! This is the kind of innovation we need - front line folks figuring out how to make things work for their patients. Now the work is spreading this knowledge and gaining support and funding for others to do the same.
Gordon

[Onlinenursing]

Good and thoughtful post. I would play rebuttal and say that health care does not have to cost what we are charging the patients. I work in a rural independent NP owned clinic (where the health systems surrounding us refused to send an MD or DO because they couldn't 'make enough money'). Productive clinic, 6 employees (includes 2 nurses and 2 NPs). Our cost for a CBC to the pt. who pays cash (sent out to lab so lab making money, with personnel, and we are too) is $14. Same CBC at local health system = 75$. CMP, PAP screenings, level 3 or 4 office visits... all the same. People can pay out of pocket cheaper to see us, and get about 30 minutes with the practitioner as driving to local health system and paying co-pay. So, what gives with the big health systems. Where is the money going?
(note - we turn no one away... turn no one over to collections... yes we have those who don't pay. We have 30% no insurance, 40% medicaid, the rest medicare and insurance.)I think something somewhere is wrong in the numbers for what health systems charge and demand of their health care providers. Just my rudimentary 2 cents worth. Keep up the great blog work!