Access to good primary care is the cornerstone of high performing health systems. Good primary care leads to better health outcomes and that leads to less cost since we catch problems before they get out of hand.
"With more people covered, access is certainly going to be a problem,"
(This is opposed to what we do now - we hamstring primary care with inadequate funding to do the work & crush the primary care workforce with paperwork and wonder why we're unable to spend the time people need to do our work really well. This results in missed opportunities and very high cost catch-up care in 'centers of excellence' for heart disease, cancer and the like. Hey, why be satisfied with $50 to find and fix a small problem when you can milk the system for $50,000 through your center for excellence?)
So what are we going to do with a shortage of good primary care? First we need to reflect on root cause. From a study of medical student career choice* we see that medical students avoid primary care because it is an unattractive career: doctors on hamster wheels bearing the brunt of administrative trivia while being denied the time and tools they need to do their work well.
The solution to the root cause is then relatively obvious:
- make primary care an attractive career choice by empowering them to get off the hamster wheel
- provide the funding and tools they need to do their work well
- eliminate the administrative trivia that has nothing to do with good patient care
There are very few environments that provide the full support for excellent primary care. Group Health Cooperative, maybe Geisinger, some Kaiser practices, and a smattering of 'other.' If you're Mississippi or Massachusetts (and soon the rest of the U.S.) you might therefore conclude that you need to bring Group Health or Kaiser to town, but then you may not be attracted to Big Box Medicine or it might not fit your rural environment, and what about all the solo and small practices that already exist in your region - you going to Walmart them out of existence? I hope not.
Solo and small practices make up almost two thirds (depending on the survey) of the practices in the U.S. Because we've demonstrated that solo and small practices can indeed deliver very high quality care that improves outcomes and lowers costs there is no reason to crush them with a big box.
If you're Mississippi or Massachusetts or any other state you can make moves to support your local practices by providing adequate funding for the work, by eliminating the insane burden of paperwork that has nothing to do with good care or outcomes.
It's time to stop doing what we've always been doing and it's time to start following the evidence as we contemplate the PCP shortage.
*Hauer KE, Durning SJ, Kernan WN; et al. Factors associated with medical students' career choices regarding internal medicine. JAMA. 2008;300(10):1154-1164.