In a recent PHS 795 lecture, UW Health ACO chief Dr. Jonathan Jaffery discussed the importance of ensuring that health care providers are spending their time “practicing at the top of their license.” A PHS student notes that availability of supervisory physicians is serving as a barrier to nurse practitioners in “filling the primary care gap.” They write:
This article discusses the ongoing demand for primary care physicians. Despite efforts in the past few years to increase the number of primary care physicians, and the demand is increasing as more Americans get health coverage through the ACA. They used match data to track the number of new primary care physicians and nurse practitioner graduation rates. The number of nurse practitioners (NPs) has greatly increased but the number of primary care physicians isn’t keeping up with the number of new NPs, and since there are many regulations around the type of work and amount of supervision needed for NPs, it inhibits NPs from filling the primary care gap. There are still 10 states that limit the number of NPs physicians can supervise, which means that some states cannot make use of all of the available NPs because there aren’t enough primary care physicians to oversee the NPs. The article mentions that in order to meet the goals of the “Triple Aim” health care system approach, we need to make it possible for all providers to provide the maximum care that their licenses permit.
The changes implemented by the ACA (both insurance and delivery reform) cannot be fully realized unless we can change the policies and regulations limiting the roles of health care providers and improve incentives to work as primary care providers. In Jaffery’s class lecture, he spoke about how the aspect of health care that needs the most improvement is routine and preventative care. We need more primary care physicians and NPs to not only catch up to the increasing demand for primary care services, but also to improve primary care and make primary care more accessible.
Primary Care Workforce: The Need To Remove Barriers For Nurse Practitioners And Physicians healthaffairs.org
Primary Care Workforce: The Need To Remove Barriers For Nurse Practitioners And Physicians | At the intersection of health, health care, and policy.
The Fantasy Equation 
This article brought two points to mind for me that I’d like to know more about. First, I found this description of the PCP shortage (from http://bhpr.hrsa.gov/healthworkforce/supplydemand/usworkforce/primarycare/) to be surprising: “Aging and population growth are projected to account for 81 percent of the change in demand between 2010 and 2020.” That’s a large percentage representing what seems a unique historical moment in U.S. population and care provision. I also wonder how much of the shortage is due to negative aspects of the PCP role discouraging students, compared to the NP/PA options. Can the work being done to make the role of the primary care provider more attractive, and integrate PAs and NPs effectively, possibly happen quickly enough to meet the needs for care, given population demographics?
Second, the article mentions that “eight years ago, there was a national required change in the adult NP (the NP role that is congruent with primary care internal medicine in terms of age and focus) preparation requirements to include considerable educational emphasis on the older adult, given the U.S. demographics”. I know when I considered occupational therapy, I shadowed providers who worked with older adults and wondered about students’ population preferences. There is a surprising (to me, at least) amount of research available on how students feel about working with older populations and how curriculums can be designed to attract them to gerontology. This paper, The Influence of Ageism, Experience, and Relationships with Older Adults on Physical Therapy Students’ Perception of Geriatrics (http://www.tandfonline.com/doi/abs/10.1080/02701960.2015.1079709) is a qualitative study that asked pertinent questions on the topic.
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I think this gap, unfortunately, comes down to lack of reimbursement for primary care physicians. In one of our discussions, possibly in another class, a classmate cavalierly said, why would you choose to be a family physician when, instead, you could be a neurosurgeon and make a million dollars a year. Medical students have the same training up to the point of applying to residency, and besides possible test scores and grades, they are, in essence, equally as well-qualified to practice either specialty. As terrible as it is, whoever made that comment in class, shares a similar attitude to many medical students. There is a lack of respect for primary care physicians in this country and a severe lack of reimbursement. I myself am a family medicine resident. Family medicine was my first choice for residency and I chose it because I love the patient relationships that form, the continuity and the breadth of practice. I didn’t chose it for the money. I have nearly $200,000 in medical student loans waiting for repayment and I can expect a salary of $250,000 annually when I graduate from residency. This will be more than enough to live comfortably on and make an impact in my community, but it is far from comparable to my specialist peers. A classmate from medical school pursued orthopedic surgery and he just signed a contract to make 1 million dollars per year (this is true). That will be 4 times as much as I will be making. With increasing student loan debt following the rising cost of medical school tuition and the salary gap widening between primary care and specialists, I think enticement toward primary care will be difficult. Until the salary gap narrows and/or loan reimbursement for primary care is automatic, I think the enticement to primary care will continue to wane.
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In response to this article, and particularly to the previous comment made- this is very much true across the board- for any profession related to serving the growing middle and low income populations. Across the U.S., tuition costs are increasing while salaries for primary care physicians, as well as social workers and social service providers remain stagnant. The balance between student debt and financial security/stability is a major concern for our generation (and most likely will be for generations to come) unless there is serious reform to how we invest in well rounded social services/medical care.
During our lecture concerning “measuring and incentivizing quality care”, we discussed many issues around the fees-for-service approach currently in use. With our current system, many of the ways for health care providers to close their own gap between debt and financial security is to find ways of increasing their own personal financial gains, which will continue to be a detriment to patient care as quantity (or specialty) overshadows quality. If the gap continues to grow between the demand for primary care and how the U.S. views and supports primary care and social service providers, this issue will only grow in severity.
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In response to: Balancing nurse practitioners and physicians to improve primary care access
This article brought two points to mind for me that I’d like to know more about. First, I found this description of the PCP shortage (from http://bhpr.hrsa.gov/healthworkforce/supplydemand/usworkforce/primarycare/) to be surprising: “Aging and population growth are projected to account for 81 percent of the change in demand between 2010 and 2020.” That’s a large percentage representing what seems a unique historical moment in U.S. population and care provision. I also wonder how much of the shortage is due to negative aspects of the PCP role discouraging students, compared to the NP/PA options. Can the work being done to make the role of the primary care provider more attractive, and integrate PAs and NPs effectively, possibly happen quickly enough to meet the needs for care, given population demographics?
Second, the article mentions that “eight years ago, there was a national required change in the adult NP (the NP role that is congruent with primary care internal medicine in terms of age and focus) preparation requirements to include considerable educational emphasis on the older adult, given the U.S. demographics”. I know when I considered occupational therapy, I shadowed providers who worked with older adults and wondered about students’ population preferences. There is a surprising (to me, at least) amount of research available on how students feel about working with older populations and how curriculums can be designed to attract them to gerontology. This paper, The Influence of Ageism, Experience, and Relationships with Older Adults on Physical Therapy Students’ Perception of Geriatrics (http://www.tandfonline.com/doi/abs/10.1080/02701960.2015.1079709) is a qualitative study that asked pertinent questions on the topic.
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