Will the doctor see you now? Healthcare systems changing the landscape

From Julie ApplebyANDMichael Andrews

Lucia Agajanian, a 25-year-old freelance film producer in Chicago, doesn’t have a specific primary care doctor, preferring the convenience of visiting a local clinic for flu shots or going online for video visits. You say what you need and there’s a 15-minute wait time, she said, explaining how her appointments usually work. Loved it.

But Olga Lucia Torres, a 52-year-old who teaches narrative medicine at Columbia University in New York, misses her longtime primary care physician, who has kept a close eye on her conditions, including lupus and rheumatoid arthritis, and made sure she was up to date on vaccines and screening tests. Two years ago, Torres received a letter informing her that she was moving into a boutique practice and charged a $10,000 down payment to stay on as a patient.

I felt really sad and abandoned, Torres said. This was my PCP. I was like, Dude, I thought we were together!

The two women reflect an ongoing reality: The primary care landscape is changing in ways that could affect patient access and quality of care now and for decades to come. A strong and lasting relationship with a primary care physician who knows a patient’s history and can monitor for new problems has long been considered the foundation of a quality healthcare system. But investment in primary care in the US is lower than in other high-income countries, and America has a lower share of primary care physicians than most of its European counterparts.

According to the Robert Graham Center, a research and analysis organization that studies primary care, approximately one-third of all physicians in the United States are primary care physicians which include family medicine physicians, general internists, and pediatricians. Other researchers say the numbers are lower, with the Peterson-KFF Health System Tracker reporting that just 12% of US physicians are generalists, compared to 23% in Germany and up to 45% in the Netherlands.

This means that it is often difficult to find a doctor and make an appointment that is not weeks or months away.

This is a simmering issue that is now beginning to erupt in some simmering communities. That front door to the healthcare system is hard to find, said Ann Greiner, president and CEO of the Primary Care Collaborative, a nonprofit organization.

Today, a lower percentage of physicians are entering the field than are practicing, suggesting that shortages will worsen over time.

Interest has declined in part because, in the United States, primary care produces lower salaries than other medical and surgical specialties.

Some doctors now in practice also say they are exhausted, facing cumbersome electronic health record systems and limitations on appointment times, making it more difficult to get to know a patient and establish a relationship.

Others are retiring or selling their practices. Hospitals, insurers like Aetna-CVS Health, and other corporate entities like Amazon are in a buyout rush, buying up primary care practices, driving a move away from MD-style neighborhood doctor Marcus Welby. About 48% of primary care physicians currently work in practices they don’t own. Two-thirds of those doctors don’t work for other doctors but are employed by private equity investors or other corporate entities, according to data from the Primary Care Chartbook, which is compiled and published by the Graham Center.

Patients who come to these offices may not see the same doctor at every visit. In fact, they may not be seen by a doctor at all but by a paraprofessional, nurse or medical assistant, for example one who works under a doctor’s license. That trend has been accelerated by new state laws and Medicare policy changes that ease requirements for medical supervisors and billing. And these jobs are predicted to be among the fastest growing decades in healthcare.

Overall, demand for primary care is surging, spurred in part by record enrollment in Affordable Care Act plans. All of these new patients, combined with the low supply of physicians, are contributing to a long-lasting downward trend. years in the number of people who report having a usual source of care, whether it is an individual doctor or a specific clinic or practice.

The researchers say this raises questions, including whether people can’t find a GP, can’t afford one, or simply don’t want an established relationship anymore.

Is it poor access or problems with supplier supply? Does it reflect a social disconnect, a solo phenomenon? asked Christopher Koller, president of the Milbank Memorial Fund, a foundation whose unbiased analyzes focus on state health care policy.

For patients, frustrating wait times are a result. A recent survey by a medical staffing firm found that it now takes an average of 21 days just to walk in to see a family medicine physician, defined as a subset of primary care, which includes general internists and pediatricians. Those doctors are many first stop patients for health care. This contrasts with the trend in other countries, where patients complain of months or years of waits for elective procedures such as hip replacements, but generally experience short waits for primary care visits.

Another complication: All of these factors add urgency to continuing concerns about attracting new primary care physicians to the specialty.

When she was in medical school, Natalie A. Cameron said, she specifically chose primary care because she enjoyed building relationships with patients and because I’m particularly interested in prevention and women’s health, and you do a lot in primary care . The 33-year-old is currently an instructor of medicine at Northwestern University, where she also sees patients in a primary care practice.

However, he understands why many of his colleagues have chosen something else. For some, it’s the wage gap. For others, it’s because of primary care’s reputation for involving a lot of care and paperwork and coordinating a lot of issues that may not be just medical, Cameron said.

The million dollar question, then, is how much does having a usual source of care affect medical outcomes and cost? And for what types of patients is it important to have a close relationship with a doctor? While studies show that many young people enjoy the convenience of visiting urgent care, especially when it takes so long to see a primary care physician, will their long-term health suffer because of that strategy?

Many patients, especially young and generally healthy ones, shrug off the new normal, embracing alternatives that require less waiting. These options are especially appealing to millennials, who tell focus groups that the convenience of a one-time video call or department store clinic visit trumps a long-standing relationship with a doctor, especially if they have to wait days, weeks , or longer for a traditional date.

The doctor I have is a friend of the family, but I would definitely accept and ease a relationship, said Matt Degn, 24, who says it can take two to three months to book a routine appointment in Salt Lake City, where he lives. .

Patients are increasingly turning to what are dubbed retail clinics, such as CVS Minute Clinics, which offer in-person and virtual care 7 days a week. CVS Health’s more than 1,000 in-store clinics in the United States treated more than 5 million people last year, Creagh Milford, a physician and the company’s senior vice president for retail health, said in a written statement. . She cited a recent study by a data products company that shows use of retail clinics has grown 200% over the past five years.

Health policy experts say greater access to alternatives can be good, but forgoing an ongoing relationship with a regular provider is not, especially as people get older and are more likely to develop chronic conditions or other medical problems.

There’s a lot of data showing that communities with lots of primary care have better health, Koller said.

People with a regular primary care physician or practice are more likely to receive preventative care, such as cancer screenings or flu shots, studies show, and are less likely to die if they suffer a heart attack.

Doctors who see patients regularly are better able to spot patterns of seemingly minor concerns that could add up to a serious health problem.

What happens when you go to four different providers across four platforms for UTIs because, well, they’re just UTIs, posed Yalda Jabbarpour, a family physician practicing in Washington, DC, and director of the Robert Graham Center for Policy Studies. But in reality, you have a large kidney stone causing your UTI or you have some sort of immune deficiency like diabetes causing frequent UTIs. But no one tested you.

Most experts agree that figuring out how to coordinate care in this changing landscape and make it more accessible without compromising quality even when disparate physicians, locations, health systems and electronic health records are involved will be as complex as the pressures cause long waits and less interest in today’s primary care market.

And experiences sometimes lead patients to change their minds.

There’s something to be said for establishing a relationship, Agajanian said, in Chicago. He is rethinking his decision to pool care, rather than having a specific primary care doctor or clinic, following a work-related injury last year which led to shoulder surgery.

As I’m getting older, even though I’m still young, she said, I have all these issues with my body and it would be nice to have a consistent person who knows all of my issues to talk to.

KFF Health News Colleen DeGuzman contributed to this report.

KFF Health News is a national newsroom that produces in-depth journalism on health issues and is a major operating program of KFF, an independent source of research, survey and health policy journalism. Find out more about KFF.

Sign up for KFF Health News’ free morning briefing.

Previously posted on kffhealthnews.org

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