September 18, 2023 ‐ PSQH
By Matt Phillion
Burnout and staffing shortages continue to hit healthcare organizations hard even three years after the start of COVID-19. In a new report from the Larry A. Green Center and Primary Care Collaborative, 80% of respondents felt that the current workforce was too small to serve their patients’ needs.
Specifically, primary care is struggling in this area, as retirements and physicians moving on from the field continue to impact delivery of care. Initiatives like the CMS Make Care Primary program take steps to help drive funding into primary care, but is it enough? What can the industry do to turn the tide and meet patient demand?
“In terms of patient safety, we have to talk about access. The fewer healthcare providers we have, the less access our communities have to healthcare services, and that puts them at risk,” says Chris Dodd, MD, chief medical officer with Emcara Health. “If you don’t have enough of the right type of providers delivering care, they’re not getting the preventive care they need to avoid more serious problems downstream.”
We can’t discuss burnout, specifically for primary care physicians, without discussing the predominant payment model of fee for service, Dodd says.
“In a fee-for-service environment, physicians are paid to do more, and increasingly feel the churn of being asked to do more with less. I recently heard a story told by a pediatric pulmonologist who was asked to do more bronchoscopies, just because of reimbursement,” says Dodd. “It should be up to the doctor to determine when the patient needs one. But as long as the reimbursement model continues to incentive the wrong behaviors, you’re putting patient safety at risk.”
Dodd believes that a big part of the root cause of patients not achieving the outcomes they should is in part due to lack of investment in primary care.
“We still only spend $4 to $6 on primary care for every $100 in healthcare,” says Dodd. “This underinvestment, along with a maligned payment model doesn’t allow primary care providers the time they need to build trusting relationships and be the true quarterback of the healthcare journey that keeps patients healthy, home, and out of the hospital.”
The greater the shortage of primary care physicians, Dodd notes, the greater the disadvantage the industry puts itself at.
But how do we get people on board with changing the system?
“Though few in number, there are value-based primary care groups delivering better outcomes. We need to continue to highlight the success that these organizations are achieving through the right payment models, and a focus on delivering more primary care, not less,” says Dodd.
With CVS and Amazon getting into the game, the market itself is changing, Dodd notes.
“We’re seeing these titans within the healthcare delivery system now increasingly recognizing the impact of value-based primary care medical groups,” he says. “Those are encouraging signs, but at the same time, it doesn’t address widescale burnout and increasing shortages of providers.”
The system in many ways is stacked against someone who wants to go into primary care.
“We’re not producing enough primary care physicians. We’re not making it a career physicians want to train in. We don’t renumerate it as such,” says Dodd. “People who graduate in the top 20% of their medical school class are going to have a salary that is at best 50% of their peers in other medical specialties, such as dermatology. We disincentivize students from choosing a career in primary care.”
The numbers don’t add up in a way that encourages retention.
“People are graduating with hundreds of thousands of dollars of debt. You have to be incredibly motivated and passionate about primary care and the impact it makes to be willing to take a fifty percent pay cut and put yourself and your family at a disadvantage,” says Dodd.
The number of people training for primary care, whether as MDs or DOs, is not keeping up with population growth. They are also retiring earlier, Dodd points out, so with an aging primary care workforce and a lack of incoming fresh faces, it’s creating a nationwide challenge.
“The macro pieces are: do we have enough training spots in schools, which we don’t. Are we incentivizing people to choose primary care? Are we setting renumeration targets and expectations that are high enough?” says Dodd.
Returning to the payment model and burnout, under value-based care, providers are paid by the number of people they are responsible for, not how many visits they book.
“Those providers see fewer patients so they have the ability to deliver better quality care for those that need it most, which means they are able to realize more joy in their work,” says Dodd.
Those disincentives are not just monetary from an individual physician perspective, Dodd notes, but also come in the form of working in a system that doesn’t provide the kind of support a physician requires to manage their population. With more adequate funding, primary care groups have the ability to invest in systems that allow them to better manage their panel and caseload—another way to avert burnout, Dodd says.
They also support the ability to deliver team-based primary care.
“It’s not just about the physician,” Dodd says. “It’s about all those other roles—the physician’s assistant, the nurse practitioner, support from nurses, pharmacists, behavioral health professionals, and community health workers.”
Working in a team helps primary care physicians practice at the top of their license, which can help with retention and burnout.
“For example, my training as a primary care physician prepared me to care of the most complex patients, and that’s where my team and the system need me focused,” says Dodd.
But it’s easy to draw a direct line between the economics of how a primary care physician is reimbursed and if a team is even possible, he notes.
“If you don’t have the right payment model in place you don’t have the revenue to hire a team,” he says. “But if you do, it allows you as the physician to say this is how I want to spend this money so I can practice at the top of my license, and together as a team we can maximize the health outcomes of our population.”
Alternatively, the industry could simply pay primary care more to enable them to build and hire teams, but the payment upfront offers the ability to uses your own insights to best care for the patient population you serve provides the straightest approach.
The team approach allows patients in need of an annual wellness visit to see another team member, opening up time for the physician to treat the sickest patients, those with troubling symptoms or existing chronic conditions.
“If there’s a patient recently hospitalized who is living with multiple chronic conditions, including high blood pressure, depression, and uncontrolled diabetes, who is on 12 medications, those are the patients a physician should be involved with,” says Dodd. “Our most expensive resource in the delivery system is the physician, so we should have them seeing the most complex patients.”
The team-based care model not only has the right economics and enables physicians to practice at the top of their license—it encourages all those things that help keep patients healthier, from a trusting relationship with their physician and having a complete team to meet their needs.
Matt Phillion is a freelance writer covering healthcare, cybersecurity, and more. He can be reached at firstname.lastname@example.org.