Comparative Models of Healthcare Delivery in the Midst of an Expected Physician Shortage

Posted by | December 02, 2013 | No Comments

The Affordable Care Act of 2011 has changed the conventional model of healthcare delivery and payments in an effort to meet the “triple aim” of the IHI goals: Improve the general health of the defined population, enhance the patient care experience, and reduce the per-capita cost of care. Although the ACA will greatly increase patient care, physician access is still expected to be an issue due to increases in the newly insured and aging populations. The most widely accepted study on the issue was released by the Association of American Medical Colleges and projected a shortage of 124,000 full-time equivalent (FTE) physicians by 2020, with over 37% of that shortage being attributed to the primary care sector. (4)  Many studies have begun to look towards different models of healthcare delivery that will offset these expected shortages.

The State of Massachusetts pioneered mandated health insurance in 2006 and is considered to be the benchmark by which the federal reform program was designed. Dr. Mario Motta, the President of the Massachusetts Medical Society, declared the program to be flawed because, although the state has the second highest ratio of primary care physicians to patients, significant deficits in physician access still exist. This prompted Dr. Motta to coin the phrase “universal coverage does not equal universal access.”  (1) Additionally, although most models have consistently focused on primary care shortages, there are also expected to be shortages in those specialties focused on elderly services and geriatrics as the population aged 65 or older is projected to increase by 60% from 2010 to 2025; and (2) To compound the problem, one-third of US physicians are expected to retire over the next decade, fewer students are entering medical school, and many that choose medicine do not go on to complete their residencies due to federally mandated caps on the number of available graduate medical education (GME) slots. (2,3)

A small percentage of health policy researchers argue against the forecasted physician shortage, believing it to be a gross overestimation based on outdated healthcare delivery models. They point out two major changes in practice models which they trust will offset any deficit: Physician pooling and utilization of non-physician practitioners, such a NPs and PAs. (5) The trend of physician pooling is already very evident in the current healthcare landscape. Many practices have realized that by effectively “pooling” their resources, by consolidating individual practices, that they may be able to equalize patient care and physician access.  The team-based care model allows the practice physicians to free up time spent on administrative tasks by delegating clerical work, enhancing protocols, and providing standing orders. (4)  There is also evidence that this type of model makes for happier physicians; by allowing them to streamline visits and reduce long hours, physicians are less likely to experience burn-out, which increases retention in the workforce.  (4)  However, there are additional factors which must be considered in the team-based approach, such as chronic care, disease management, and specialist access which may require a reduced patient-to-provider ratio.  Additionally, there are concerns about how physician pooling affects the physician-patient relationship over time, which may have an impact on liability within the practice.

Another delivery model that is receiving much attention from the healthcare community proposes combating the physician shortage by increasing the supply and scope of mid-level providers in physician practices. This model is especially effective in the team-based care approach. By utilizing mid-levels for routine care, the physician can increase his/her access to more patients. Multiple studies have shown that the quality of care provided by PAs and NPs is at least equal to that of the physician and that there is a high level of patient satisfaction with the care provided by physician extenders. There are three primary ways in which mid-level providers are incorporated into primary care practices: utilization for acute care only, utilization for acute care and chronic care, or, depending on the state, utilization as a fully paneled provider within the practice.  (4) Of course, the offset provided by the increased use of non-physician practitioners is based upon NPs and PAs choosing to specialize in primary care which, at the present time, only a little over half do. Additionally, there are state-specific, scope-of-practice laws in place that can limit the activities of physician extenders, although many states are currently reviewing the laws and are planning expansions. (6)

Another consideration in the argument against the expected physician shortage is regarding the use of technology in the practice. Innovations in the way patients can receive care has changed the way care can and will be delivered in the future.  The mandate requiring use of electronic health records (EHR) will increase the access of health records to physicians which, in turn, will streamline diagnostics, testing, treatment, and follow-up. Also, physicians are taking advantage of IT tools, such as video conferencing (e.g., Skype), secure messaging, email, and phone “visits,” electronic monitoring of patients from home, as well as the creation of use of “virtual clinics” in high-density population areas. (1) Initial studies have found that the use of technology does increase physician access and patient outcomes while reducing the use of emergency services. Although the use of technology seems promising, there are also studies that point out an increase in office visits when patients utilize many of these electronic portals. Also, there are obvious concerns regarding the privacy and security of information, especially when it is shared between multiple practices or IT vendors.  (4)

New medical residents can also expect to hear one word again and again–incentives.  In an effort to recruit certain specialties, including primary care, some practices are “hiring” physicians right after graduation and before they complete their residency requirement in an effort to lock-in the physician’s employment contractually. These incentives go beyond the traditional “sign-on” bonus and include such lucrative monetary benefits as high-dollar stipends, loan forgiveness, relocation expenses, continuing medical education, and increased compensation once employed. (7) Of course, this incentive-based recruiting means that shortage-plagued specialties, such as urology, oncology and critical care, may be forced to spend more money up front in effort to fill slots for the future.  The recruiting measures are also leading surgical residents to the specialty-niche, which is up 30% from five years ago.  This has caused a disruption in the general surgery marketplace, creating a bidding war for generalists. (2)

There does appear to be increasing evidence to support the issue of a physician shortage over the next 10-15 years, especially for primary care, due to the aging baby-boomer population and the ACA-mandated newly-insured. Healthcare policy research and physician practices are developing novel and creative measures to contradict the shortages by increasing physician access in many different ways, including those discussed in this article. There are caveats to each approach, which must be carefully considered prior to implementing change. It is critical that a physician or practice consult with professionals, such as their professional liability agent, attorney, and government officials, before making changes in the way they provide care. If you have questions about how any of the above-discussed models will affect your practice, please contact our office at 800-457-7790 and speak with one of our highly trained agents or complete the quote form available here.

  1. Petterson, Scott M., Ph.D., Law, Winston R., M.D., Phillips, Robert L., M.D., Rabin, David L., M.D., Meyers, David S., M.D., Bazemore, Andrew W., M.D.  Projecting US Primary Care Physician Workforce Needs:  2010-2025.  Annals of Family Medicine.  Volume 10, Number 6; November/December 2012.
  2. Fromson, John M., M.D.  Physician Shortages in the Specialties Taking a Toll.  The New England Journal of Medicine – Career Center Online.  March 2011.
  3. Lasher-Todd, Heather.  AMA Urges Congress:  Retain Funding for Residency Programs, Increase Training Positions to Address Doctor Shortage.  American Medical Association Press Release.  February 4, 2013.
  4. Erikson, Clese E.  Will New Care Delivery Solve the Primary Care Physician Shortage?:  A call for more rigorous evaluation.  Center for Workface Studies, Association of American Medical Colleges.  August 2013.
  5. Kliff, Sarah.  Doctor Shortage?  What Doctor Shortage?  The Washington Post.  January 15, 2013.
  6. Berra, Amanda.  Three Main Options for Incorporating Mid-Level Providers into Primary Care Practices.  The Blueprint.  March  2011.
  7. Physician Shortage May Mean Higher Pay for New Doctors.  American Medical Association Press Release.  May 2013.
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