Access to Primary Care

by Danielle Ofri
KevinMD

“Doctor, it’s taken so long to get this appointment with you!” This is the opening line of so many medical visits, and I find myself constantly apologizing to my patients on behalf of our system. After the pandemic-induced lull in routine medical care, we’re right back where we started—doctors booked for months, patients struggling to get appointments.

The difficulty with access to medical care is endemic to our entire medical system. Even before the pandemic, less than a fifth of American doctors were able to take new patients, and more than 80% were at capacity or over-extended. Some 16,000 medical practices closed down because of the pandemic. This is especially concerning in primary care, which is on track for a shortage of up to 48,000 physicians. It’s not surprising that lack of access to primary care doctors is associated with higher mortality.

Luckily, it seems that Americans are slowly coming around to the ethical conclusion that the rest of the world has already made, that health care is something that all people deserve. While the slogan “Medicare for All” remains polarizing, the sentiment behind it holds traction, with almost 70% of American voters supporting a public option in the health insurance market. If nothing else, the Covid pandemic has been a visceral reminder that health is a community good, no matter how much of a free market dressing we try to apply.

 Creating the tens of thousands of additional doctors (not to mention even more nurses) needed to meet our healthcare needs will be a painstaking process. New medical schools and accelerated programs are helping, but it still takes about a decade to crank out a trained physician.

However, a much richer resource exists right at our fingertips. A Physicians Foundation survey reported that doctors spend, on average, 23% of their time doing non-clinical paperwork. Another study found that doctors devote 49% of their time to desk-work and the electronic medical record, twice as much as they spend with actual patients. If you visualize these statistics carved out from the total number of doctors in U.S—estimated to be about one million—it’s equivalent to several hundred thousand doctors whose stethoscopes are sitting idle.

To not be able to get an appointment with your doctor because she is spending up to half of each day on administrative work would sound ludicrous if it weren’t so dangerous. But patients and their serious medical conditions are getting short shrift as their doctors and nurses drown in metastasizing paperwork.

Freeing up clinicians’ time to see patients could make a real difference in the access problem. Amputating off even half the administrative work could produce the equivalent of 100,000 new doctors available for patients.

The other part of solving the access problem is realigning our medical resources in a way that makes clinical sense. Other countries have access issues also, but their long waiting lists relate mostly to specialties and procedures. What is uniquely American about our access problem is that it is particularly difficult to obtain primary care.  It is this inability to provide basic medical care that torpedoes the net efficacy of our medical system. Despite our superior technological advancements, we rank at the bottom for health outcomes compared to every other high-income country.

It is no secret about how to remedy this. The Commonwealth Fund identifies investing in primary care as one of the four pillars that distinguish the top-performing countries, along with universal coverage, reduced administrative burdens, and stronger social services.

When medical schools race to offer free tuition, we could prioritize such largesse for students committed to training in family medicine, internal medicine, geriatrics, gynecology, and pediatrics.  The same strategy should be applied to all the team members needed to deliver effective primary care— nurse practitioners, physician assistants, clinical pharmacists, nutritionists, nurse educators, and care coordinators.

It’s true that there are also shortfalls in some medical specialties, but having sufficient numbers of primary care clinicians—and giving them sufficient time with their patients—will reduce the need for specialty care. Much of the current state of excessive testing and unnecessary referrals is a result of primary care clinicians too overwhelmed to fully address patients’ medical needs.

Alongside increasing the pipeline of primary care clinicians, we in healthcare have to take a stand against our system that assigns more value to procedures like cataract surgery and knee arthroscopy over cognitive services and preventative care like treating diabetes and screening for cancer. This profit-driven valuation leaves us with more procedures and higher bills but poorer health outcomes. Blatant salary discrimination continually pulls medical students with their piles of debt toward the higher paid specialties, further decreasing access to basic medical care.

Newer payment systems—bundled payments, pay-for-performance, accountable care—have the potential to jigger the balance somewhat. But our fundamental hierarchy remains completely backwards. Until we reverse this and make primary care, well, primary, getting an appointment with your general doctor in the United States will be the Achille’s heel of medicine.

Unless, of course, that heel needs a botox injection for its wrinkles. That you can get done in an instant.