Primary care physician shortage creates challenges for medical homes
■ An additional 6,355 doctors would be needed to handle only half of the follow-up care done by specialists treating seven chronic conditions, a study says.
By Carolyne Krupa — Posted Nov. 29, 2010
Transitioning to a medical home model of care under health system reform calls for primary care physicians to take on much of the routine care provided by specialists.
But a nationwide shortage of primary care physicians makes such a change unfeasible in the near future, according to a new study by the University of Michigan Health System. An additional 6,355 primary care doctors would be needed to handle just half of the routine follow-up care provided by specialists for patients with one of seven chronic conditions.
Researchers came to that conclusion by analyzing 2007 Centers for Disease Control and Prevention data of outpatient visits to U.S. office-based physicians. They found that 29% to 63% of annual ambulatory visits were to specialists, with most made by established patients who could be seen by primary care physician-directed medical homes, according to the study published online Oct. 18 in the journal Medical Care.
"We were surprised by the sheer volume of care that we estimated specialists doing now," said lead study author John Hollingsworth, MD, assistant professor of urology at the University of Michigan Medical School. "These were only seven conditions; they don't even account for all of the care that specialists might provide."
The conditions considered in the study were chronic obstructive pulmonary disease, low back pain, diabetes, coronary artery disease, congestive heart failure, chronic kidney disease and depression.
Adopting the medical home approach would reduce costs, improve efficiency and ensure that patients receive comprehensive health care, said Glen R. Stream, MD, president-elect of the American Academy of Family Physicians. The model emphasizes a shift to more team-based care in which physicians in a medical home handle routine care and collaborate closely with specialists.
"The idea of the medical home is not that all of this care be done through the medical home, but rather that it be coordinated through a primary care physician," Dr. Stream said.
Implementing health reform
Much of the discussion about health system reform has centered on primary care, but the study emphasizes that specialists also will play a key role, Dr. Hollingsworth said. Implementation of the law will require a shift from the current "specialty-focused health care delivery system" to one that relies on collaboration between primary care physicians and specialists, he said.
"We can't forget about the specialists, and how the two might interact," Dr. Hollingsworth said.
Redistributing follow-up care would allow specialists to see patients more quickly and better use their expertise on the rarer and more complex cases, he said.
Patients would receive better care, because they would have a medical home looking out for all their health needs, Dr. Stream said. Under the current system, for example, a nephrologist seeing a female patient with kidney disease is focused on treating her disease and isn't likely to recommend routine care such as a mammogram, he said.
In the medical home, a primary care physician would coordinate that care, he said. But due to physician shortages, more routine care will need to be delegated to nurses, physician assistants and others. "Through use of other staff in the office, you can use the physician more efficiently," Dr. Stream said.
To raise the number of primary care physicians, their pay should be increased, and more residency positions should be created to accommodate a growing number of medical school graduates, he said.
The health reform law includes elements that will help increase the supply, such as student loan forgiveness programs. But more is needed, he said. "We need a significant cultural shift in how we value primary care."