The shrinking number of primary care physicians is reaching a tipping point
washingtonpost.com
washingtonpost.com
Take a search space of all doctors within 50 mile radius. Now start applying filters: Must be "in network" with my insurance (-A%), must be of specialty "primary care physician" (-B%), must be accepting new patients (-C%), actually picks up the phone when called or returns your call (-D%). A%xB%xC%xD% leaves me with about 3 candidate doctors.
New patient appointments are out 3 months for Doctor X, 5 months for Doctor Y and 9 months for Doctor Z.
Doctor X
So I set up an appointment for Doctor X. 3 months later, the front desk receptionist calls and informs me that Doctor X is unavailable on the day of my appointment, so I need to make a new appointment--a wait of another 2 months. So I make that appointment. 2 months later, front desk receptionist calls and says Doctor X is retiring and no longer taking patients.
Doctor Y
Next I set up an appointment for Doctor Y. 4 months later, I get a call from Doctor Y who informs me he is also no longer taking new patients.
Doctor Z
Finally, I now have an appointment with Doctor Z for some time in 2024. Fingers crossed...
It seems a better strategy would have been to just set up appointments with all of them in parallel and just go with the first one to actually want to take my money.
When people try to argue against socialized medicine they like to point out how the American system doesn't have wait times, and systems like Canada and U.K. make you wait many months for a doctor. Obviously they haven't tried finding a USA doctor recently.
It is annoying to book an annual physical, and to establish a long term PCP relationship. It takes forever to book my PCP; months. But I've learned simply never to go to my PCP directly for stuff.
My system thankfully has great access to PCPs, so I virtually never make a nonemergency referral; coordinating this care is the role of the PCP and entirely outside of my scope of expertise and training. Urgent care seems like a poor replacement for having fair access to a PCP, but maybe that's just like, my opinion, man.
Wait till you find out why America has a shrinking number of primary care physicians.
There are many other failures as well. For example, most programs requiring a bachelor degree to start. This artificially raises the cost. There are a few programs now that intake high-school graduates and add a year or so to cover the basic courses that they need, such as anatomy and physiology, but effectively cut off about 3 years of higher education.
I am curious what the post above was alluding to.
In Australia, in a semi-socialised system I can usually get an appointment the same week, and often the same day it needed. On the other hand I needed to wait 4 months for a specialist.
So yeah, the relation between those things is not that simple.
The advantage for him is that he never deals with insurance companies again. The disadvantage for me is that, since I have few health issues, and they're minor when I do, it would cost a lot more per year.
One of the older models for a physician went like this:
- you opened a practice
- you charged a "subscription" to be a part of your practice
- people could come as much as they wanted
What's crazy to me is that MORE doctors don't do this since I'm 100% sure there is a demand for a service like this.
Insurance companies, along with declining pay and the gobbling up of private practice by giant medical corporations who treat doctors like low level employees are driving GPs away, and into specializations.
If the government wants to stem this shit tide they need to tell insurance companies to get fucked, limit the intrusion of corporate bean counters, and give incentives like the cancellation of school debt to folks who go into GP. No number of highly paid specialists will ever replace GPs
No wonder my medical costs are so high. Every high premium and medical bill is my turn to personally support 20% of the nation. I wonder how much is left over for the doctor?
This will be difficult to solve because "make the system simpler and fire lots of people" is painful and not politically popular.
[0] https://www.census.gov/library/stories/2020/10/health-care-s...
One interesting question is: why is one hospital's rate for procedure X different than another? how can providers work at different hospitals? The answer lies somewhere in the "it's a maze of subcontractor relationships", "it's a maze of one off insurance contracts"...
It's a very good example of why vertical integration beats subcontracting. :)
Licensing serves no purpose if you're not going to take it away in cases of incompetence and malice. This has turned me into a fan of malpractice suits with large punitive damages.
Finding a doctor is easy. Finding a good doctor that will try to figure things out when things go very wrong is very challenging and frustrating.
The monopolies formed for these health networks are bad for everyone. The staff are miserable, patients don’t heal, and half the time the companies are losing money. My primary care was bought by a hospital network, which was bought by some multi-state network that is under financial stress yet just boight another regional network to ruin.
One BIG reason that my wife and I remain working in a U.S. Federal system (in which the federal government pays for all necessary care) is that I don't have to deal with insurance. It is soul-crushing to have pencil pushers hundreds of miles away díctate the care you provide.
On the other hand, not having to make appointments weeks in advance, and even being able to send a text message to save a visit has some value. I don't think that would be possible with my insurance (the doctor wouldn't get compensated).
The system literally generates more revenue the sicker people are. So it’s no wonder it optimizes itself away from keeping people from getting sick. It worked for a while, perhaps because most doctors have morals, but now it seems the shareholders are in charge rather than the doctors.
There is an alternative (“value-based care”) that is slowly catching on, as the governments and companies paying for all these unnecessary services are starting to wonder if there’s a better way. Essentially, you pay a fixed amount per person, so the system is incented to keep people healthier, not sicker. But lord, there are so many entrenched interests fighting against improvement. And even that system can of course be gamed at the expense of society.
Young people today have never experienced such a system, but for decades it was the system. We started moving away from it in the 90s, and completed that move away from it in 2011. Coincidentally (or maybe not so-coincidentally) we've had faster-than-inflation healthcare cost increases since then.
This sounds like rationing. Sorry buddy, they only pay a fixed amount per person so we can’t actually afford that expensive surgery or MRI or whatever else you need, go home and walk it off.
I think if you compare the “expensive” MRI in the US to other countries, you’ll find it’s “expensive” because it’s connected to an infinite money spigot and there’s no upper limit on how much it can cost, not because it’s a better MRI.
So providers have an incentive to encourage adverse selection and keep the “difficult patients” away from their practices.
Practicing primary care in this era is a nightmare. Like the article says - most clinics are run by PE or hospitals that push 'providers' to see a complex patient every 10 minutes while absorbing none of the liability for rushed, low-quality care. The compensation for these positions is now significantly less than most of the salaries that you see in the "Who's hiring?" threads on HN except with a tremendous amount of liability attached, a ton of customer service and a guarantee that your salary will go down relative to inflation.
The idea that NPs or PAs could just fill in the holes in our primary care system was always laughable to anyone who understands how medicine is actually practiced - to do the job well you need well trained, highly intelligent people. The punchline of the joke is that very few PAs/NPs ever intended to go into primary care and now the market is flooded with "Psych NPs" and "Derm NPs" pedaling Ritalin and botox.
Nothing will fix this problem short of a complete, ground-up rebuild of our healthcare system.
The one that sticks out to me was a few years ago. I’m prone to sinus infections and this one just wouldn’t go away. I booked an appointment with an NP.
She took a brief look at me and then advised that I go to the hospital because “you might have a brain tumor”. I told her I get sinus issues all the time. She responded that her sister died of a brain tumor.
So off to the ER I went and 2k later I had an ER doc look at me like I was an idiot and diagnose me with a sinus infection.
It's not just private equity pulling these shenanigans. Our local Children's chain is a non-profit and they pull some real shady shit.
People overuse doctors. Most of what younger people (under, say, 50) go to the doctor for, a good NP can do just as well or better. One of my weird hobbyhorses is how dumb the name "nurse practitioner" is; they should just call them "associate physicians".
(Note here that we're talking about "urgent care", which are clinics run by health chains, staffed with a doctor or two, a couple NPs, and a bunch of nurses; "urgent care" is not the ER, which is a thing people gotten hung up on HN about before, because I guess every country calls their ER something different. Going to the ER for routine care is insane.)
Even then it was phrased as more "If it were me, and I had similar comorbidities, I'd get that looked at ASAP"
Ended up hospitalized for 4 days.
Well, there are "physician assistants", PAs, which are the same rung of the ladder as NP but via different path. Areas tend to somehow converge either on NPs or PAs, but not both so often.
My background is CA & NYC. I am able to get same day or same week (if less urgent) appts by calling my primary (PCP). In the event that my PCP has no availability or it's late in the day, I'll consider going to urgent care since it's the only thing open.
I can understand other people posting how hard it is to find a good PCP (or even dentist frankly). I got lucky and found a good, local PCP that I've been seeing for years.
The ER and urgent care at my local hospital are next door to each other. Until the last year or so, it was the only urgent care in the area (and is the only ER).
It works extremely well with my doctor's health system, and I'll add that my doctor's health system is notorious in the area for sucking to work with, so if I switched to, like, Rush or Northwestern, presumably it'd be even better.
One argument could be that treating non emergency cases would ruin availability or increase costs, both of which seems like big assumptions at a system design level (vs the actual constraints and incentives that have lead to the existing service configuration).
I'm sure that there are regulatory drivers, but I expect they are things we should seek (as a society) to improve, rather than accept and ignore.
Primary care is good for dealing with ongoing issues. It is cheaper because only staff what they need. But have to schedule appointments far out. They could leave slots open for urgent issues but then would cost more.
Urgent care is to handle the urgent but minor issues. Stuff that doctor could handle if they were open or had appointments. They are more expensive since they are open longer hours and less likely to get insurance.
One thing that would help fix the system is lots more free 24-hour urgent care clinics. That would keep people out of ER.
Agree NP is a poor term.
Administrative bloat is killing these places
The administrators are fucking vipers. These orgs are rotted at the heart. They do everything they can to stretch the staff thin while shifting their targets and gaslighting them into thinking they're underperforming. Execs are doing great, but in the meantime they're hemorrhaging docs, nurses, and office staff because the conditions suck.
If you have a mole or something that needs to get checked out, try a plastic surgeon.
"Opinion"
Seems like the primary issues are poor compensation and lack of respect.
It’s such a huge investment of time and money, that it’s very hard to convince anyone to get into the field.
We have this immutable education track, seemingly because that’s the way we’ve always done it in the US. But I’d be very curious if we actually achieve better outcomes than countries with shorter medical educations.
The article mentions that NPs and PAs also favor higher lying specialties - but it seems much easier to solve that supply and demand problem than paying the cost for more MDs
The filter is on entering med school.
It's not: it's only been that way since the nineteenth century. There used to be a Bachelor of Medicine degree that represented six years or so of study and was sufficient to practice medicine.
We want this. This is us.
https://nationalpost.com/news/canada/canada-maid-assisted-su...
I've been thinking about that a lot recently. You're right: this is who, at least a large group of us, are.
It could equally be argued that 27% of Canadians do not agree that MAID should be restricted, the poll question was preambled:
At this point, only an adult with a grievous and irremediable medical condition can seek medical assistance in dying in Canada ...
One extreme interpretation is that all those replies indicate support for culling the weak.
The other extreme interpretation is that all those replies support the self determined right to seek assisted suicide regardless of conditions.
Do you have a source for that?
The stuff I saw says that a certain number of slots are reserved for international students, which further constrains the supply.
https://www.nrmp.org/wp-content/uploads/2023/03/Match-Rates-...
Of course, the end result of all the short-term cost saving, is that care is switching to emergency only, which is a lot more expensive for everyone.
The medical field has both. Suppliers are working at capacity - there's a limited amount of residency spots[1]
Increasing supply is also incredibly hard, because it has a decade+ of lead time.
Neither one of those "our modern economy" can fix. The latter requires loosening training requirements. That's why we have Nurse Practitioners, which folks are loudly complaining about a few threads above.
The number of residents is capped because new residents cost money. Hospitals used to make up for that by relying on Medicare, but that funding hasn't been increased. And so the economy works exactly as designed, the expensive good of "residency slots" is only offered to a limited amount, where it makes financial sense.
It doesn't matter that additional doctors would make sense, the hospitals can't make money of more residency spots. Existing doctors don't complain, because it drives their salaries up.
All of this very much makes the eloquent point that our modern economy is not the right tool for education or medical services. It can't work, given the forces around it.
And so it goes.
[1] https://www.medicaleconomics.com/view/match-day-2023-a-remin...
It's documented to have happened at least as early as with the romans. The exact same things happened that we're seeing now: people made less babies, rich got richer, the middleclass turned into poor(er), most people stopped being productive and switched to rent seeking (owning land and properties became the goal instead of actually making things or delivering services) and so on.
This particular one is a self-inflicted problem in most major US metro areas, by way of medium density housing being explicitly or implicitly banned for decades.
To any pre-medical students, please seriously consider a better pathway forwards. There are literally SO MANY BETTER METHODS "to help people" and "to make money." If these are two of your primary reasons for joining medicine, please spend the time thinking about how you want a well-lived life.
src: dropped out of medical school, after ER rotation, prior to ACA. Hadn't thought enough about a livable professional experience. I became an electrician.
U.S. WILL PAY TO REDUCE DOCTOR GLUT
Washington Post, August 24, 1997
https://www.washingtonpost.com/archive/politics/1997/08/24/u...
In primary care especially the fees are low, and to be any good you need to explain things to the patients - which takes time. In the current medical billing culture it's about throughput, so taking time to explain falls by the wayside.
This is industrial medicine.
Is this true?
There's still a lot of things I want to see and do.
And that hip surgery I had? Yea, I need to see a doctor, not a PA who just sends me for an MRI and then refers me to a doctor.
And then there are DOs. Also something I avoid.
Insurance is really trying to pay less for a visit... They can start by not re-imbursing homeopathic stuff & chiropractors.
They take the same licensing exams, and the same residencies.