Dr. Morris-Singer: Addressing the primary-care shortage through grassroots advocacy

Solving the primary care physician shortage will require more than simply payment changes and increased funding for physician education. Andrew Morris-Singer, M.D., president and founder of Primary Care Progress is an Intermal Medicine physician who is turning his 15 years of grassroots advocacy experience into a movement to help improve primary care access in the United States. An internist at a Boston practice and an instructor at Harvard Medical School, Dr. Morris-Singer answerd some questions for HealthCXO on the primary care physician shortage and his approach to addressing this issue.


Health CXO: With an estimated 65,000 fewer primary care physicians than needed by 2025, where is the primary care workforce going to come from and what does it look like?

Dr. Morris-Singer: One thing is certain, going forward the primary care workforce will increasingly need to come from both our medical schools as well as the other health professions schools (training pharmacists, social workers, nurses, etc.). This is a reflection of not only the unprecedented demand for primary care health services in the nation, but also the ability of non-M.D.s to provide a whole host of truly valuable primary care functions. 

The current trend of moving away from a “lone ranger” model of health care delivery – where physicians try to carry the healthcare load all by themselves – toward a more team-based model is enabling more of us to discover something truly disruptive. Not only the variety of ways in which other care team members can handle functions previously carried by the physicians (like vaccinations and health coaching), but also the new domains of healthcare and health promotion where these professionals are adding new services most patients had previously gone without. For instance, clinical pharmacists in primary care practices are now providing patients with incredibly practical advice on how to take their medications and helping closely manage medications for diseases like diabetes.  Health coaches are using motivational interviewing and new tools for patient education to help patients get engaged in their own care in an unprecedented way. 

As we continue to identify the unique roles and services that can be provided by each member of the care team, and shift training and education to produce graduates with the appropriate skill sets and competencies, Americans are going to discover that their health and healthcare needs are being met in a much more cohesive, comprehensive and patient-centered manner. 

 

Health CXO: Are current government ideas, such as the proposed increase in spending on primary care training in the president's most recent budget, sufficient to address the shortage of primary care practitioners? Why or why not?

Dr. Morris-Singer: Unfortunately, the seeds of our primary care provider shortage were laid approximately 100 years ago when our entire medical education system was definitively shifted toward a hospital-based and largely biomedical research focused approach to combating disease.  Since then, the overwhelming majority of trainees have received the overwhelming majority of their education in hospitals, taught by specialists about some of the most complicated and rare diseases, with relatively little time spent focusing on public health, primary care and addressing community needs. 

The shortage of primary care providers is one of the many legacies of this phenomenon. Remedying this will require a multi-faceted approach, including a number of changes at the “grasstops” level in how research funding flows to medical schools, how Medicare pays for residency training, and how insurers pay for healthcare services. The President’s recent budget takes important steps in the right direction, by increasing funds to primary care training programs and by investing in primary care providers, but these should be thought of as “baby steps.” Without definitive changes that address the huge disparities in payment between primary care providers and specialists, it will be difficult to reverse the decades-old trend of future physicians avoiding primary care careers.   

 

Health CXO: To what extent does primary care today have an image problem that discourages talented and ambitious top medical school graduates from pursing careers in this area of medicine, and how do we improve the reputation of primary care?

Dr. Morris-Singer: Primary care has a tremendous image problem. This is partly due to the real challenges we have faced and the profound lack of investment that society has made in us. (Despite the fact that the United States spends about 18 percent of GDP on healthcare, only a paltry 5 percent of that spending goes to primary care).

However, this is also due to how we’ve presented our value proposition and ourselves. At present the average primary care clinic is woefully underinvested in, and understaffed. This bears out in the data, where studies seem to indicate that up to 50 percent of patients with certain diseases like high blood pressure and diabetes are not receiving all of their recommended care. 

It’s no surprise. Our services are so poorly compensated that the only way most providers can stay in business is by keeping staff small and keeping office visits short. Frankly, these providers are the victims of a healthcare system that is much more focused on treating disease with the latest gadgets in the most expensive settings as opposed to preventing and effectively managing those conditions in the first place.

The problem is that primary care providers have portrayed themselves as victims in the hopes of motivating policy makers to make necessary changes. Not only has this strategy been unfruitful, but it has also helped turn off students from primary care careers. A better strategy would be for our community to start highlighting the definitive ways in which robust primary care can solve the most pressing problems these policy makers and large employers are now facing: The concurrent need to manage the health of defined populations, improve the quality of care and lower the overall amount spent on healthcare.

Primary care can do this.  In fact, it is doing this – in a way that the rest of healthcare cannot. And that’s what we should be highlighting. The fact is that robust primary care is the most effective, patient-centered, efficient and sustainable method to keep patients from developing disease in the first place, manage existing health conditions, and get patients to the appropriate services they need.  In that way we’re no longer a charity case or a victim. Rather, we’re our healthcare systems’ strongest horse, who deserves robust investment.

 

Health CXO: What can a grass-roots advocacy approach to the primary care shortage problem do that perhaps other forms of action cannot?

Dr. Morris-Singer: Fixing our dilapidated primary care system is going to require using all tools in our toolbox. It’s also going to require all hands on deck. Changing medical education and payment for medical services is going to require large, powerful institutions to shift certain policies and practices. So the real questions are: How do we bring about that change? What resources do we have at our disposal?   

Fortunately, we have the data. Decades of data shows that robust systems of primary care lead to lower healthcare spending as well as happier, healthier and more productive people. However, we need more than data.  We also need to mobilize the voices and perspectives of healthcare stakeholders to call for those changes in policy and practice. That’s where grassroots advocacy comes in: Convening the perspectives and “votes” of large groups of people to try and leverage certain changes from institutions.

In the United States, we’ve seen countless examples of this approach leading to real and impactful change. This includes changes in services and products when customers raise their collective voices, as well as amendments to discriminatory laws when citizens concurrently vote their minds. Bottom line is that grassroots advocacy has played a critical role in bringing about almost every major societal change we’ve seen since the founding of our nation. So shouldn’t we heed this important lesson of history and leverage this powerful social strategy to help in the effort to revitalize our primary care healthcare system? At Primary Care Progress, we definitely think so and we believe the next generation – students and trainees – have an important role to play in that movement. 

Lena Kauffman,

Contributor

Lena Kauffman is a contributing writer based in Ann Arbor, Michigan.

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