Primary Care in Peril

A recent study published in JAMA looked at the relationship between primary care physician supply and population mortality in the United States. The study covered the 2005-2015 time period.

3 min read

Primary Care in Peril

A recent study published in JAMA looked at the relationship between primary care physician supply and population mortality in the United States. The study covered the 2005-2015 time period.

The authors of the study found that 10 additional primary care physicians per 100,000 population, was associated with decreases in cardiovascular disease mortality, cancer and respiratory mortality by 0.9% to 1.4%. These findings were further validation of the seminal work done by Dr. Barbara Starfield and her colleagues in the past. That’s the good news!

However, in the same time period from 2000 to 2015, the density of primary care clinicians throughout the US decreased from 46.6 to 41.4 per 100,000 population. And even more concerning for Texas, the primary care supply declined more in rural than in urban areas on average.

  • Why the shortage of primary care clinicians? Here are a few major reasons:
  • Current low payment structure
  • Significant payment disparities between primary care and procedural specialties
  • Level of debt from medical school and residency can drive young doctors toward higher paying specialties
  • Perceived heavy workload and work hours
  • High burden of quality and performance measurement
  • Administrative hassles of pre-authorizations and lack of electronic health record interoperability
  • Reluctance to practice in more rural areas with less specialty support

Another factor in the equation of primary care is chronic maldistribution of physicians across the state. As an example, the state’s five most populous counties (Harris, Dallas, Tarrant, Bexar and Travis) have 57% of the Texas physician workforce but only 44% of the total Texas population. Further, in those same five counties, 72% of the physicians are specialists and 28% are primary care physicians. A 2013 study by Parkland Hospital and the Dallas County Health Department highlighted that the ratio of physician-population varies dramatically within Dallas County with a high ratio of 252/100,000 in the Stemmons Corridor to 5/100,000 in the southern sector Wilmer-Hutchins/Seagoville area. The study supports the observation that there is frequently a preponderance of physicians in more affluent areas and fewer in less affluent areas.

Texas ranks  47/50 in the US for primary care physicians per 100,000 population. 33 of 254 Texas counties have no physician at all. And, the closure of rural hospitals adds to the urgency of the need for better distribution of physicians.

There are some bright spots in this story. The 85th Texas legislature granted generous funding for Graduate Medical Education Expansion programs in Texas through which health science centers, medical schools, hospitals and foundations received awards for 63 residency programs. A total of 1,265 residency positions will be supported. Many of the awardees are in rural communities.

The Texas Academy of Family Physicians, Texas Chapter of the American College of Physicians and the Texas Pediatric Society have operated medical student preceptorship programs for more than 10 years. Through funding from the Texas legislature, these programs have paired hundreds of medical students who spend 2-4 weeks with practicing primary care physicians across Texas. There is good evidence that this early exposure to primary care increases the likelihood that the student will pursue a career in primary care. The Texas Medical Association has championed the Physician Loan Repayment program through which physicians in certain specialties (primary care and mental health) who choose to practice in Health Professional Shortage Areas for at least four years receive significant loan repayment funding. Similar programs exist for nurses.

Texas A&M’s ARCHI (Rural and Community Health Institute) recently received a generous grant from Blue Cross Blue Shield of Texas to reimagine rural healthcare in Texas.

How can we more equitably distribute primary care throughout our vast state? There are a several innovative ways including telemedicine and the use of ECHO technology.  A number of organizations are piloting virtual specialist consults to make accessing specialty care easier, especially for rural practices. Community healthcare workers are a vital part of the healthcare team and are being utilized increasingly.

While the aforementioned remedies are ramping up and moving to scale, I believe that we should invest our time and energies into forming high functioning teams in our practices. Effective and efficient teams have great potential to address some of the most vexing problems we are facing. A recent study showed that with well-trained teams, physicians and other clinicians may experience less burnout.

We are honored to have such a team from Bellin Healthcare in Wisconsin participate in the upcoming annual summit of the Texas Primary Care Consortium. Dr. Jim Jerzak, family physician and originator of Bellins’ team based model and Kathy Kerscher, his administrative counterpart will share their experiences and guidance with the Summit attendees. You can read more about Dr. Jerzak and Bellin Health here.

It has been said that necessity is the mother of invention. In Texas, there are practices and systems innovating every day to improve access to primary care. We’ll feature a number of these at the 2019 Summit. So please join us June 20-21 at the Renaissance at the Arboretum in Austin. You’ll be glad you did! For more information, please visit: