Staff Shortages, Pay Gaps, and Burnout. Why Reid Blackwelder Is Still Hopeful About Primary Care

Kenneth W. Lin, MD, MPH


February 04, 2022

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Kenneth W. Lin, MD, MPH

Kenneth W. Lin, MD, MPH: We're here today to follow up on an interview that you gave Medscape in 2013 about how the Affordable Care Act (ACA) would affect primary care. As a result of the ACA and, more recently, the American Rescue Plan, millions of previously uninsured Americans have signed up for insurance over the past decade. An analysis by the AAFP's Robert Graham Center, which got a great deal of publicity at the time, projected that we would need 52,000 additional primary care physicians by 2025 owing to population growth, population aging, and insurance expansion. That's now less than 3 years away. Have family physicians been overwhelmed with new patients, or has the supply of medical students and other health professionals entering primary care kept up with the demand?

Reid Blackwelder, MD

Reid Blackwelder, MD: Obviously, this is still an issue, and I'm afraid the pandemic has really underscored it tremendously. Ideally, we should have at least 50% primary care and 50% subspecialty physicians, and we're far below that right now in this country.

An interesting aspect of the pandemic is that it has kept a lot of patients away from primary care offices — greatly to their detriment. We're seeing a lot of health issues that aren't necessarily related to COVID but in people who have not been able to get out or have chosen not to go see their primary care physician, and whose chronic diseases have not been managed as well as they should have been.

So, I think the shortage still exists. But sadly, there's also now a parallel shortage of nurses. That is even more of a crisis than the primary care crisis. And we're seeing a lot of people on the frontlines, which include nurse practitioners and primary care physicians, actually leaving their practices. We're still facing a shortage, a very serious one, and significant access to primary care issues. The challenge is how to help our country truly walk its talk and put energy, money, and support at the primary care level to better serve our population.

Lin: In your previous interview, you pointed out that one factor that drives medical students into specialties rather than primary care is the inequities in payment that lead to our very top-heavy subspecialist healthcare system — which, incidentally, produces poorer health outcomes than other economically advanced nations that have closer to a 50:50 ratio. What has been done over the past decade to reduce the payment gap? And what more do you think needs to be done about it?

Blackwelder: This is a serious reality. Realistically, there will always be a gap. It just needs to be smaller. There have been some steps in the right direction. Some value-based payment models have increased investment in primary care. That's been long overdue, and it's helpful. Unfortunately, there are still challenges in how much administrative burden goes along with some of those: the checklists and stars. The word I love — and I did not coin it — is "administrivia." That's so much of what we do. We do more chart care than patient care. I think anything that we do to address primary care payment needs to be done without adding administrative burdens.

The Centers for Medicare & Medicaid Services (CMS) updated its clinical labor pricing (CLP) in the 2022 Medicare physician fee schedule. CLP is used to calculate the practice expense portion of Medicare physician payment rates to account for the cost of staff salaries and benefits, and CMS hasn't updated it in almost 20 years. Instead, it has been using data from the Bureau of Labor Statistics from 2002. Since then, the mean annual wage for registered nurses has risen by 60% (about $30,000), and the average wage for medical assistants has risen 30%. Medicare rates today don't reflect any of these cost increases, as many of us well know.

Without these essential salary updates, and the staffing shortages they contribute to, patients may experience longer wait times to see doctors and have delays in receiving test results. Underpaying physician practices can also lead to practices closing, which creates barriers for patients to access care in a timely manner within their communities.

Another thing that would be really important — and we had it with the ACA for 5 years — is Medicaid-Medicare parity. Seventy million Americans are on Medicaid. It's a state-by-state process. Unfortunately, most states pay one third to two thirds of Medicare rates. And in fact, primary care physicians lose money taking care of Medicaid patients. When we had that Medicaid-Medicare parity, it was great, but it sunsetted after 5 years without a permanent change. Given that so many family physicians are on the front lines in rural areas and are taking care of the Medicaid population, anything we can do to move toward that parity would be important. There is legislation that Congress could act on, but at the moment, I don't think that's happening; that's something that we really need to push. This is still a real issue, and until we get more investment in primary care, it's going to be a very serious one.

Lin: At the medical school where I teach, we're always discussing how, when we place students in clerkships, we want to place them with physicians who are not too burned out or run down because that experience is not likely to cause someone to choose family medicine or general internal medicine. What's your take on the psychological status of primary care physicians right now, 2 years into the pandemic? Will it attract or repel students?

Blackwelder: The issue of wellness and resiliency and the corresponding concern and reality of burnout is really prevalent through all of medical education and medical practice. It's not just a primary care issue. In fact, even before the pandemic, places like Stanford were investing in wellness programs, and a lot of medical schools and residences do the same. The pandemic unfortunately accelerated a lot of the stress. You're seeing this play out day to day with everybody. The frontline workers, the nurses, and all the nonphysician support staff are really struggling. Primary care isn't necessarily struggling more. We're all struggling together as a system, and I'm afraid the system has shown where its difficulties are, because we have relied on fragmented, siloed care and emergency rooms long before the pandemic.

That said, we're still seeing a lot of people wanting to go into medical school, and it's inspiring. In fact, last year we saw a huge increase in applications to medical school. There are some generational differences that are intriguing to me as a baby boomer. I grew up at the time of service. I view medicine as a calling, whereas other generations consider it a job, and that's fine. That's their reality.

But I do think some of the newer generations have a strong service connection. I'm seeing it in a lot of our medical students. Here at Quillen College of Medicine, where I where I teach and practice, we have opportunities for rural experiences and even global experiences. Our students, when they have these kinds of experiences, realize some aspect of that calling. Whether they call it that or not doesn't matter. There is still a strong and maybe even an increasing desire to serve and to recognize that our country can really benefit. And of course, primary care gives you one of the best opportunities to really be on those front lines. I'm encouraged by what I see and I have a lot of hope for the future.

Lin: On a related note, in 2018, several family medicine organizations launched the 25 x 2030 Student Choice Collaborative, which aims very ambitiously to more than double the percentage of medical students who match in the family medicine residency programs in just 8 years from now. Do you think this goal is achievable? And regardless of how you feel about the precise number, what do you think it would take to make that happen?

Blackwelder: I think it's a needed aspirational goal. A real problem for our country in terms of healthcare outcomes and costs is that we're backward. Every other comparison country has at least a 50% primary care workforce, and we're around 33%. That has to change and we are making progress. However, we really do need our country to view primary care as foundational to our system, which means valuing it and putting money into it, addressing things like the salary gap and medical school debt. Those are the key factors that will drive students into primary care.

As a member of the admissions committee, when I meet candidates for medical school, they say universally, "I want to help people." Because we are a rural primary care medical school, they almost always say, "I want to do rural primary care." Obviously, some of that is what you say to get into medical school, and some of it is said without really knowing what that means, but almost never do I hear a candidate say, "I really want to be an interventional radiologist." There is nothing wrong with that profession. We need outstanding interventional radiologists. But students want that global experience of helping people, and primary care opens that door. I think the pandemic gives us an opportunity to revisit some of these issues, and I'm very encouraged that every year we're bringing in more family medicine residents. It is really the secret to success for our country in improving health outcomes and decreasing costs.

Lin: We're seeing a small but increasing number of practicing family medicine positions — including, incidentally, my own personal physician — transitioning to either concierge or direct primary care practices. The main effect is to reduce the size of their patient panels by up to 80%. On the one hand, as I've seen, this is good for doctor morale. People have found that they've been able to reduce burnout and potentially attract more medical students to the field because they see people operating in more sustainable practices. But on the other hand, you've got the same number of doctors caring for a smaller number of patients. What do you think the effect of these types of models are going to be on future supply and demand in primary care?

Blackwelder: All of these models are ways of investing in primary care. Primary care is about relationships and communication, and that's really one of the benefits of any model. With the pandemic, we've made some changes in how we interact with our patients that I think were exactly what we needed. Many of the direct primary care models, like the one developed by my good friend Dr Brian Forrest in North Carolina, are in underserved areas and are designed to take care of people who aren't getting any care at all. So even though they can reduce panel size, they can also improve access. I'm seeing a lot of businesses now recognizing how valuable primary care is to reduce time lost from work and increase morale and the health of their employees. Businesses are buying direct care models in their local communities, and employers are paying for them because they will save money downstream.

There has been a slow increase in the direct primary care movement. When I was on the board of the American Academy of Family Physicians, it was about 4%. Now it's about 6%. It has shown to be a viable model and one that really recreates what's most important for primary care.

Lin: Another even more recent phenomenon that David Blumenthal wrote about in the Harvard Business Review is all the retailers sensing a business opportunity in the primary care space — companies like CVS, Walgreens, Walmart, and Amazon. Do you think that that these new players are ultimately going to benefit primary care? Or could they have a negative effect, maybe driving independent practices out of business?

Blackwelder: I've been around for a long time. I have a long gray beard and gray hair. This was an issue that was happening when I was on the board of the AAFP, and I can comfortably say it is not something that's a death knell or even necessarily competition for primary care practices. What's most important about this issue, however, is that the negative side of it is that it reinforces what already exists in our country — which is fragmented, siloed care.

I'm in a relatively rural area here in northeast Tennessee, and one of the most frustrating elements is not that my patients can get vaccines or be seen for an urgent care problem someplace, but that those places don't communicate with me. Unless we're communicating well, you can get duplication of care. Important comorbidities can be missed. From a practical perspective, I'm assessed on how many of my patients get a flu vaccine, and if my patients are getting a flu vaccine at Walgreens or Walmart or CVS, and no one tells me, I get dinged for my patients not being vaccinated. I know that sounds like a minor point. The patient's vaccinated, which is important. But I don't have a record of that, and it affects payment to primary care.

What is most important is not the turf battles or that one is better than the other, but how we can communicate among the different providers more consistently. I have great relationships with some local pharmacists and I absolutely will send my patients there for vaccines, or we'll have conversations about what's the best way to manage some medications. That is a phenomenally powerful and beneficial relationship for patients. We are almost seeing a direct primary care model in retail clinics. Retail clinics are finding family physicians and general internists and pediatricians to run a more comprehensive clinic. That's probably the most important issue to pay attention to. Episodic care of urgent issues is good, but what patients need most is comprehensive, longitudinal, and coordinated care. The more that we can do in communities and cities and systems to get everybody working together, the better.

Lin: We started with a policy question, and I thought we could finish with another. During the 2020 presidential campaign, some candidates advocated for moving beyond the ACA to a single-payer healthcare system, like Medicare for All. But now it looks like the legislative process is bogged down and even the relatively modest expansion provisions of the Build Back Better Act may not come to pass. Some of those provisions are important to primary care, including workforce investments, premium subsidies and initiatives supporting maternal health and preventive care. If the bill goes nowhere, do you see any other avenues potentially on the state level or elsewhere where primary care advocates could pass similar family medicine-friendly legislation?

Blackwelder: Unfortunately, partisan posturing has limited any action on healthcare. "Medicare for All" is a fascinating term because Medicare is Congressionally mandated health insurance, which was not designed for prevention and proactive care. It was initially implemented for patients with chronic health conditions like end-stage renal disease, and it requires Congressional amendments in order to take care of screening. So personally, I'm not sure I want Medicare for All. What I want is something that truly does address a primary care home for every person in this country. There's no question that the AAFP and its leadership are not just waiting to see if legislative action results in the passage of bills. They are constantly on the Hill and talking to federal representatives and helping support our state chapters to have those conversations at the state level.

Much of this really can be addressed on the state level. Medicaid is primarily run by the states, and the opportunities to look at how they invest in that vulnerable population from each state can be affected by advocacy. State chapters are looking at things like Medicaid-Medicare parity and ways of addressing value-based payment. In other words, there's not going to be any waiting around from the Academy's perspective. We have had successes; I'll go back to the revision of the CLP — that was a significant accomplishment for the AAFP, and as a federal change, it will benefit family physicians all over the country. So I think there are still successes despite the challenges, and we just got to keep pushing the needle.

I'm continuing to advocate for family medicine anywhere I can. It's something we just need to do a better job of. Physicians need to be better advocates for their patients, for themselves, and for their specialties. We really don't do as good a job in medical school and residency of preparing physicians for that essential role. Some of the best care you can provide your patient is to be willing to go to communities, be on the health boards, run for office, go to the state capitals, and simply advocate — because people want to hear our stories. We just need to do more of it.

Lin: We've come quite a long way since you gave the previous interview, and maybe we'll be talking to you 10 years from now about what's happened since then. I really appreciate your time and insights on where primary care is and where we're going.

Kenny Lin, MD, MPH, teaches family medicine, preventive medicine, and health policy at Georgetown University School of Medicine. He is deputy editor of the journal American Family Physician.

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