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Are We Underestimating Primary Care Capacity?

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The shortage of primary care doctors has been a vexing, persistent challenge in New York State, just like in many other regions of the country. This challenge will be heightened with the implementation of health reform this January that should result in an extra one million New Yorkers having health insurance coverage and looking for more primary care. The pressing question as coverage expands will become: "Who will care for all these newly-insured people?"

We know that New York State is home to numerous "primary care deserts" which have no federally qualified health centers (FQHCs) and limited access to timely primary care services. And we know that many health centers have health care provider vacancies that limit the care they can deliver; the Community Health Care Association of New York State found that, if all vacant health care provider positions were filled, New York's FQHCs could serve an additional 185,000 patients annually.

We are seeing steps to address the shortage of primary care providers and to grow community health centers. The Affordable Care Act includes $11 billion to strengthen health centers, increases funding for programs like the National Health Service Corps, and expands training and residency programs for primary care providers. And programs like Doctors Across New York and the Primary Care Service Corps in New York State are working to recruit and retain primary care providers in high-need areas.

But, we need to get more creative to stretch our primary care resources even further. First, we should redefine the problem so that the focus is about meeting the needs of consumers instead of being bound by the old idea that more primary care means more physicians. Rather than relying on the traditional approach of almost begging young medical students to consider primary care, we should change regulations and energize the market so that advanced nurses and care managers and a range of other types of health care professionals can deliver more aspects of primary care.

Secondly, at least in the New York City area, we should look more closely at whether the market isn't adapting more than we think. The website ZocDoc.com allows patients to find primary care providers and book appointments online; many of the participating clinicians offer same-day appointments. And new urgent care centers opening across Manhattan are designed to care for immediate primary care issues for a younger, professional population that does not have chronic care issues. CityMD, for example, now has seven clinics open from 8 a.m. to 10 p.m. on weekdays and 9 a.m. to 9 p.m. on weekends. Premier Care and PM Pediatrics have similar clinics in operation across Long Island.

Could these urgent care centers begin to expand in lower-income neighborhoods as insurance coverage expands and makes these clinics more financially viable? And, how is it that these centers are expanding when conventional wisdom says we have inadequate primary care capacity? The answer seems to be that centers like these tend to hire physicians trained in emergency medicine who know how to work quickly, are effective diagnosticians, and can handle a range of medical problems. And, not to be ignored, these emergency medicine physicians are paid higher salaries than primary care physicians and are in slightly better supply.

I also hear from health care providers that more and more specialists in New York City are spending a good portion of their workday handling primary care problems among people who visit them for a chronic condition. And some of the cardiologists on ZocDoc, for example, are accepting appointments for primary care services for the full spectrum of patients, not just those requiring cardiology services. So we may have deeper reserves of willing providers of primary care than reported. But, it is still not clear if urgent care centers or cardiologists doing primary care is best for patients. New York State's Public Health and Health Planning Council is examining how best to regulate urgent care centers and similar ambulatory care facilities, but we also need more analysis of when these new sources of primary care are effective.

Also, this option may not work in rural New York, where there are acute shortages of both specialists and primary care physicians. Perhaps the solution in rural New York is to better link existing rural primary care practices to medical centers in the major upstate cities. Fast-breaking advances in telehealth technologies make integration of these urban medical centers with practitioners and patients in rural communities more possible. Many people want a one-on-one, in-person relationship with their primary care provider but this is not the highest priority for every patient.

Of course, the long-run solution to shortages in primary care is payment reform that changes the payment calculus so groups of medical providers are paid a fixed amount of money to care for a population of people (the basic idea behind the concept of Accountable Care Organizations). In this type of payment system, provider organizations (whether led by hospitals or doctors) will do financially better if they devote adequate resources to primary care that decreases the likelihood that the population will need expensive acute care services. It will be worthwhile for ACO type organizations to pay primary care physicians well, and find creative ways to use nurses and other properly trained health professionals to deliver certain types of primary care. In addition, it will be key to distinguish situations where urgent care makes sense and where ongoing, highly coordinated primary care makes sense.

The important conclusion is that we need to be creative, to deploy our existing primary care resources as smartly as possible, and to think outside the normal health care box to come up with new approaches to meeting the primary care needs of New Yorkers.