Health-care options as physician shortage looms

The Association of American Medical Colleges projects that the nation will face a shortage of 12,000 to 31,000 primary-care physicians by 2025. So it's no wonder you may be finding it harder to find a doctor or to schedule an appointment with the one you have.

What's fueling this problem? The baby boom generation pouring into older age, an aging physician workforce preparing to retire and an estimated 30 million Americans joining the ranks of the insured since enactment of the Affordable Care Act in 2010.

What that means is that you may not be seeing a doctor at all the next time you go for .

"The impending physician shortage is an opportunity to move to a health care model where the physician can be more of a quarterback on a team of health care providers, rather than being on the front lines," said Dr. David Gorstein, managing director of Health Innovations, a health care consulting firm in Charleston, S.C., focusing on new models of health care. It's time to look to other, more affordable and accessible settings, he said.

Here are five options for addressing shortages and reining in costs.

Retail clinics

Maybe you have a scratchy throat and suspect another cold, but there's a two-week wait to see your doctor. Or you're out of town on business or are self-employed without health insurance.

Typically located in pharmacies, groceries and "big box" stores, these walk-in clinics began cropping up in 2000 and served more than 20 million patients in 2014, according to their trade association, the Convenient Care Association. To date, they number more than 1,800 in 40 states and Washington, D.C., offering lower-cost options for health services with transparent pricing, so consumers know what they are paying for.

Visits typically range from $40 to $75 and address acute conditions, such as bronchitis and ear infections, as well as provide immunizations and physicals. Usually staffed by nurse practitioners, who are highly trained registered nurses, some incorporate pharmacists into ongoing care (which is particularly valuable in medication counseling for chronic diseases like diabetes or asthma). The clinics generally accept health insurance and can send a record of your visit to your primary-care physician.

"While the care can be excellent and the wait times and cost to the patient much less than emergency rooms, it's important to understand that walk-in clinics only treat a limited list of problems," said Dr. John W. Rowe, professor of health policy and aging at the Columbia University Mailman School of Public Health. They should not be relied on as a source of ongoing care, he cautioned. Yet Dr. Don Goldmann, chief medical and scientific officer at the Institute for Healthcare Improvement in Cambridge, Mass., sees their growth as proof that they fill important needs, providing "easier access to providers and quick, convenient care."

Urgent-care centers

Although they've been around for decades, the more than 6,400 urgent-care centers in the U.S are seeing an upswing in growth (from 8,000 to 9,300 since 2008), fueled by consumer frustration with long waits in emergency rooms and for appointments with primary-care physicians. These same-day walk-in clinics focus primarily on emergency medicine for acute (but less severe) medical problems. Typically staffed by trained and licensed physicians and medical assistants, registered nurses and X-ray technicians, nearly one-third of them are hospital owned and operated.

Many offer evening and weekend hours, perform X-rays and some on-site lab tests (like urinalysis and pregnancy and strep tests) and provide procedures like suturing and casting, usually more economically and with less wait time than hospital emergency rooms. In some communities, they function as primary-care practices for some patients. One study estimated that up to 27 percent of emergency room visits could be handled appropriately at retail clinics and urgent-care centers, offering cost savings of $4.4 billion per year.

Nurse-led practices

Nurse practitioners, nurse anesthetists, nurse midwives: You find them in every setting where patients receive care, including doctor's offices (where they often treat patients with more routine complaints, thus freeing up doctors), , hospitals, nursing-care facilities, schools, clinics, free-standing practices and hospices. Known as advanced-practice registered nurses, or APRNs, they are nationally certified registered nurses who have completed master's or doctoral programs and have advanced clinical training in patient-centered primary care. They can practice independently in 19 states and the District of Columbia.

Nurse practitioners, a subgroup of APRNs, perform a range of duties, from diagnosing and treating conditions like diabetes, high blood pressure, infections and injuries to prescribing medications, promoting disease prevention and providing health education and counseling.

Although U.S. nurse practitioners have been providing health care for half a century, the health care system now is seeing the benefits of patient access to nurse practitioner-provided health services, said Tay Kopanos, vice president, state government affairs for the American Association of Nurse Practitioners, who added that many patients are choosing NPs as their primary-care providers. The Bureau of Labor Statistics estimates job growth for APRNs to rise by 31 percent between the years 2012 and 2022.

Could physicians want to "protect their turf" by limiting the practice of nurse practitioners? "I would think they'd welcome this arrangement," Gorstein said. "The doctor would see the interesting patients - the ones who have more than a minor ear infection or sore throat - and also would be getting referrals and income from a network of NPs. This is the Walgreens and CVS clinic model; while not perfect yet, it's on the right track."

Team-based care

The average length of a health care visit is less than 15 minutes, hardly enough time to address all of a patient's needs. That's why many practices are creating physician-led teams. Nurses, doctors, community health workers and other work together so the patient receives comprehensive care.

This approach can be more efficient and effective, allowing more time with the professional who has the right expertise, said Dr. Andrew Morris-Singer, president of Primary Care Progress, a grass-roots organization working to revitalize the primary-care system.

"We're seeing team-based care in large groups, solo practices, hospital-based clinics and community-based settings," he said. For instance, for some patients with diabetes, a pharmacist can set up a medication plan, while a registered dietitian can advise on proper nutrition guidelines, eliminating the need for physician visits. The American Medical Association supports this approach to help meet the surge in demands on health care.

Physician assistants

The need for them emerged out of a shortage of primary-care physicians in the mid-1960s. Their training was based on the accelerated training doctors got during World War II. Now, nearly six decades later, physician assistants are part of team-based care and are found in doctor's offices, hospitals and other health care settings. Though they don't practice independently like (most states require the presence of a supervising physician), they typically undergo 26 months of medical training, including about 2,000 hours of supervised clinical practice.

Applicants to an accredited PA program must have a two-year minimum of college education, with a basic focus on science and behavioral science. Many students have worked as paramedics or registered nurses before pursuing their degrees. PA duties typically include performing physicals, taking patient histories, ordering/interpreting tests, developing treatment plans, prescribing medication and assisting in surgery.

General internist Dr. Jane Orient, a member of the American Association of Physicians and Surgeons, recommends looking for a PA "who has experience and has been practicing for a while, rather than someone fresh out of school."

In some states, constant on-site presence of a doctor is not always necessary; in many rural and underserved areas, a PA may be the only primary-care provider for miles. As the need for health care increases, the Bureau of Labor Statistics estimates, the number of PA jobs will increase by 39 percent between 2008 and 2018.


Once a way to connect rural or disabled residents with licensed physicians, this year about 800,000 remote visits will take place in urban areas as well, according to the American Telemedicine Association. "Patients increasingly will want to take advantage of advances in mobile technology via their smartphones and remote monitoring," said Goldmann, who thinks that they have the potential to change the traditional face-to-face physician visits.

For patients, telemedicine offers convenience and time and money saved on travel. Many physicians favor this approach as a way to cut down on overhead and allow more time with patients. Remotely, they can diagnose a condition and prescribe medication or advise patients to visit a specialist or an emergency room.

While some office-based physicians add these consultations to their offerings, it's more common for providers to practice telemedicine exclusively, either at call centers or telecommuting from their video-equipped home offices. Retail clinics are getting into the game, too: Rite Aid, the first to enter telemedicine, offers it at some of its stores in 22 states with its NowClinic program, allowing patients a 10-minute, $45 virtual visit with a physician from OptumHealth. (Walgreens and CVS have gotten into the telemedicine business, including mobile apps, too.) Some experts caution that this cannot and should not replace regular office visits, especially for more complex medical issues.

Dr. Ronald Weinstein, co-founder and director of the Arizona Telemedicine Program, said telemedicine state parity laws require private insurers to cover telemedicine-provided services that are comparable to in-person visits. Considering that the number of states with those laws has doubled in the last three years, there may be a lot more physician-patient online chatter in the future.


When you don't have a doctor

It's good to have an established relationship with a physician before you need one in an emergency situation, said Dr. Robert Wergin, president of the American Academy of Family Physicians, but if you seek care beyond your own physician, or you don't have one, here are some tips:

- Make the provider aware of your medical background and history.

- Be prepared to describe your symptoms, their severity and duration.

- Get a treatment plan at the end of your visit. Ask: What do I do if I don't get better? Are there other health concerns I should have?

- Get a list of qualified physicians or specialists in your area.

- Request that the report of your visit be sent to your personal physician (if you have one) to ensure coordination of care. You don't want important information to fall through the cracks.

©2015 Chicago Tribune
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