Will there be enough primary care doctors in North Carolina?

Every so often a report comes out that forecasts a physician shortage, especially among primary care doctors. It happened again in March when the Association of American Medical Colleges warned that as many as 31,000 more primary care physicians in the United States are needed by 2025.

Projections for North Carolina aren’t any rosier. By 2030, the state will need 1,885 additional primary care doctors – a 31 percent increase – according to a 2013 report from the Robert Graham Center (PDF), a Washington think tank on family medicine.

These sorts of predictions – fueled in part by the Affordable Care Act bringing more insured patients into the health care system – have given rise to an equal and opposite reaction from critics who say the fears are overblown.

They point to a distribution problem, not a supply problem: Rural and inner-city areas and some underserved populations do need more doctors, but we have enough total primary care practitioners to go around.

So which is it?

Ask Thomas White, MD, a solo physician in Cherryville and current president of the North Carolina Academy of Family Physicians, and he’ll tell you it’s both. “I think it’s a shortage and a maldistribution. We certainly have a lot of small communities and rural areas that simply don’t have primary care physicians, or if they do, their physician is overwhelmed and taking care of too many patients.”

If these small-town trends play out across the state, it might not bode well for patients. It could mean, for example, longer wait times to see a doctor or a greater likelihood of seeking care at the emergency department.

But the doomsday scenario of patients being unable to find medical help when they need it isn’t likely to occur here. Better incentives for entering family and internal medicine, more use of team-based care delivered partly by physician assistants and others, and easing administrative burdens on doctors will all play a role in helping North Carolinians have ready access to primary care.

One simple fact illustrates the primary care challenge as well as anything: Sub-specialists like cardiologists and anesthesiologists tend to make about double what primary care physicians earn. In response, the state’s medical schools, the North Carolina Academy of Family Physicians and others have worked to make primary care a more attractive option for medical students.

In 2010 the Academy’s foundation started the Family Medicine Interest and Scholars Program with grant support from the Blue Cross and Blue Shield of North Carolina Foundation. The program pairs first-year medical students with a primary care physician in a mentoring relationship. It also provides financial incentives to those who enter a family medicine residency program and then agree to practice in primary care in North Carolina.

So far more than 50 medical students have entered the program. It’s too early to tell about long-term results, but Greg Griggs, executive vice president of the NCAFP, says the mentoring program is especially helpful in getting medical students to see the benefits of family medicine and other primary care specialties as a career path. And that’s good progress in the medical school setting, where there’s a long-standing cultural bias in favor of sub-specialties.

Another way to alleviate fears of a primary care shortage is to shift some responsibilities to physician assistants, nurse practitioners and other appropriate caregivers. Susan Weaver, MD, chief medical officer at BCBSNC, says this notion is picking up steam among physicians, many of whom see their role as being head coach of a team-based approach to care.

“Reducing the administrative burden on physicians and encouraging a patient-centric, team-based approach to care will allow each member of the care team to practice at the top of their license,” she says. Doing so accomplishes two things, she adds: Enhancing the patient experience and mitigating any potential shortage of primary care physicians.

Transitioning to team-based care raises the question: Will there be enough players on the team?

The state’s supply of physician assistants and nurse practitioners has been increasing steadily since the mid-1990s, according to data from the Cecil G. Sheps Center for Health Services Research. There’s only one problem: The proportion of these health care professionals devoted to primary care has been slowly declining, according to a 2014 presentation from the Sheps Center for Health Services Research (PDF), which is part of UNC-Chapel Hill.

Still, the estimated 8,200 physician assistants and nurse practitioners working in North Carolina (as of 2012) represent an important resource for ensuring that patients can get the primary care services they need.

There’s a third factor at work: Making it easier for physicians to actually do what they were trained to do, which is treat patients.

Primary care doctors typically have a list of 2,000 to 3,000 patients. Combine that with the day-to-day duties of running a practice, hiring and managing a staff, staying up to speed on technology, handling insurance claims and meeting a variety of quality standards, and it’s a lot to ask.

The allure of joining a large health care system or multi-office medical practice is strong. As more physician practices either merge or join forces with health systems, it might help ease fears of a primary care shortage, according to a study published in the journal Health Affairs in 2013. It theorized, in part, that large practices can handle more of the practice management and administrative tasks, freeing up doctors to see more patients.

But that analysis doesn’t necessarily speak to the distribution problem. In sections of the state with no major health system or teaching hospital nearby, opportunities are more limited for primary care physicians to do more by joining forces with other practices or health systems.

Health insurers are addressing primary care’s administrative challenges. BCBSNC, for instance, boosts primary care practices’ incomes through incentive payments when those physicians meet nationally recognized quality standards. Quality experts at BCBSNC also help practices get up to speed on those standards.

BCBSNC’s Weaver says the company is working on additional ways to pay primary care doctors for the value they bring patients. One goal is to enable physicians who want to remain independent to do just that – and not feel forced to merge or sell.

In the Gaston County town of Cherryville, White, the family physician, knows both sides of the owned vs. independent divide. He manages a solo practice in his hometown, population 5,760 – the right size to be characterized as a small town, yet close enough to Charlotte to draw enough practicing physicians to meet the community’s needs. Until a year ago, he was employed in a clinic run by Carolinas Healthcare System, the big health system in Charlotte.

White says whatever shortage North Carolina may face in primary care will worsen – but will be tempered by the renewed emphasis on family medicine in medical schools and the shift toward paying doctors and hospitals for quality and value. But then he thinks of one more worry.

“I’m 60. A significant percentage of the membership [in the NCAFP] is over 50, and many are over 60. I get the general sense that they’re retiring and leaving medicine earlier than they ever intended to.

“We need to work to encourage physicians to practice longer, not retire early.”