When professor Yashaswini Singh, a health economist, accepted an offer to teach at Brown in 2023, the first piece of advice she received was: “Get on a waitlist for a primary care doctor. If you wait till you’re here, it’ll be an additional year of waiting.” Singh “wasn’t entirely surprised.” Part of the expertise she brought to the School of Public Health was how the corporatization and consolidation of medicine have contributed to the very primary-care crisis she was trying to navigate.
More than 100 million people in the United States don’t have a primary care physician (PCP), and of those without PCPs, about a quarter are children, according to the National Association of Community Health Centers.
“Until the 1940s, 70 to 80 percent of all physicians in the United States were generalists, which are primary care providers,” said Jeffrey Borkan, assistant dean for primary care–population health at the Warren Alpert Medical School. “We’re now somewhere between 20 and 30 percent. We need to be around 40 or 50 percent primary care physicians. So the national deficit is enormous.”
For patients, this means long waitlists to get a provider, trouble booking appointments, or finding out that their PCP retired or quit without a transition plan. The upshot? More Americans have no access to the most important part of health care.
“Primary care is the only part of the health system where we can document that the more we have, the longer populations live and the more health equity we have,” said Christopher Koller, a professor of the practice of health services, policy, and practice at the School of Public Health. “We can’t say that about hospitals, about plastic surgeons.” Research also shows that primary care saves money.
Why is there now a dearth of primary care doctors? The answer lies in a story that Koller tells: A medical school student in Michigan doing a rotation with a primary care doctor “looked at the doc and said, ‘Why would I want to go into primary care? You work harder than anybody else, and you don’t get paid as much.’ That’s it in a nutshell.”
PCPs have become de facto care coordinators, monitoring labs and imaging, chasing specialist reports, communicating through patient portals, and documenting every step of care. Often, said Koller, “the clinicians are home in the evening in their [pajamas] trying to answer all these questions.”
And we don’t pay them enough. “The average specialist in this country makes over $400,000 a year,” said Singh. “The average PCP makes somewhere between $250,000 to $275,000.”
That disparity is exacerbated by fees for specific services. As the largest single payer of health care in the United States, Medicare essentially sets the standards everyone else follows—especially what they can bill for a particular service or procedure. The committee determining those fees “has a disproportionate representation of specialists rather than generalists,” said Singh. So payments for specialty care services and procedures have risen much faster than they have in primary care. What follows is medical students, burdened with debt, flocking to higher-paying specialties. Of those who do choose primary care residencies, “only one-third end up practicing primary care,” said Singh. “There’s attrition at every stage.”
Nurse practitioners and physicians’ assistants make up for some of the shortfall, but there are still not enough PCPs, said Borkan. Barriers include state-by-state variations in how PCPs are allowed to practice and the same fee disparity that also pushes doctors into specialty care.
“In the last 20 years, we’ve had underinvestment in primary care training, reimbursement, and infrastructure,” said Borkan. Out of all health spending in the United States, only 5 percent goes to primary care, compared to 13 percent in other high-income countries.
Enter private equity
As primary care weakened, private equity firms saw an opportunity: a product with steady and growing demand, a fragmented market of small practices, and the chance for quick returns through consolidation and cost cutting. “Private equity is focused on taking poor-performing assets and generating better financial performance so that investors can make money,” said Koller. In health care, private equity does that by focusing on “specialty services, laying off people in hospitals, and lowering expenses.”
Private equity can “reduce some of what has made the practice of primary care so daunting,” said Singh. But profit pressures change the work. Providers are pushed to see more patients and bill for more services.
And that undermines the very reason most do the job. “If you ask physicians why they go into medicine, it’s always to spend more time with patients,” said Singh. Under corporate pressure, morale often drops and burnout rates rise.
New practice models
With the medical system straining, “there’s a growth of new practice models,” said Singh. One, called direct primary
care, cuts out insurance companies, and patients instead pay providers a monthly or annual fee. Concierge practices also charge membership fees, often very high, in exchange for guaranteed access to clinicians. “It solves some of the burnout problem,” said Singh. “Rather than seeing 2,000 patients per year, you might see 500.” But few patients can afford the cost, so “it doesn’t solve the access problem in a sustainable way.”
What will? Medicare reform is key. One bipartisan proposal, the Pay PCPs Act, introduced by U.S. Senators Sheldon Whitehouse, of Rhode Island, and Bill Cassidy, of Louisiana, calls for a new Medicare fee structure that would pay providers for each patient they serve in addition to paying for specific services and lowering patients’ share of costs.
Other approaches include increasing the number of primary care residencies, shortening medical school to three years for students who commit to the field, implementing loan forgiveness for primary care doctors, and easing the administrative burden on physicians.
In Rhode Island, Governor Dan McKee and Attorney General Peter Neronha have advanced a number of measures to deal with the shortage of primary care doctors, including requiring commercial insurers to increase primary care reimbursement rates, eliminating the prior authorization requirement (to reduce paperwork), and awarding grants to help doctors expand their primary care practices.
“We’re in a pretty deep hole,” said Borkan. “To dig out of it, we’re going to need multiple programs and multiple points of improvement.”
another new pipeline
In 2019, the first students graduated from Brown’s Primary Care–Population Medicine Program, which offers a joint MD and master’s degree. The MD focuses on primary care. The master’s is in population medicine, centered on improving health outcomes for entire communities.
“It’s an effort to increase the number of students doing primary care,” said Borkan, “but also to create a cohort who could be leaders in thinking about ‘How do you take care of individuals, families, communities, and populations?’”
More than 60 percent of the graduates have entered primary care, and many have already taken on leadership roles in health policy.
“They’ve created quite a buzz, in Rhode Island and nationally,” said Borkan, “as individuals who will be able to solve this multifactorial problem of how we create a health-care system that works efficiently and effectively.”
