Difficulty scheduling an urgent or time-sensitive appointment is now the most common gripe my patients sound off about to my primary care colleagues and me.
Our practice is not the exception — it has become the rule. A 2022 national survey showed that, on average, it takes 20.6 days to get a family medicine appointment. There are many reasons for this, including, most significantly, a shorthanded clinician workforce, with many physicians either leaving primary care or opting for models like concierge medicine, which allow clinicians to care for smaller, more manageable numbers of patients. Not enough medical school graduates are choosing primary care — instead, many are selecting lucrative specialties to offset surging student loan debt and due to perceived lower primary care career satisfaction.
But one of the most profound influences on access to care is far less discussed: Value-based payment has altered physician incentive structure in non-concierge primary care.
There has been a welcome shift away from simply paying primary care physicians a fee for the volume of services we provide, toward rewarding the “value” of that care — measurable metrics of quality such as success in having eligible patients complete cancer screening and achieving control of chronic diseases, such as hypertension and diabetes. Physicians practicing in a value-based environment must balance individualized care with management of populations, or groups at risk. In many cases, that means priority status goes to encounters that satisfy payer requirements and population-based metrics — annual wellness visits, post-hospital care, comprehensive care visits, and chronic care management — leaving limited access for problems like acute pain, suspected infection, and new mental health concerns. Unable to see their primary care doctor on short notice, patients increasingly end up at urgent care centers or emergency rooms when they are unwell. This works fine in some cases, but leaves many people disappointed that their own doctor with whom they have developed a trusting rapport is unavailable to help solve an acute problem. Many dedicated physicians manage this conundrum by double- or triple-booking patients in order to get them seen sooner than the formal schedule allows.
The goals of value-based care are laudable: improving health outcomes by stressing data-driven focus on prevention, management of at-risk populations, limiting unnecessary hospital admission and re-admission, reducing health care costs, and empowerment and prioritization of primary care. Improved value-based reimbursements finance practice support services that can help unburden doctors from the “widget factory” mindset and excessive task work that are major contributors to burnout. To bring this to fruition effectively, though, requires a much smaller, thoroughly risk-adjusted number of patients than the 2,000 to 3,000-plus that many primary care clinicians currently carry. This, in turn, calls for a clinician workforce capacity that we do not have.
To add capacity, many practices have embraced advance practice providers and developed highly collaborative, team-based care models. Patients who get to know more than one clinician are more likely to see a familiar face if their primary clinician is away or unavailable. Deploying some clinicians to focus the majority of their time to acute/subacute care is another strategy; however, these clinicians cannot build their own core group of patients, which may impede practice growth. This makes a dent in the acute/subacute care access conundrum, but is not a solution. Patient education on making the most of nurse triage, along with what truly requires an office visit, may limit demand, but a patient’s level of concern should always supersede any algorithmic triage assessment.
De facto outsourcing or wedging patients with time-sensitive issues into overbooked schedules is not sustainable. Patients who value a trusting relationship with their physicians agree, judging by the swelling number of messages my colleagues and I have seen from disappointed (and sometimes angry) patients who cannot see a member of their primary clinical team in a time of need.
Physician leaders must push for value-based incentives that better align with patient needs and goals, and allow primary care clinicians the autonomy to balance routine and acute/subacute visits to meet practice demands. For instance, limiting yearly comprehensive visits to patients in the highest risk subgroups should meet the metric threshold.
We must also leverage visit supply and demand data to assess regularly if a practice is allowing sufficient visit schedule slots for time-sensitive access. Support team virtual outreach may often successfully address wellness and quality goals and should suffice for lower risk patients, rather than requiring perfunctory clinician visits, while remote monitoring tools and artificial intelligence applications have much untapped potential for preventive care. Ongoing efforts to reduce the heavy administrative burden clinicians currently face can free up more time to spend with patients.
Ultimately, success is contingent on attracting more clinicians to primary care. If we build it — value-based care with incentives to meet the needs of patients and clinicians most effectively — they will come.
Jeffrey Millstein, M.D., FACP, is an internist, clinical assistant professor at the Perelman School of Medicine of the University of Pennsylvania, and regional medical director for Penn Primary Care.