Q&A: Researcher discusses how buying primary care on the free market adds to doctor shortages

Burned-out primary care physicians are increasingly seeking safe haven in concierge care and other free-market models of practice. This has resulted in an exodus from traditional primary care practices and exacerbated an already acute shortage of primary care physicians. These alternative models also give patients more personalized care and attention. But for the rest of people who get their primary care from traditional practices, the already pressing shortage of primary care doctors often gets worse.

But this evolution toward the free market has pros and cons for doctors and patients alike, highlighting an urgency to strengthen traditional forms of primary care, according to a recent perspective in NEJM, co-authored by Harvard Medical School researcher Zirui Song.

To find out what this trend portends for primary care, Harvard Medicine News spoke with Song, who is an associate professor of health care policy in the Blavatnik Institute at HMS and a primary care doctor at Massachusetts General Hospital. He co-authored the piece with Jane M. Zhu, a primary care physician and associate professor of medicine at Oregon Health & Science University.

Why is the persistent shortage of primary care doctors such a grave concern?

Not only is good primary care a trusted first stop for patients, it’s a safety blanket that follows you through life. It knows you, prevents disease, and anticipates needs. As the population gets older, medicine more sophisticated, and the health care system more complex, having good primary care doctors available for the people of this country is a necessity, not a luxury.

Unfortunately, primary care is becoming increasingly hard to get. Over 30 percent of U.S. adults now don’t have a regular source of primary care.

What drives this shortage?

A lot of primary care physicians are close to retirement, and there aren’t enough trainees to fill the gap.

Burnout, income disparities between PCPs and specialists, and the loss of autonomy in practices owned by health systems have contributed to primary care doctors leaving medicine. Meanwhile, physicians in training, with medical school debt averaging over $200,000, generally look to other specialties when choosing careers in the United States.

You and your colleagues have found that concierge care and direct-pay care, two alternative models of primary care, are growing. Why?

Concierge practices offer personalized care and exclusive access, including same-day or next-day appointments, home visits, and sometimes accompanied visits to specialists. Doctors still bill insurance. Membership fees can range from thousands to tens of thousands of dollars a year. Direct primary care (“DPC”) does not deal with insurance. So, patients avoid premiums and co-pays for primary care, instead paying for its services and common prescription drugs out-of-pocket, often at reduced, bulk-purchasing prices. Membership fees are often several hundred to thousands of dollars a year. Some practices have features of both concierge and DPC.

For doctors, these models can restore their autonomy and joys of practicing medicine, with less paperwork, less administrative burden, smaller caseloads, and more face time with patients—all while earning higher incomes. This can extend careers. Patients get shorter wait times, their doctor’s cell phone number, and personalized attention, provided they can afford it.

How does this free market figure into the primary care shortage?

Patient panels are much smaller in these models—a few hundred, rather than upwards of 2,000 or more for a full-time doctor. For every doctor who leaves traditional primary care, most of their patients remain in the old practice looking for a new primary care doctor. This can add work to the remaining doctors, making it more likely the next physician will leave too.

Of course, if a doctor was going to exit medicine altogether, then at least taking a few hundred patients to a concierge or DPC practice makes the shortage less bad than it would have been if they’d just retired or changed careers. But not all doctors leaving for concierge or DPC may be on the cusp of leaving medicine altogether. Even if they all are, the urgency to help traditional practices stay afloat amid this exodus remains.

Finally, the shortage hits people differently. Disadvantaged patients may be less able to follow their doctors into membership practices or find a new doctor altogether.

Has there been any movement on the policy front to fix the problem?

Yes, at the federal level, many have advocated raising the fees of primary care services. Increasing primary care residency slots, forgiving medical school loans for primary care doctors, and “value-based” payment models that have given extra lump sum payments to primary care have also been tried. It’s not clear how these well-intended efforts are competing with the appeal of the free market, but time will tell.

Nearly 20 state governments have taken steps to invest in primary care too—raising spending on primary care services and encouraging more lump-sum payments to primary care. The evidence is still emerging.

Are health systems or physicians themselves trying to find solutions?

Some health systems have made investments in primary care. This has included adding support teams for physicians, such as nurse practitioners and physician assistants, and technology like AI scribes to make it easier to write clinic notes. Offloading prior authorization work, phone calls and electronic messages, or weekend on-call responsibilities are other examples.

Fundamentally, however, many physicians leaving for these newer practices prefer autonomy over employment in a health system and prefer to not deal with insurance. This may limit what payers and health systems can do.

What does all this mean and is there a way forward?

Primary care has long been viewed as a common good, but it’s increasingly supplied and demanded on a free market. This market can teach us a lot about what doctors and patients like and how to make the primary care job—and patient experience—more satisfying.

Many advocate that everyone in the country should have a personal physician in one of these new practice models—free from insurance, administrative burden, and large patient panels. That ideal, however, is unfortunately far from the reality faced by many communities today. Until the day we have enough primary care doctors to make that possible, the challenge right in front of us is helping traditional practices take care of more patients with fewer doctors. Bolstering primary care through payment, staffing, and technology is likely the more realistic next step.