By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“Focused Action Beats Brilliance”

– Mark Sanborn, U.S. Author

Coming out of the COVID pandemic, the shortage of primary care and specialty clinicians that has been building over the prior 2 decades has become noticeably more acute.  Early retirements, some deaths and disabilities related to COVID contributed to this, as well as a changing expectation of a better work-life balance which means that the average clinician coming out of training is working less hours per week and expects less-intense on-call responsibilities.  Graduate Medical Education training slots funded by Medicare have been stagnant since the late 1990s, so the supply is getting progressively constrained relative to a growing population, and the average age of physicians is higher than ever as a result.

For many specialists, the most common payer is Medicare, so the stagnant Medicare physician reimbursement rates of the past 25 years (actually a 26% decline when adjusted for inflation) have led to a trend of less specialists in private practice, and more working for medical groups or hospitals.  In rural areas, where there are less groups and hospital employment options, some specialties have been especially impacted.  When the number of specialists drops in a community, the remaining specialists end up taking more call for ED and hospital consultation, making their practice more exhausting and causing a feedback loop of additional retirements.

In the past decade, some factors have alleviated the specialist shortages somewhat, but they do not resolve the underlying issues.

1. Wider use of video telemedicine
2. Primary care clinician using eConsult services to avoid referrals or make the referrals more streamlined.
3. Primary Care Clinicians use UpToDate and other resources to care for their patients without a referral or make referrals more targeted and efficient.
4. Some specialist physicians have hired Nurse Practitioners or Physician Assistants to be Specialist Extenders for initial consultations and ongoing care.
5. Artificial Intelligence-assisted transcription services make documentation and communication more efficient when deployed by specialists.
6. Changing documentation requirements in 2022 has alleviated the burden of inefficient, low-quality clinical documentation.
7. Partnership’s Transportation Benefit allows access to specialists who are further away, when no specialists are available locally.
8. Some tribal health centers, rural health centers and tribal health centers have begun contracting with specialists directly.

What can primary care clinicians do to help?

1. Good workups before referral. Primary care clinicians, especially the growing number of primary care Nurse Practitioners and Physician Assistants, can alleviate specialty demand further by developing systems to ensure that all referrals are warranted and well worked up.  Reserving specialty referral for patients that cannot be cared for by primary care clinicians frees up specialty visits for those patients who need to see specialists.  Send over good documentation with the referral to make the specialist’s workup more efficient.
2. Use telemedicine where possible. Sign up for, use, and embrace Partnership’s specialty telemedicine program.
3. Target specialty referral to the specialist most appropriate to the patient’s needs. Don’t send many referrals to several specialists for the same patient, and clog up the referral system.
4. Have conversations with impacted specialists and their specialist coordinators in your community. These help set expectations and prioritization, as well as standard procedures.  This makes the referral process more efficient for everyone: primary care, specialists, and patients.   Partnership hosts “referral roundtables” in each community: be sure to send your referral staff to these events.

What policy interventions are needed?

1. Medicare Rates: First and foremost, having the U.S. Congress change the Medicare reimbursement system from automatically generating cuts to physician rates to one that inflation-indexes future rates (H.R. 2474).  Related to this, short-term relief by actually generating Medicare rate increases is also important (H.R. 6683). Physicians should coordinate communication with their elected representatives with the American Medical Association, being sensitive to how legislative staff respond to arguments that paying physicians more is key for specialty access.
2. Graduate Medical Education: A dramatic increase in funded GME slots nationally is needed in specialties with the greatest shortages (gastroenterology, cardiology, rheumatology, endocrinology, ENT, neurology) as well as for primary care (H.R. 2389 and S. 1302).
3. Ballot Initiative in California to Lock in MCO Tax link to Medi-Cal Rates. While DHCS plans to increase specialist rates for Medi-Cal starting in 2025, a planned ballot initiative would lock these into place for the future.

What more can be done?

Although there is a broad shortage of specialists, the shortage is more acute for some specialties in some communities.  In these cases, the local hospital may be willing to subsidize recruitment to ensure hospital coverage of the specialist.  A local Health Center may be willing to bring in a specialist under their umbrella.  Partnership is working to track the shortages in each geographic area and to work with community partners to focus energy on these.  Please reach out to your local Partnership regional leadership if you want to help with this effort.