No one’s promising you can keep your doctor anymore

“You’re not going to go back to the old days,” Bernie Sanders (I-Vt.), the chair of the Senate panel with responsibility for the nation’s health care, said in an interview.

Both Republicans and Democrats agree the old way is no longer feasible — and they’re helping to speed its demise.

Sanders has proposed legislation with Kansas Republican Sen. Roger Marshall that aims to reorganize primary care — but their goal isn’t to restore the reign of independent practices where a town doctor served a community for a lifetime. “That day,” Sanders said, is “largely gone.”

Even before the pandemic accelerated a massive shift to virtual care, more than a quarter of Americans were seeing nurses and physician assistants at their health care visits, according to research published in The BMJ. The study also found that the percentage of visits handled by non-physicians nearly doubled between 2013 and 2019.

Some doctors worry about the impact on care, but it’s a shift born of larger forces. Doctors say high overhead costs and their growing administrative workloads make running a small private practice impossible. Compared with other medical specialties, primary care physicians work long hours for lower pay.

Primary care doctors retiring or leaving the field outnumber new medical school graduates choosing a career in family medicine, according to a recent report from the Primary Care Collaborative, a nonprofit representing clinicians and health care organizations. Every state has seen a reduction in primary care doctors per capita.

To deal with that dearth, the Biden administration and Congress are pushing policies to change how primary care providers are paid and to encourage nurses to take on larger roles. They’re facilitating virtual care’s expansion by lifting restrictions on when and how it can be used.

The administration has set aside over $100 million in grants to train more nurses — in part focused on furthering their training so they can open primary care practices on their own.

“We’re doing this because we got marching orders,” Health and Human Services Secretary Xavier Becerra said when announcing the grants. “We got marching orders directly from President Biden.”

The movement in Washington is accelerating a trend that many Americans are discovering on their own when seeking a new doctor or trying to get an appointment with an old one — the traditional annual physical, in person, with a medical doctor, is getting harder to come by.

Primary care reimagined

Most Americans share a common frustration when they get sick — by the time they can get an appointment with their doctor, they’re feeling better.

As a result, people often go to the emergency room, urgent care, or a pharmacy clinic to get checked out.

Beyond the immediate frustration in getting seen, patients are finding a medical system that’s more transactional than the idealized past.

“There’s no relationship between the person and the doctor,” Sanders said of the current system for many. “The doctor doesn’t know what’s going on in your family, the stresses you may be going through.”

Sanders and Marshall are envisioning a new approach in which more people will receive care at community health centers. Though far from the physician practices of the past, the centers work to make prevention-focused treatment accessible and affordable, especially to patients with little or no insurance coverage.

“Is this transformative? It is,” Sanders said of his bill. “It is a start in the right direction.”

The bill also proposes funding to train more health workers, from doctors to nurses to advanced nurse practitioners — aiming to both build a larger workforce and also upskill the clinicians working in it.

Sanders argues making preventive care more accessible will reduce costs in the long run, but some lawmakers aren’t convinced.

Sen. Bill Cassidy
(R-La.), a gastroenterologist and the ranking member of Sanders’ committee, sees merit in expanded community health centers but opposes the bill on cost grounds.

“We can agree with the diagnosis and disagree with the prescription,” he said at a hearing about the legislation.

Cassidy offered a proposal that would give community health centers a boost in funding, albeit more modest than the one proposed by Sanders and Marshall. But he suggested the private sector should be devising new approaches.

The Biden administration is working on a separate track toward the same objective — stretching the system to serve more patients.

The Department of Health and Human Services is funneling money to primary care doctors, training more health workers and expanding the definition of a primary care provider.

The Centers for Medicare and Medicaid Services has plans to pay more to clinicians providing preventive care, even at the expense of how much specialists are paid.

The agency is standing up an eight-state pilot program that, over the next decade, aims to boost primary care access for Medicare and Medicaid patients — complementing a smattering of demonstration projects testing new ideas.

Even the Department of Veterans Affairs has joined the effort. The agency, which provides health care for more than 9 million veterans, is developing standards that could allow nurses and physician assistants to serve patients more broadly than they can now.

Many provider groups say the VA’s decisions could have outsized impacts on how state governments, usually in charge of the standards, set their requirements.

Care for the other half

If the new world Congress and the Biden administration are shaping doesn’t appeal, there’s an alternative: concierge medicine.

The catch: It will cost you.

Patients willing to pay out-of-pocket fees typically in the range of $2,000 per year — on top of the exorbitant cost of private health insurance — see their primary care doctors on their terms.

“It requires resources. It means that people who struggle to make ends meet or are maybe either uninsured or publicly insured aren’t going to be able to access that care,” said Dr. Elisabeth Wilson, a family physician who chairs the community and family medicine department at Dartmouth Health and the Geisel School of Medicine in New Hampshire.

Concierge medicine appeals because patients don’t have to schedule appointments months in advance. There’s no waiting, exams are unhurried and the doctors respond to phone calls. Some concierge doctors even join patients during specialist visits to weigh in on their care.

The nation’s largest concierge group, MDVIP, includes 1,200 affiliated doctors treating 385,000 patients. It estimates there are roughly 6,500 concierge providers in the field overall.

That’s just a sliver of the nation’s roughly 200,000 full-time family and internal medicine doctors.

But concierge medicine is growing steadily. One market research firm recently pegged the growth rate from now to 2030 at more than 10 percent a year.

Big tech is trying to make membership-based primary care more affordable, albeit without promising a one-on-one relationship with a doctor.

Earlier this month, Amazon announced that members of its Prime service ($14.99 per month) could pay an additional $9 each month to join its One Medical subsidiary and with it access to round-the-clock virtual care and easy-to-schedule in-person appointments.

The company sees it meeting keen consumer demand.

“It’s not physically possible to have your doctor be with you 24/7, but as a consumer, you want that,” Dr. Sunita Mishra, Amazon Health Services’ chief medical officer, said.

The _____ will see you now

Anyone who’s checked their insurers’ list of available primary care doctors of late will attest: Many of them aren’t doctors, but nurses or physician assistants.

This is a feature of the new primary care, not a bug. Expanding nurses’ and physician assistants’ “scope of practice” is one of the ways policymakers are trying to improve access to care.

Both the Biden and Trump administrations have offered grants to nurse practitioner residency programs, aimed at enabling NPs’ to do more work previously reserved for doctors.

Doctors’ groups have historically opposed those changes and many still do, arguing that it will endanger patients and ultimately make care more costly.

“What we need is programs to increase the number of our physicians,” Dr. Gary Floyd, former president of the Texas Medical Association, told POLITICO after the Biden administration announced grants to help nurse practitioners set up their own practices.

Nurse practitioners’ groups have argued that they have adequate training to take on a larger role in the system — and that outdated laws need to be updated to reflect that.

Many doctors in primary care have acknowledged that the system has to change and even willingly outsourced more of their work. By having nurses and physician assistants handle more of the care, they can increase their patient volumes and incomes.

They say it works because a doctor is still providing oversight.

“We’re thrilled to have more nurse practitioners and more physician assistants,” said Wilson, the family physician in New Hampshire. “The onus is on us to help people understand that as a team we actually provide better care and they will have better outcomes,” she said.

Dr. Ateev Mehrotra, a professor of health care policy and medicine at Harvard Medical School, oversaw the BMJ study that found a rapid increase starting a decade ago in patient visits handled by non-doctors.

Instead of replacing doctors, he said the study suggests that nurse practitioners may be addressing less severe illnesses, like urinary tract infections, respiratory illnesses and annual exams, while doctors handle visits where their training is most needed, like heart disease and new patient visits.

“It’s happening, but is it leading to worse or better care? I don’t know of any evidence to raise concern for the public,” Mehrotra said.

A tech transformation

Telehealth boomed during the Covid pandemic, driven by decisions by the Trump administration and Congress to permit Medicare to pay for virtual visits.

Congress has extended those permissions through 2024, and lawmakers are already looking to make them permanent.

In the private sector, investment in virtual care ballooned.

Early research on how expanded virtual care is working out is largely positive — finding that patients who can more easily access care are more likely to do so and getting routine preventive care keeps us healthier longer.

But this future also means less face time with a single doctor — telehealth models typically direct patients to available clinicians, some of whom are doctors, some nurses and some physician assistants.

Some telehealth businesses are experimenting with models that try to preserve the caring in care.

Mehrotra pointed to Iora Health. It uses health coaches as the primary point of contact for patients, while medical doctors oversee care behind the scenes. The concept is meant to ensure culturally competent care, since coaches are hired from the patient’s community, sometimes even their hometown.

Iora was purchased by One Medical in 2021 and is now an Amazon subsidiary.

Other providers, like Firefly Health, see a virtual-care model as a way to offer patients a better selection of providers — who are experts in their needs or to whom they feel they can better relate.

Wilson said that virtual visits save her rural patients hours of driving and having to take off work. It’s a great option for monitoring chronic diseases or talking through the side effects of a new medication, she said.

Still, she worries about losing a key component of what primary doctors love about their work: relationships.

“There’s something to be said about that in-person interaction,” she said.

Goodbye to the family doctor

Dr. Allen Ditto is among the last of a dying breed.

He’s a third-generation primary care doctor who grew up going on house calls with his father and grandfather.

But over the course of his nearly 40-year career in Hagerstown, Md. — a small, working class town 70 miles northwest of Washington — independent practice became unsustainable. Ditto moved from solo practice to group practice and finally to a local health system before retiring in 2019. He was even courted by a concierge medical company later in his career, although he opted not to take the plunge.

It’s no longer viable to go it alone, he said, and administrative requirements from insurance companies are time-consuming and burdensome. “That’s killing things. It’s just so incredibly complex,” he said.

Wilson also said after-hours administrative work influenced younger colleagues’ decisions not to do full-time clinical care. “We know that every evening and a lot of the weekend is going to be taken up,” she said.

Still, she’s hopeful about the field, describing family medicine as a kind of social movement: “It’s a way to provide the kind of care that our communities need,” she said.

What that care looks like is just different than it once was. “The small, one-person or two-person practice can no longer afford to keep the doors open,” she said.

Ditto’s son is also a doctor, but he’s chosen a different path than his dad. He’s practicing part time and teaching residents family medicine in the local hospital system.

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