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The Keckley Report

The Missing Piece in the Primary Care Physician Shortage Puzzle

By January 23, 2023March 1st, 2023No Comments

In its latest assessment of the U.S. physician workforce, the venerable Association of Academic Medical Centers (AAMC) projects a shortage of between 17,800 and 48,000 primary care physicians by 2034.

“The demand projections reflect changing demographics as the population grows and ages, the rapidly growing supply of advanced practice registered nurses (APRNs) and physician assistants (PAs), and other important trends in health care such as a growing emphasis on achieving population health goals. Because it is impossible to predict with certainty the degree to which any scenario will transpire, the projected shortages are presented as a range under the most likely scenarios rather than as a single number.”

Appropriately so. A shortage in primary care physicians has been a staple of AAMC’s forecasts since 2008. In its latest (January 2023), it offers…

·       “In 2021, the specialties with the largest numbers of active physicians were the primary care specialties of internal medicine (120,342 physicians), family medicine/general practice (118,641), and pediatrics (60,305).

·       In 2021, the specialties with the largest numbers of first-year ACGME residents and fellows were the primary care specialties of internal medicine (11,297), family medicine/general practice (4,856), and pediatrics (3,143). “

Through the years, AAMC has modified its models to include scope of practice expansion (pharmacists, advanced practice nurses et al), financial incentives (i.e., ACOs, Direct Contracting) and telehealth services in its calculus, but the results have been the same. It has reviewed administrative relief programs offered by hospitals and the terms and conditions of physician employment in organizations like Optum, Iora, Oak et al to compare primary care settings with the same result: shortages. And an aging population, increased chronic disease prevalence and inaccessibility of primary care services in rural and under-served populations exacerbate shortages with no easy solutions in sight.

My take:

AAMC serves a critical role in the U.S. health system overseeing medical training in 170 U.S. & Canadian medical schools, 400 teaching hospitals and nearly 80 academic societies involving 191,000 medical faculty, 149,000 medical residents and 95,000 medical students. Its’ task is daunting. Its 19-person Board of academicians, health system leaders and public representatives has a full plate– curriculum design, residency expansion and oversight, competency training, diversity and more. Arguably, transforming primary care is its most urgent.

Solutions to the shortage have shown promise, but an important piece is missing: AAMC must embrace technology enabled self-care as a core competence. Amazon, CVS, Walmart, Best Buy, Walmart  and others are betting on it and AI solution providers like Open AI (ChatGPT launched in November 22) are enabling it. It is an orientation to primary care that’s holistic (physical, emotional, spiritual), omnipresent and personalized. But in many academic circles, its runs afoul of biases against consumerism in healthcare.

Polls show individuals want information about their conditions, treatment options, risks and costs. Satisfaction with the status quo is low so they’re receptive to new approaches, especially younger and middle-age consumers in the working age population. The population of primary care physicians is worn-out and thinning: many are older and unable to keep the 2400 patient visits/year expectation. And 90% of those recently trained in general internal medicine and 40% trained in pediatrics will up practicing as specialists.

The keys to mitigating the primary care shortage are multi-factorial, but technology-enabled self-care must be prioritized as a core competence. It’s the missing piece.



Primary Care 3.0 The Keckley Report September 24, 2018

2022 Physician Specialty Data Report Executive Summary: January 2023

The Complexities of Physician Supply and Demand: Projections From 2019 to 2034 June 2021 Prepared for the AAMC by IHS Markit Ltd.

Fazio SB, Demasi M, Farren E, et al. Blueprint for an undergraduate primary care curriculum. Acad Med. 2016;91:1628–1637.

Dalen JE, Ryan KJ, Alpert JS. Where have the generalists gone? They became specialists, then subspecialists. Am J Med. 2017;130:766–768.

Deutchman M, Macaluso F, Chao J, et al. Contributions of US medical schools to primary care (2003-2014): Determining and predicting who really goes into primary care. Fam Med. 2020;52:483–490.

Donnelly MJ, Thornton SC, Radabaugh CL, Friedland AR, Cross JT, Ruch-Ross HS. Characteristics of the combined internal medicine-pediatrics workforce. Am J Med. 2015;128:1374–1379


“If brand and complex clinical capabilities are traditional strengths of AMCs, access has long been a traditional weakness. Across multiple geographic areas, all AMCs leaders we spoke with acknowledged that patients struggle to access their facilities promptly. Most saw this as an issue necessary to fix — both from a moral and economic perspective” Oliver Wyman THE FUTURE OF ACADEMIC MEDICAL

“In the last 40 years, medical schools have seen fewer Black male medical students and fewer Native American students. According to a new report, Black male students now only account for 2.9% of the U.S. medical student body, while Native American students account for less than 1%. There are many barriers that prevent these and other underrepresented groups from being selected by admissions committees, or even applying to medical schools in the first place. For one, the price of admission to medical school is very high; the average annual tuition for a medical student is $37,000 while the application process is over $7,500. Second, overreliance on cognitive metrics like GPA and MCAT also disadvantage underrepresented minority applicants.” Acuity Insights November 2021

“Young people are always an enigma to their elders: Socrates surely wasn’t the first to grumble that the young are disrespectful, even tyrannical, towards adults. It’s no wonder, however, that today’s youth seem mysterious. Gen-Z are woke, broke and complicated. They have thin wallets and expensive tastes. They crave authenticity even as they are constantly immersed in an ersatz digital world. From brands they demand both instant gratification and a social conscience. They want different things from their employers, too: flexibility, more security—and more money. Their elders, meanwhile, argue over everything from how strictly to discipline children in school to how much time kids should spend on their phones. But if youngsters baffle the rest of the world, they also inspire it for their activism and ambition. They constitute a generation unlike any before. The Economist January 21, 2023

“Blood-pressure devices, glucometers, and dialysis machines all once resided exclusively in the hospital or clinic, and now patients routinely employ them at home. In fact, this approach is currently being tested two hundred and fifty miles above Earth’s surface, where crew members aboard the International Space Station are using ultrasound to assess themselves for eye injuries, fractures, and other ills…Scott Dulchavsky, a surgeon, recently led a number of NASA’s ultrasound research investigations. If artificial intelligence progresses, he said, and if the price of portable ultrasound devices continues to fall, “it’s going to be ultrasound for dummies pretty soon.” Stethoscopes were just for doctors. Ultrasound could be for everyone. Clifford Marks “Could Ultrasound Replace the Stethoscope Miniaturization, experimentation, and A.I. have unlocked revolutionary potential in an old technology. January 20, 2023New Yorker January

 “We believe the current primary care land grab will bring about a wave of behavioral health investment. It is clinically undeniable that coordination between behavioral health and primary care providers significantly improves patient outcomes. However, due to the scarcity of behavioral health providers, many of the fastest growing primary care platforms do not provide fully integrated behavioral health services. As the MA space becomes more competitive—and as CMS rachets up star rating benchmarks and prioritizes behavioral health network access—we believe primary care providers that can manage patients longitudinally alongside behavioral health services will be at a distinct advantage.” Pitchbook Takeaways from the 2023 J.P. Morgan Healthcare Conference: Deals, Trends, and Predictions January 18, 2023


Gallup: majority dissatisfied with the health system: “For the first time in Gallup’s two-decade trend, less than half of Americans are complimentary about the quality of U.S. healthcare, with 48% rating it “excellent” or “good.” The slight majority now rate healthcare quality as subpar, including 31% saying it is “only fair” and 21% — a new high — calling it “poor. The latest excellent/good rating for U.S. healthcare quality is just two percentage points lower than in 2021; however, it is well below the 62% high point twice recorded in the early 2010s. It also trails the average 55% reading since 2001.” Other highlights of the latest Gallup survey:

·       56% of Republicans rate healthcare quality as excellent or good, whereas 69% felt this way in 2020 and 75% in 2019. Democrats’ positive ratings have been steady at a lower level (currently 44%).

·       Since 2012, public satisfaction with healthcare has trended downward among middle-aged and younger adults, while remaining high among those 55 and older.

·       24% are satisfied with health costs and 76% dissatisfied. The percentage satisfied has averaged 22% since 2001, only once straying more than a few points from that — in 2020 during the pandemic, when 30% were satisfied.

·       38% of respondents or a family member delayed treatment over costs in 2022, a 12 % increase compared to 2020 and 2021. the largest over one year since Gallup first began tracking these data more than two decades ago. The previous high was 33% in 2014 and 2019, while an average of 29% of patients reported delayed care over costs from 2001 to 2021.

Americans Sour on U.S. Healthcare Quality Gallup January 19, 2023

Morning Consult: 55% trust public health agencies: The MC survey was conducted Dec. 14-19, 2022, among a representative sample of 2,210 U.S. adults. Highlights:

·       55% of U.S. adults said they trust public health institutions to manage a potential future pandemic considering how the COVID-19 crisis was handled vs. 37% who said they do not trust institutions to handle the response,

·       Baby boomers made up 45% of those who said they trust health institutions “a lot,” compared with 26% who said “not at all.” Gen Zers and millennials made up a larger share of those who do not trust public health institutions on future pandemics than those who do.

·       Among respondents who said they trust institutions to manage the next pandemic “a lot,” nearly 2 in 3 were Democrats, while Republicans accounted for more than half of those who responded “not at all.”

·       Americans are more likely to trust health information from public health agencies (67%) than the White House (48%).

·       Nearly 7 in 10 said social distancing is the most effective measure used to stop the spread of COVID-19.

Public Health Agencies Are Retooling as COVID-19 Response Winds Down. A Slim Majority of Adults Trusts Them to Manage Another Pandemic January 19, 2023

Public Opinion Strategy: Healthcare non-factor in 2022 mid-term election but big in 2024: “Health care was not a major factor in the 2022 midterm elections. In fact, it was not even offered as a choice for “most important issue” to the 18, 571 voters who completed the Edison Research exit poll (the exit poll used by ABC, CBS, CNN, and NBC) …

Two surveys of actual midterm voters showed where health care ranked on the issues list. In a Harvard T.H. Chan School of Public Health survey, 34% of voters said health care was extremely important to their vote, ranking 12th of 19 issues tested.4 Further, in a Public Opinion Strategies survey, 9% said health care was one of the top 2 issues that factored into their vote, ranking the issue seventh of 10 issues tested…

What may elevate health care back to the top of the issue set are widespread concerns regarding health care costs. A Kaiser Family Foundation survey from March found that more than 40% of US individuals live in a household where someone has postponed receiving medical care during the past year due to cost. Further, two-thirds of US individuals express concern that an illness or medical emergency in their family would be followed by bankruptcy.

Lewis, Stryker the Role of Health Care in the 2022 Midterm Elections January 18, 2023. doi:10.1001/jamahealthforum.2022.5489

Axios study: Gen Z career aspirations: Young people today are more likely to job-hop, but they are also looking for stability by pursuing careers as CEOs, doctors and engineers” according to a Axios/Generation Lab January ‘23 study of 824 young people 18-29. Highlights:  

·       Gen Z-ers prefer larger companies — with 58% saying they’d prefer a big or mid-sized corporation over a startup or a government job. Just 14% aspire to work for the government.

·       Gen Z leading motivator as they advance in their careers is personal fulfillment (49%), followed by wealth (25%).

·       “Contrary to polling that indicates Gen Z cares more about their employers’ stances on social issues more than previous generations, just 9% of respondents said societal impact is their top driver when it comes to work.

·       Gen Z is also driving the “quiet-quitting” trend, with 82% of them saying the idea of doing the minimum required to keep their jobs is pretty or extremely appealing.”

Axios + Generation Lab Youth Poll: Career Aspirations January 21, 2023


Inflation slowed but conditions remain challenging: December marked the sixth straight month of slowing inflation — a welcome sign for consumers and policymakers. Despite the slower inflation, consumer spending appears to have ended 2022 on a disappointing note. Morning Consult’s consumer spending data showed a 4.3% decline in December, directionally in line with Bloomberg Consensus forecast for retail and food services sales. 

·       Inflation continued to slow in December, but this dose of price relief seemed unable to meaningfully boost spending.

·       Consumer demand appears to be flagging for both goods and services as consumers increasingly make trade-offs amid budgetary pressures.

·       Household finances are starting 2023 on considerably weaker footing than was the case a year ago, with higher earners less insulated from the negative effects of elevated inflation. 

Morning Consult’s January U.S. Consumer Spending & Inflation Report.

SPACs face uncertain future: “At their peak, SPACs accounted for 70% of all IPOs, with $95 billion raised. But now, the market has dried up and shares of companies that did SPAC deals have crashed. WSJ explains the decline of the IPO vehicle. Illustration: Ali Larkin

SPACs typically have two years to do a deal or they must return cash to investors and the creators forfeit the money they spent to set up the SPAC, normally around $10 million. More of those liquidations have occurred in recent weeks than happened in the entire market’s history, fueling losses for creators above $1 billion.”

SPAC Deals Shrink After Speculation Wanes: Small mergers to take startups public are replacing the splashy deals of 2021 WSJ January 21, 2023

Freddie Mac: Housing affordability slightly improved but well below pre-pandemic: The National Association of Realtors on Friday reported that a seasonally-adjusted 4.02 million previously-owned homes were sold in December, at an annual rate, down from 4.08 million existing-home sales in November. That was the lowest sales pace since November 2010—one of the worst months of the housing bust.

On Thursday, Freddie Mac reported that the weekly average rate on a 30-year fixed mortgage was 6.15%, which compares with a peak of 7.08% in early November. Prices are falling, too—with the caveat that the NAR doesn’t adjust for the mix of homes sold, Friday’s release showed the median price on an existing home was $366,900 in December versus a high of $413,800 in June.

An affordability index released earlier this month by the NAR, based on home prices, median family incomes and prevailing mortgage rates, rose to 95.5 in November from a multidecade low of 91.3 hit in October. (Lower values indicate lower affordability.) For comparison’s sake, over the 12 months before the Covid crisis struck, it averaged 162.

Housing’s Big Hurdle Is Affordability: Home prices and mortgage rates are coming down, but not enough WSJ January.20, 2023


Study: Hospital price transparency remains low: Researchers from Harvard, Yale and GoodRx analyzed a nationally representative sample of nonprofit, for-profit, teaching and other hospitals to evaluate whether or not they were posting their prices online. Findings:

  • Of the 64 acute care hospitals selected, 19% fully complied with CMS price transparency rules.

  • Teaching and non-profit hospitals were more likely to comply with half of the requirements.

Loccoh, E.C., Khera, R., van Meijgaard, J. et al. Hospital Adherence to the Federal Price Transparency Mandate: Results from a Nationally Representative Sample. J GEN INTERN MED (2023).


KFF lit review on effect of Medicaid expansion in states: KFF analyzed findings of 24 studies published between April 2021 and December 2022 on the economic impact of Medicaid expansion on providers. Conclusions:

·       “Consistent with previous research, nearly all recent studies find that expansion has resulted in payer mix improvements, including among patients treated for specific conditions, as well as decreases in UCC. “

·       Recent studies continue to find mostly positive financial impacts of expansion on specific types of hospitals, clinics, and other providers.: Hospitals experienced higher reimbursements and that decreased uncompensated care costs outweighed increases in unreimbursed Medicaid care for a net positive effect. Federally qualified health centers and community health centers experienced increased revenue following expansion and one study found higher salary growth for primary care providers in expansion versus non-expansion states. “

What Does the Recent Literature Say About Medicaid Expansion?: Economic Impacts on Providers KFF January 18,

Study: reimbursement for televisits vs, in-person similar: KFF analyzed nearly 100 million claims compiled by the Health Care Cost Institute to compare the average amount private insurers paid for in-person and telehealth evaluation and management (E&M) services and mental health therapies in 2020. Findings:

·       Mental health therapy claims payments were similar for in-person and virtual care that year. For example, a 30-minute psychotherapy session was $48 for a privately insured individual, regardless of whether it was provided in-person or via telehealth.

·       Among the majority of doctors who offered both telehealth and in-person care, the average paid amount for claims delivered virtually was within plus or minus 10% of that for claims delivered in person.

·       Private insurers paid roughly the same for telehealth and in-person visits during the early days of the COVID-19 pandemic as virtual care surged.


Study: mandatory high deductible plans increase diabetes risks for employees: “In this cohort study of 245, 055 US adults with diabetes enrolled in employer-sponsored health plans between 2010 and 2018, forced transition to an HDHP increased the odds of experiencing an emergency department (ED) or hospital visit for severe hyperglycemia by 25% during the study period, with the odds increasing 5% for each year of HDHP enrollment. Although forced transition to HDHP did not increase the odds of ED and/or hospital visits for severe hypoglycemia over the whole observation period, the odds increased by 2% for each year enrolled in an HDHP.

In this study, patients with diabetes who switched to HDHPs were significantly more likely to experience serious, but preventable, acute diabetes complications compared with patients who remained in conventional insurance plans; these findings suggest the need for policy solutions to address health plan-mediated barriers to diabetes care.”

Jiang et al Evaluation of High-Deductible Health Plans and Acute Glycemic Complications Among Adults with Diabetes JAMA Netw Open January 20, 2023;6(1):e2250602. doi:10.1001/jamanetworkopen.2022.50602


Medical residents joining unions: Physicians-in-training at top teaching hospitals across the country are joining unions, demanding higher pay and better working conditions. The Committee of Interns and Residents, the largest group representing doctors in residency and fellowship programs, said it added chapters at five teaching hospitals last year and two in 2021, up from a pracademic pace of roughly one a year. CIR, which is affiliated with the Service Employees International Union, said it represents about 15% of the nation’s 140,000 residents and fellows. 

Medical Residents Unionize Over Pay, Working

Health Costs

Study: Global burden of ortho disorders due to BMI: “In this cross-sectional study of 192 countries and territories, 7.3 million years lived with disability and $180.7 billion total costs associated with musculoskeletal disorders were attributable to high BMI: $605 billion in direct medical expense and $120.2 billion in indirect costs.

In terms of the global health care costs, 58.9%was borne by the public sector, 24.0% by the private sector, and 17.1% by the out-of-pocket sector. On average, the total costs accounted for 0.2% of global gross domestic product. Great inequalities in the disease and economic burden existed across regions and countries. Nearly 80% of global health care (82.4%) and morbidity-related costs (82.9%) were paid by high-income countries, whereas more than 60% (61.4%) of global YLDs occurred in middle-income countries.”

Chen et al Health and Economic Outcomes Associated with Musculoskeletal Disorders Attributable to High Body Mass Index in 192 Countries and Territories in 2019JAMA Network Open. 2023;6(1):e2250674. doi:10.1001/jamanetworkopen.2022.50674

Study: private ownership of ambulance services associated with increased costs: Researchers analyzed the correlation between ownership of ambulance services and surprise billing for patient transport services. Findings: “Overall, we found that 28% of commercially insured emergency ground ambulance transports during the period 2014–17 resulted in a potential surprise bill… being transported by a private-sector ambulance in an emergency comes with substantially higher allowed amounts, patient cost sharing, and potential surprise bills compared with being transported by a public-sector ambulance. Further, allowed amounts and cost sharing tended to be higher for private equity– or publicly traded company–owned ambulances than other private-sector ambulances. These findings highlight substantial patient liability and important differences in pricing and billing patterns between public- and private-sector ground ambulance organizations.”

Adler et al Ground Ambulance Billing And Prices Differ By Ownership Structure  Health Affairs: January 18, 2023


CDC: Fentanyl overdose deaths in 2021 26 times higher than in 2011:

·       From 2010 to 2020, the rate of opioid prescriptions dispensed per 100 people fell nearly 47% from 81.3 to 43.3. In West Virginia, which had the nation’s highest rate in 2010, it fell by 62%. Yet, as opioid prescriptions waned, overdose deaths from any opioid more than tripled during that time.

·       When adjusted for population, West Virginia had 2021’s highest rate of fentanyl overdose deaths: 66 per 100,000 people. This was about 44% higher than Washington, DC, which had the nation’s second-highest rate. Of the nation’s 10 most-populated states, Ohio was the only one also in the top 10 of opioid overdose deaths.

·       South Dakota had 2021’s lowest rate of fentanyl overdose deaths, with 3.7 per 100,000 residents


USDA Targets Products Falsely Labeled as Organic: Last week, the Agriculture Department released a new rule, strengthening enforcement of strict definitions of being organic, “which must rely on natural substances and physical, mechanical, or biologically based farming methods to the fullest extent possible,”. The rule requires increases in business and supply chain inspections of certification by the USDA’s National Organic Program for all imported organic foods.

US Department of Agriculture