Who’s Your Doctor? The Primary Care Crisis Through the Lens of a Family Physician

The National Academy of Medicine defined Primary Care as “the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.”¹

Though this is our stated ideal, the current reality is that fewer and fewer patients are able to establish and maintain a lasting relationship with a personal physician. Why?

Primary Care is Facing Increasing Threats from Many Sources

Here are threats to family care:

1. Administrative cuts to healthcare agencies that undermine the research and services physicians rely on.

2. Proposed cuts to Medicaid that will further erode the ability of states like Missouri to attract and support primary care physicians (who see more Medicaid beneficiaries than other physicians).

3. Education cuts that threaten the pipeline for physicians.

4. Expanding scope of practices of non-physician healthcare providers and growth of retail and convenient urgent care centers.²

5. Demographically, the supply of primary care physicians is expected to increase only 3% by 2037, while demand is projected to increase 12%.^3,4 This mismatch is even more pronounced for physicians providing geriatric care.

6. Geographic disparities, especially in rural and inner-city areas, exacerbate the issues for broad swaths of Missouri residents.⁵

Primary care was a central focus of the Institute of Medicine’s Study of Primary Care, initiated in 1994 and published in 1996. Despite the 2010 Affordable Care Act’s expansion of Federally Qualified Health Centers, Medicaid, and healthcare information technology, most recommendations for primary care have not been actualized. The US healthcare system remains highly fragmented, overspecialized, and functions within a profit-driven environment. This is not a structure that lends itself well to producing improvements in the overall health of the nation nor to responding adequately to national health emergencies.

Profit-driven healthcare mergers and acquisitions, while promising efficiencies of scale, are causing instability as physician groups adjust. Retail companies like Amazon, CVS, and Walmart are expanding their footprint in primary care, offering virtual and preventative services but are struggling to gain traction. Theoretically, this should increase availability of primary care but is not because they are profit driven. Nevertheless, this movement is leading self-employed physicians to move to contract and retail-based primary care.

In addition, the current healthcare financing and regulatory system is dysfunctional and disruptive. Primary care physicians are struggling to compete for resources. Inadequate reimbursement for primary care is a key driver of burnout and workforce challenges.⁶ Perceptions and reality are often at odds regarding the realities of primary care in our US system. Patients indicate that primary care is very important to US health and perceive that significant funds are being spent on primary care. A recent study published in the Annals of Family Medicine found that US adults estimate that 51.8% of US healthcare funding is spent on primary care compared to actual spend of 4.7%.⁷

Access to high quality primary care disproportionally affects rural communities. Lack of rural primary care physicians across the country impacts the immediate health of each individual living there as well as the overall health of that rural community. Additionally, critical access hospitals are closing at an alarming rate. These hospitals/healthcare systems are a significant employer in rural areas.⁸ Shortages of primary care physicians and hospital closures have broader economic impacts on jobs, local economies, and community well-being. Rural and low-income communities are hit hardest, exacerbating existing health disparities in these underserved areas.

When patients lose access to regular primary care physicians, it is detrimental to their health, while strong patient-physician relationships improve outcomes. Without adequate access to primary care, medical conditions may go undiagnosed or untreated until they become more severe. Fragmented care can also lead to missed diagnoses, redundant tests, and medication errors, compromising overall healthcare quality and driving up costs.

New technology often promises to be the solution to increase patient care delivery, and efficiency, improving health outcomes while addressing physician burnout. Lack of regulation can make it difficult for all physicians to adopt new technology, and the jury is still out whether these technologies will address administrative burden once implemented. The most relevant example of this is Artificial Intelligence (AI). A Rock Health survey commissioned by the AAFP showed 87% of Family Physicians use AI daily.⁹ Like other new developments, these tools offer to reduce workload, automate documentation, enhance diagnostics, streamline administrative tasks, and provide personalized treatment plans. Yet regulations mandating documentation of a physician’s involvement in the work is preventing physicians from fully exploiting this tool in the same way most other businesses have been able to do. It is also important to consider these tools are quite costly and often beyond the reach of many rural practices with prices near $100–$600 per user per month and have varied levels of EHR integration.

Without necessary regulatory changes, AIs potential may still be over the horizon for most primary care physicians. There is no doubt AI will be fully integrated into physicians’ practices but, like other technologies, will not solve fundamental problems facing primary care today.

As our healthcare system continues to evolve, the importance of primary care cannot be overstated. The need for comprehensive, accessible, and effective primary care services in Missouri has reached critical levels. Physician-led primary care should be the gold standard. Among the various disciplines within primary care, Family Medicine is well positioned and ready to address the diverse needs of our communities and enhance the future of healthcare delivery.

Family Medicine physicians are uniquely trained to provide holistic care to patients of all ages and backgrounds. Their rigorous education encompasses a wide range of medical fields, including but not limited to acute and chronic ambulatory primary care. This allows them to diagnose and treat a variety of conditions locally while fostering meaningful relationships with patients. This broad training not only improves individual health outcomes it impacts the system while lowering healthcare costs. Family Physicians strengthen community ties, as they serve not only the first point of contact in the healthcare system but also for chronic care across the continuum of care.

Family Medicine physicians are adept at addressing social determinants of health, which play a crucial role in patient well-being. By understanding the complex interplay of factors such as socioeconomic status, geography, and cultural context, these physicians can tailor their care to meet the specific needs of their patients and advocate for resources that promote health equity.

One key driver in the workforce development that is needed to address the lack of family physicians and primary care, rests with how our medical education is funded and administered. This includes the fact that across the US the location of many of our medical schools and residency programs are in urban centers. Students who may initially want to practice in the rural communities in which they grew up move to urban areas for their education and wind-up practicing where they trained. Missouri has made significant progress in developing/supporting rural regional medical schools as well as offering programs to support primary care residency training in rural areas. Any long-term solutions must address these workforce problems.

In Missouri, the future of primary care depends on recognizing the vital role that Family Medicine and all primary care physicians play in our healthcare landscape. With a commitment to preventative care, chronic disease management, and patient education, these physicians are well-positioned to lead initiatives that improve overall health outcomes and lower healthcare costs.

Investing in Family Medicine training programs, increasing support for loan repayment for rural and underserved service, and advocating for policies that empower these physicians will be essential. Addressing payment reform and compensation, reducing administrative burden and making technology accessible are also critical steps in growing this workforce. By doing so, we can ensure that primary care in Missouri is not only sustainable but also truly reflective of the diverse needs of our population.

Figure 1.

Shortages of primary care physicians and hospital closures have broader economic impacts on jobs, local economies, and community well-being.