By Josh Zeitlin, Senior Editor
Earlier this month, the Association of American Medical Colleges released new data on the number of actively practicing physicians by state per 100,000 population.
As you can see on the map below, the gap between the states with the most and least doctors by population is pretty stark—Massachusetts' rate of doctors per 100,000 population (443.5) is more than double that of Mississippi's (186.1).
That got the Daily Briefing team thinking about much-debated questions: How many physicians are "enough"—and is the much-discussed "physician shortage" truly looming? Beyond that, what are top providers doing to ensure patients have sufficient access to care?
I took those questions to two experts: Michele Molden, a senior vice president with Advisory Board Consulting who works with health systems and physician groups on patient access; and Hamza Hasan, a practice manager with Advisory Board's Medical Group Strategy Council.
Question: Our map above reflects the number of physicians per 100,000 people, which is probably too high-level to really answer whether any particular state has enough doctors to care for patients. But in your dives into the data, what have you seen? Is there a physician shortage, or one on the horizon?
Michele Molden: When it comes to physician supply and demand, most of the models are built on relatively old data, and they don't take into account two key trends.
First, they don't account for one of the intended outcomes of population health management. If executed successfully, population health should reduce demand for certain specialists. In addition, high-deductible health plans are, in many cases, negatively impacting demand in primary care settings. Those trends may, in some markets, actually reduce overall demand for physicians.
Second, there's been an incredible increase in the demand for and deployment of advance practice providers (APPs). Lots of patients are willing to be treated sooner by an APP rather than waiting for a doctor. This means there's a lot of potential for systems and physician groups to take more advantage of APPs. We work a lot with systems on what their advanced practice provider model should be—on their plan to use them top-of-license, to have specialty-relevant and standardized models, to develop peer coaching fellowships to help make APPs better equipped to provide quality (and lower-cost) specialty care, etc.
Hamza Hasan: I'd add one factor to what Michele mentioned, and that's technology. Ira Nash, executive director of Northwell Health Physician Partners and an SVP at Northwell Health, put it well in a blog post. Nash said, "What is striking about [projected physician shortage] is that it fails to consider the impact of the technologies that are poised to revolutionize medical practice." He noted that in the late 1890s, plenty of experts predicted that because of population growth, there would soon be so many horses on the roads that the streets of London would be buried in manure. Of course, then the car came along. There will inevitably be further innovations in how we practice medicine and in technology that may affect physician demand.
On the other hand, many rural areas already face a physician shortage. Medical group leaders tell us that they really struggle to recruit doctors to many rural markets. I can see that persisting, even amid these broader trends.
Q: What about ensuring that patients can actually access care, regardless of how many physicians are in their area? What patient access best practices are you advising organizations to follow?
Molden: Before I get into best practices, I want to take a step back, because the truth is most organizations we speak with struggle to define what "patient access" really is. If you ask 10 people, you might get 10 different answers.
We think about access as the "process of the visit"—all the logistics and activities that take place before and after the appointment itself. It's one of the three pillars of the patient encounter, alongside the "management of the visit" (the provision of care) and the "business of the visit" (how organizations are paid). In most organizations, that second pillar, management, is controlled by the practice managers, while the third pillar is shared by the practices and the revenue cycle department (which, by the way, often uses the term "patient access" in a different context).
But in most places, the "process of the visit" is the Wild Wild West. In other words, there's often no single executive or department in charge of making sure that things go as smoothly and consistently as possible once a patient starts to interact with a health care organization. Many organizations haven't optimized provider scheduling templates to promote timely access and ensure appropriate capacity. They don't have good call management to make it easy for patients to get an appointment or follow up on a referral. They might have tried to centralize a call center and failed miserably because every provider has his or her own restrictive scheduling rules, never mind matching true provider supply and patient demand.
So my team helps organizations define what they really mean by "access" and determine the right goals. We work with them to say, "OK, how do we redefine and simplify the ‘process of the visit' to make sure it meets your vision and your patients' expectations?"
Organizations often start their change management with primary care before working on specialty physicians. But it all depends on the system, their degree of sophistication, the outlets that they have for patients, and their vision. Some places need to start with making sure they are answering the phones; others are more ready for progressive access models and actively curating ongoing care management and communication with patients.
Q: To dive a bit deeper on that, what factors cause some organizations to have a different vision than others of the right model for "patient access?"
Molden: There are a couple components. The first is, how do you want to position yourself in the market? Even small enhancements to patient access tend to be incredibly differentiating. Some organizations are willing to endure short-term pain to make their access a market differentiator.
The second is culture. Changing schedules is often a "third-rail" issue for physicians. One of the things we do when working with organizations is assess possible resistance to changes that might improve patient access. With some medical groups, you can go full speed ahead. With others, you may need to first build a physician compact, create a bigger guiding coalition, map nodes of provider influence, identify pockets of resistance, and work to bring doctors along more slowly to build a more culturally compatible environment for change. You don't have to stop the access work; it just takes a little longer, and you have to start with more foundational things before you move to jumping into providers' schedules.
The third component is, what is the level of patient satisfaction in your clinics, and does that motivate you to do this work faster and sooner?
We usually work with groups of executives to create a steering committee—we call them guiding coalitions—to work through the dynamics of each of the three components I've talked about (market, culture, and patient satisfaction) and come up with "guardrail" expectations of what we think is possible. Then we guide them through a visioning process, and we help them construct a roadmap to say, given the guardrails and the vision, what should you do first, second, third and so on? We also always build for them an operational dashboard so that they are tracking the right things to make sure that their access initiatives are hitting the mark.
Next: Learn how to engage physicians from day one
Join our experts on Thursday, Dec. 7 at 1 pm ET where we will share methods for better early integration of physicians through robust onboarding and cultural-fit screens.