Eliza Daily (00:00):
Hi everyone, Eliza Daily here. You may recognize my voice from previous episodes as a guest. I'm usually on here talking about anything that has to do with physicians and medical groups. I went to Rae a few weeks ago because I wanted her to rerun one of my favorite episodes on the 4 Ways to Prevent a Physician Shortage.

(00:20):
This episode originally came out in May of 2022. And a year later, many organizations are still behind on the four interventions we talked about. But there's more I want to say on one intervention in particular, and that's advanced practice providers.

(00:39):
So after we rerun the original episode, I'll be back to share more about how leaders can strategically deploy their APPs in primary care, and the research we've done in the last year. Here's Rae, with that episode from last year.

Rae Woods (00:56):
From Advisory Board, we are bringing you a Radio Advisory. My name is Rachel Woods. You can call me Rae. Today I want to return to one of my favorite topics. Physicians. I am still seeing a lot of headlines and hearing a lot of concern about physician shortages. So today we're going to talk about whether there really is a physician shortage and we'll talk about the solutions that you can take right now to prevent one.

(01:27):
To do that, I've brought one of our resident physician experts, Daniel Kuzmanovich, and a new voice, Sebastian Beckmann, who leads quantitative analysis for Advisory Board. Welcome back Daniel, and welcome to Radio Advisory, Sebastian.

Daniel Kuzmanovich (01:41):
Good to be back.

Sebastian Beckmann (01:42):
Hi, thanks for having me.

Rae Woods (01:43):
No pressure Sebastian, but have you listened to Radio Advisory?

Sebastian Beckmann (01:48):
I'm actually a devoted Radio Advisory listener.

Rae Woods (01:51):
Yes.

Sebastian Beckmann (01:51):
And obviously before this one listened to callback to Daniel's horse (bleep) episode, since we're continuing that conversation today.

Rae Woods (02:02):
One of my favorite... Every episode of Daniel is a good one. But when we're talking about physicians and when we somehow manage to talk about horse (beep), it's going to be a good episode. So obviously we've been covering workforce issues quite a bit on Radio Advisory, and we are going to be diving back into the topic of physician shortages, not just because it's an interesting topic, but frankly we keep seeing alarm over it. Daniel, what are you seeing from the headlines and hearing from the market?

Daniel Kuzmanovich (02:51):
When it comes to physician shortages, there's still this debate right now. I think a lot of people find themselves in the camp that, yeah, we are actually going to find ourselves in a physician shortage. There was actually an interesting analysis of ownership of physician practices that sets up more of this, "Are we going to run out of doctors in America?" Concern that's going along so much.

Rae Woods (03:11):
But we are obviously skeptical about this and frankly we have been skeptical for some time. Why do we not think that the headlines are accurate here?

Daniel Kuzmanovich (03:20):
Why do we think they're horse (beep) to quote my all time-

Rae Woods (03:21):
Oh my God, there's going to be so many bleeps in this episode.

Daniel Kuzmanovich (03:22):
To quote my all time greatest Advisory Board episode. I think the reason that we are so skeptical and maybe even more skeptical now, is that there's a big difference between bodies and capacity. And those two aren't the same thing. You might have a ton of bodies, but not a lot of capacity. We see some of that in nursing. You might not have as many bodies as you might think you need, but still have more capacity than you actually do.

Rae Woods (03:53):
And we've been pretty bullish about this. My question is, do we have stronger evidence to back this up. If we're even more skeptical today, do we actually have the evidence to back that up?

Daniel Kuzmanovich (04:07):
I think we do. Because Sebastian asked us a really good question a couple weeks ago.

Sebastian Beckmann (04:11):
Yes. So we have a lot of research already that we've had for years that show particular productivity improvements and how they can increase the amount of visits that primary care physicians can take on. So what we did this year is we modeled out how many visits exist, and how many visits could exist in the primary care workforce, if we all implemented these proven productivity improvements.

(04:37):
And when we did that, we found there's probably not going to be a primary care shortage. I'm going to resist the temptation here to go deep into how we did this. I think it's really cool. You should go into the show notes, click the link, read the whole thing. And by the way, there's a downloadable methodology to come if you really want to nerd out with us about it.

Rae Woods (04:57):
Classic data nerd saying, go read all of the methods.

Sebastian Beckmann (05:02):
The one big caveat, we look at primary care physicians in advanced practice practitioners as equivalent in terms of the number of visits they're able to take on for purposes of primary care demand.

Rae Woods (05:15):
And that's for good reason, because in the primary care space, which is the focus of this conversation, we have evidence and strongly believe that APPs can be doing 90 plus percent of what physicians can be doing. So to Daniel's point of talking about capacity and not just bodies, we need to be looking at advanced practice providers as well as physicians. So I don't want to hide the ball here. We are saying that in the US we will not see a physician shortage. Is that correct?

Daniel Kuzmanovich (05:43):
At least not in primary care.

Sebastian Beckmann (05:45):
And it's not just not a shortage. If you implement all of our conservative estimates, the surplus of visits is actually three times as big-

Daniel Kuzmanovich (05:53):
Wow.

Sebastian Beckmann (05:54):
... as the shortage we would have if we did nothing. It's not just a small, okay, we barely scoot by. It's we could really make providers lives better in addition to alleviating the shortage if we implement these productivity improvement at scale.

Rae Woods (06:10):
And is this even true in rural settings? That's where I hear a lot of the biggest concern right now.

Sebastian Beckmann (06:16):
So our analysis just looked at the national level. So based on the math we did here, I can't say confidently X market versus Y market, but because these interventions have such a huge effect, my guess is that most markets could avoid a shortage. Daniel, what do you think about that?

Daniel Kuzmanovich (06:34):
Rural markets often get discussed in this construct of, "They can't attract or recruit talent." But big newsflash that actually can be an advantage. A lot of rural markets actually become very innovative-

Rae Woods (06:46):
That's right.

Daniel Kuzmanovich (06:48):
... in their response to some of these shortage components. And I actually think that yes, our data analysis at the national level. But if you look at what rural markets can do with APPs in a much more sophisticated level than your usual city, I think it's translatable.

Rae Woods (07:02):
I want to be careful here. We're saying that the US can completely avoid a physician shortage at least in primary care. At Advisory Board, do we have that same message for the rest of the clinical workforce?

Daniel Kuzmanovich (07:14):
I think this is one where nuance is important. Primary care, physicians, APPs, capacity. Our message is yes, we can completely avoid a shortage. Other parts of the workforce, medical assistants, nurses, that I don't think we're talking about in this construct. I think that we could still be seeing a shortage. We're actually seeing that workforce crisis and shortage right now. But for primary care physicians and primary care APPs and visits, our data says "Hey, you actually don't have a shortage if you implement some of these interventions."

Sebastian Beckmann (07:45):
I would add specialists onto that. So we haven't looked at specialty care and there's obviously big differences in the supply of orthopedic surgeons for example, versus neurosurgeons or psychiatrists. So big differences in physician supply there as well.

Rae Woods (08:01):
But what I'm hearing from both of you is actually a really hopeful message that there is something that leaders can do to solve for the misapplication of provider time and capacity. And to your point, Sebastian, that that's not just going to help us avoid a shortage, but that's actually going to support provider practice. Let's get into what leaders actually need to do. How do you solve for that misapplication of physician time and capacity?

Sebastian Beckmann (08:30):
We looked at evidence from a host of different Advisory Board case studies in four categories, workflow optimization, care team redesign, telemedicine, and other capacity enabling technology. And then for each of those, we looked at the top intervention, and what impact that has on the amount of visits a physician or an advanced practice practitioner is able to do over the course of a year.

Rae Woods (08:54):
Can you give me an example of what some of those interventions might be in workflow, care teams, telemedicine and other enabling technology?

Daniel Kuzmanovich (09:02):
Sure. To Sebastian's point, there are a number of things that have already been done in primary care to be innovative and effective. We looked at those four categories and we looked at specific interventions that actually make them better. For example, enabling technology, artificially intelligent scribes or natural language processing documentation assistance. That's one such example of, here's an enabling technology that supports primary care physicians.

Rae Woods (09:29):
Got it.

Daniel Kuzmanovich (09:29):
When it comes to care team redesign, we looked at things like more holistic care team redesign with maybe richer ratios rather than, hey, here's your traditional number of people per physician benchmarked approach. Those are some of the interventions we considered.

Sebastian Beckmann (09:45):
One thing I want to underscore there is these are all proven interventions. So these are not horizon technologies or things that are in Stage 2 venture capital funding. These are things that real practices are already doing and have been for several years.

Rae Woods (10:01):
Do these interventions have equal impact or are some more impactful than others?

Daniel Kuzmanovich (10:05):
It's definitely not all exactly the same. So when we look at which ones actually make the biggest degree of difference, more robust medical assistant staffing ratios, as part of a more holistic care team redesign by far and away the most impactful intervention you could put out there to improve primary care capacity.

(10:25):
Whereas things more about how do you actually train physicians to better navigate the workflow, that workflow optimization category, that's not as impactful, shall we say, as the MA piece, but it's also got longer legs, it's more sustainable perhaps.

Rae Woods (11:50):
I know I said that this message is overall pretty hopeful, but it's also a pretty wild departure from the familiar narrative about shortages today. And I imagine that our listeners are probably still a little bit skeptical. How attainable are these changes? Not just implementing the workflow intervention, but getting the results that we've modeled out on our end.

Sebastian Beckmann (12:12):
Two thoughts. One is we've picked the most conservative estimate. So there's actually several different interventions you could put in any one of these categories. We're looking at just the impact of one of those interventions. We're assuming that's not going to have the full impact that we saw at some of the organizations that we interviewed and vetted. It's not going to work exactly the same way at every organization. So conservative estimate, only one intervention instead of a suite of interventions. Even with those assumptions, you still end up with the provider surplus, instead of a provider deficit.

Daniel Kuzmanovich (12:45):
And what's really big there is what Sebastian pointed out earlier. We took stuff that's not magic, that's not in the future, stuff that actually-

Rae Woods (12:52):
That's right.

Daniel Kuzmanovich (12:53):
... exists today in a primary care capacity, ran the numbers and then we're very conservative about it and still got, "Hey, not only do we have enough primary care physicians to provide the visits we need, but we have three times as many if we account for all of these elements of workflow and capacity and time management change."

Rae Woods (13:13):
So what happens if an organization succeeds in one but not all? Let's say they can really focus on holistic care team redesign and they really expand the number of medical assistants that they have, but they're not really able to do asynchronous telehealth yet, or they can't spend the money to invest in documentation assistance or EMR training or even a better EMR. What might that mean for that organization?

Daniel Kuzmanovich (13:40):
A little bit of something, is worth a whole lot more than a whole lot of nothing. Just doing one of these things. We looked at four categories broad suite of interventions. Just doing one of these things, can help drastically in terms of improving primary care visit capacity, primary care supply in a particular market or a particular organization. You don't have to do all four. Doing one thing well is a lot more sustainable than doing four things badly or doing nothing at all.

Rae Woods (14:09):
Where do you want organizations to start?

Daniel Kuzmanovich (14:11):
By far and away the medical assistant opportunity, the holistic care team redesign opportunity. If you have one option, one place to throw your resources, time and effort, that's probably the big one. It's got wins all around and it's the most impactful. But I can feel someone thinking, yeah, but there aren't a lot of medical assistants out there right now.

Rae Woods (14:32):
Yeah Daniel, you actually said at the beginning that there might be a shortage of medical assistants in parts of the country.

Daniel Kuzmanovich (14:38):
It's fair. And that's where we might need to look at technology.

Sebastian Beckmann (14:41):
And if you look at that increased MA staffing ratio, that comprises about half of the savings in provider time.

Rae Woods (14:48):
Wow.

Sebastian Beckmann (14:48):
But the other interventions together comprise the other half half. So if you're able to get one of those right, you're still making a huge impact on provider capacity.

Rae Woods (14:58):
Bottom line is, we're not going to be seeing this shortage. And we've talked about what organizations can do to prevent a shortage from happening and perhaps even get to a surplus. Now I want to talk for a moment about how, especially when it comes to approaching these conversations with physicians themselves, even though we're talking about things that can make their lives better.

(15:18):
Daniel, you and I know that it is not always that simple when you're going to a group of providers and saying, I want to change the way that you practice medicine or I want to change the way that you go about your day. How do you suggest you approach those conversations with doctors?

Sebastian Beckmann (15:34):
I think about the what's in it for me for physicians. So what I mean by that is, these are all interventions that increase the amount of time you have available to focus on direct patient care. So these are all things that reduce the amount of documentation you have to work on, reduce the administrative burden, and hopefully in doing so, not only increase the number of visits available, but also reduce the burnout effect of all of that administrative work. Daniel, how would you position that to a physician leader?

Daniel Kuzmanovich (16:04):
The way I approach this with a physician leader, it goes like this, your docs are working too long, doing work that for a lot of the portion of primary care they don't actually like to do, that ultimately can have burnout and disengagement benefits. What we're doing with some of these things, I'll pick documentation assistance. I'm getting technology to take over some of the most frustrating parts of a physician's workflow, so they can spend more time on patient care.

Rae Woods (16:30):
That's right.

Daniel Kuzmanovich (16:31):
So if I'm a physician leader, this makes a ton of sense. It reminds me of that druckerism. There is nothing so useless as making someone more efficient at something they shouldn't be doing in the first place. I'm getting docs back to doing what they should be doing in the first place.

Rae Woods (16:46):
Overall, this is an incredibly helpful conversation. We are saying that you can get a surplus of visits with relatively easy, already proven interventions, that not only get us out of a shortage in primary care, but actually support the real lives of the people that we are struggling to support right now.

(17:04):
That said, our conversation has been focused on primary care. I know that the analysis didn't go deep into specialty care, but since I have our two experts on the line, do we think these same interventions can support some of the challenges we've seen on the specialty care side?

Daniel Kuzmanovich (17:22):
Yes, with the caveat that there's a lot of variability in not just specialty care, but perhaps within a specific specialty. Regular cardiology, general cardiology and interventional cardiology, very different.

Rae Woods (17:36):
That's right.

Daniel Kuzmanovich (17:36):
So with the specialty construct, it needs a little bit more nuance and a little bit of unpacking, but there are certainly examples where these types of interventions might be able to reduce capacity constraints and supply constraints in the specialty world.

Rae Woods (17:51):
Can you give me an example of a specialty that might see some benefit here?

Daniel Kuzmanovich (17:54):
I think about dermatology for example, or even psychiatry, telemedicine, virtual visits, eConsults in dermatology. Those are things that actually really have so far been able to extend the bench and increase the supply of dermatology and psychiatry, which are not specialties where we have as much supply as we probably have demand. Because of those interventions brought on by the pandemic, we've seen, hey, we've actually been able to meet some of our dermatology and psychiatry needs through telemedicine and enabling technologies.

Rae Woods (18:25):
Well, Daniel, Sebastian, thank you so much for coming on Radio Advisory. I do want to give you the final word. When it comes to preventing a physician shortage, what is the one thing that you want our listeners to do?

Sebastian Beckmann (18:37):
First of all, take models with a big grain of salt. In the last episode, Daniel talked about how London had modeled out the amount of cleaning would have to do after horse droppings, which became irrelevant because of the car.

Rae Woods (18:49):
That's right.

Sebastian Beckmann (18:50):
Our model suffers that same caveat here, so we're only looking at what's happening right now, and what other organizations have done in the past. There's also some big assumptions in our model, like that APP assumption that we outlined earlier. So any other model that forecasts demand especially over a long timeframe compared to supply, is definitely something you need to be careful of.

Daniel Kuzmanovich (19:11):
Definitely take models with a grain, if not a jar of salt. But don't get bogged down and is it perfect, is it not? As a matter of fact, the big thing that our analysis reveals is action, agency. Leaders can do something about this potential physician shortage. If there is in fact going to be one or as our modeling suggests, there's not. You can do something, but you don't do something by doing nothing. It's got to be, action has got to be focused and right now, feels like a really good time given everything that's going on in the world, to start combating the potential of a future primary care shortage.

Rae Woods (19:46):
Well, Daniel, Sebastian, thanks for coming on Radio Advisory.

Daniel Kuzmanovich (19:51):
Thanks for having us.

Sebastian Beckmann (19:51):
Thanks for having me.

Eliza Daily (19:52):
Hey there, it's Eliza again. As I said earlier, I want to double click on APPs because we've seen so much growth in this workforce in the past few years and they're really going to play a pivotal role in primary care going forward. So to do that, I've invited my Advisory Board colleague and workforce expert, Sydney Moondra, to talk about what we've seen in our research in the years since that original episode was recorded. Sydney, welcome to Radio Advisory.

Sydney Moondra (20:24):
Thanks, Liza. Excited to be here.

Eliza Daily (20:27):
I think the most important question to start with is where is Calif right now?

Sydney Moondra (20:33):
Calif is my dog for those of you listening. And he is laying on the carpet where I would like to be laying right now, taking a big nap. He's nap employed.

Eliza Daily (20:45):
Honestly, Pretzel is doing the same thing thing right now. I feel like dogs are the best coworkers, especially when we work laptop to laptop like we do.

Sydney Moondra (20:54):
Yeah. Dog takes first place. Cat comes in close second. She steps on the keyboard way too frequently.

Eliza Daily (21:01):
Well, I'm excited to have a conversation with you about the episode we just listened to, because a lot has changed in the last year since it originally aired. In particular, workforce shortages have been more enduring than a lot of leaders expected. But APPs are actually one of the few roles where the job outlook remains strong. What does the landscape look like today?

Sydney Moondra (21:24):
Well, right off the bat, you're right, Eliza. This is a truly growing workforce. So much so, I think the Bureau of Labor Statistics measures APPs like nurses and PAs having a growth rate of anywhere between 30 to 40%, which is way more than average. They're growing so much that we actually got our researchers Advisory Board to do some modeling to unpack and see when and/if APPs would become the majority type of primary care clinicians across markets.

Eliza Daily (21:55):
And what did that data find? Because we've been looking at this for a couple of years and I think we've been predicting that this would happen soon. But it sounds like you have some data and numbers to back it up here.

Sydney Moondra (22:07):
Yeah. APPs have already become the majority in non-metro markets. This means that they are outnumbering the number of family medicine and internal medicine physicians and most of the rural markets across the nation. And data shows that happening as early as 2021, which clearly emphasizes the value that these providers offer to areas with potential access issues.

Eliza Daily (22:30):
So you're telling me it's already happened in rural markets. How about urban markets?

Sydney Moondra (22:36):
So for metro areas, APPs are projected to become the majority in 2032. I'm not going to get into the nitty-gritty of all the different ways that our QI team played with the data, but regardless of how you cut it, APPs becoming the majority of the primary care workforce has already happened in some markets. And at the current rate, it's inevitable across the nation.

Eliza Daily (22:58):
So our team first started researching APPs over five years ago, and we told leaders then that they needed to start preparing for an APP majority workforce. You're telling us now this has already happened in rural markets. It will be the case soon in urban markets. Candidly, in my own conversations, I've even heard rumors of an APP surplus. Can you help set the record straight.

Sydney Moondra (23:23):
Eliza, I think in our research we have a bit of a hot take here.

Eliza Daily (23:27):
I think you have a hot take, Sydney.

Sydney Moondra (23:29):
Fine. I'll own it. I have a little bit of a hot take here, and I think this requires a little bit of unpacking of what we mean when we say surplus. Because yes, a lot of the models measure APP supply outweighing APP demand, which technically equates to a surplus. HRSA and other entities are measuring about 41 states having a surplus of APPs as of 2023, resulting in the supply of APPs being about 119% of "demand."

(24:00):
But in my opinion, I think we have to push on that demand piece. Because often these measurements aren't taking into consideration the ways that APPs can be creatively deployed. In a time where the workforce crisis is at a peak, I don't think any stakeholders should be able to walk away thinking that they and their market has a surplus of APPs if they are truly strategically deploying their APPs, especially if you have existing areas of shortages and or business goals and challenges that you can deploy this workforce against.

Eliza Daily (24:32):
So what I hear you saying is that having a surplus of APPs isn't a problem. It actually presents an opportunity. And I think you've shared data with me that in two thirds of the states where there's currently a physician shortage, there's also a surplus of APPs, which to me seems like a one-to-one solution to that problem. I also love that you just said we need to deploy APPs strategically and creatively because I often see APPs put in these default roles.

(25:05):
We're going to deploy them in urgent care or they're going to see overflow from the physician's panel. And at Advisory Board, we've long said that APP should practice autonomously. Can you tell us what this autonomous strategic deployment actually looks like in practice?

Sydney Moondra (25:21):
Simply employing more APPs isn't enough. And it's no secret that our position at Advisory Board for years has been that you need to be able to deploy APPs autonomously. In fact, if you look at the show notes and all of our linked resources, Eliza's name is on a lot of those.

(25:39):
Much of the convo before was considering that APPs can take on a large percentage of primary care needs and demands. But I think our new research is pushing us a little further into giving tactical examples of how APPs can also support business need and challenges. So I'd like to give you four examples of this.

(25:59):
One, you can deploy them against rural access challenges. Two, they can help with physician burnout by increasing provider capacity. Three, there are great low risk, low cost way to pilot new services. And four, great for giving care for specific patient populations that are high touch and or require a lot of patient education.

(26:22):
Which strategy will be best to use is going to be dependent on your unique organization and what that business challenge is of most priority. But I think we have a good group of different strategies that no matter what your regulatory standards are, you can run after one of these.

Eliza Daily (26:38):
So what I hear you saying is that the key to autonomous strategic deployment is to have a really clear business goal that you're going to deploy your APPs against. And I want to talk about that first use case you mentioned because based on the number you shared earlier, rural markets really are foreshadowing what other markets should expect to see across the next decade.

(27:00):
So why do APPs work so well in rural primary care, and what would it take to replicate that success in urban and suburban markets?

Sydney Moondra (27:09):
They work so well being deployed in non-metro markets because there's a unique incentive of clinical agency and autonomy. And because of that, we've seen it's a lot easier to hire APPs in this market and has allowed a lot of different organizations to expand into these new regions at a much lower cost.

(27:28):
A lot of organizations have been using a hub and spoke model in order to execute on this, where the hubs serve as the base for larger communities with multiple physicians and APPs. And for the rural communities, APPs are owning a smaller spoke clinic.

Eliza Daily (27:46):
So they really are the ones running these practices, seeing patients day to day.

Sydney Moondra (27:51):
Correct. And if we think about the second part of your question in terms of replicability for urban areas, this would look like finding more opportunities within your existing infrastructure to give APPs more autonomy and clinical agency, while deploying them against low risk care delivery.

Eliza Daily (28:09):
So earlier you top lined a couple different use cases where we see APPs deployed really well. We don't have time to get into them, but I do want to leave our listeners with a little bit of a cliffhanger, a little bit of an incentive to go read the research. Do you have one, that's a favorite?

Sydney Moondra (28:24):
Oh gosh, that's a hard one. But I definitely have to say the strategy about leveraging APPs to be the primary provider for those unique patient populations that require a lot of patient education. They are great at delivering specific, detailed, and really holistic care for that patient population. But you'll have to read more about that in the artic that we're going to publish.

Eliza Daily (28:51):
I love it. Leaving everyone with a little bit of a cliffhanger. Well, Sydney, thank you for coming on Radio Advisory.

Sydney Moondra (28:57):
Thanks, Eliza. Hope to be back soon.

Eliza Daily (29:04):
We started this episode talking about the physician shortage, and the big message I want our listeners to take away is that we can avoid those shortages even in the hardest hit areas, if we put in the hard strategic work. It isn't just about hiring more physicians, more APPs, it's also about using those providers in the right way. And as Sydney and I just talked about, APPs are a big part of that. We have so much research, case studies, toolkits, executive briefings that we'll make sure to link in the show notes. And remember, we're here to help.

Rae Woods (29:48):
If you like Radio Advisory, please share it with your networks. Subscribe wherever you get your podcasts and leave a rating and a review. Radio Advisory is a production up Advisory Board. This episode was produced by me, Rae Woods, as well as Eliza Daily, Katy Anderson, Kristin Meyers and Atticus Raasch.

(30:06):
The episode was edited by Dan Tayag, with technical support by Chris Phelps and Joe Shrum. Additional support was provided by Carson Sisk, Leanne Elston and Erin Collins. Thanks for listening.