Rae Woods: 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. 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: Good to be back. Sebastian Beckmann: Hi, thanks for having me. Rae Woods: No pressure, Sebastian, but have you listened to Radio Advisory? Sebastian Beckmann: I'm actually a devoted Radio Advisory listener. Rae Woods: Yes. Sebastian Beckmann: And obviously before this one, listen to callback to Daniel's (bleep) episode, since we're continuing that conversation today. Rae Woods: One of my favorite, well, every episode with Daniel is a good one, but when we're talking about physicians and when we somehow manage to talk about horse (bleep), it's going to be a good episode. Rae Woods: 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: 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: 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: Why do we think they're horse (bleep) to quote my all time [inaudible]. Rae Woods: Oh my God, there's going to be so many bleeps in this episode. Daniel Kuzmanovich: 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: 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: I think we do because Sebastian asked us a really good question a couple weeks ago. Sebastian Beckmann: 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. 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: Classic data nerds saying, go read all of the methods. Sebastian Beckmann: The one big caveat. We look at primary care physicians and 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: 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: At least not in primary care. Sebastian Beckmann: 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- Rae Woods: Oh wow. Sebastian Beckmann: ... 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: Hmm. And is this even true in rural settings? That's where I hear a lot of the biggest concern right now. Sebastian Beckmann: 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: Rural markets often get discussed in this kind of construct of, oh, they can't attract or recruit talent. But big, big news flash, that actually can be an advantage. A lot of rural markets actually become very innovative- Rae Woods: That's right. Daniel Kuzmanovich: ... 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: 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: 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: 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: 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'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: 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 kind of 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: 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: Sure. To Sebastian's point, right. 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 it better. For example, enabling technology, artificially intelligent scribes or natural language processing, documentation assistants. That's one such example of here's an enabling technology that supports primary care physicians. Rae Woods: Got it. Daniel Kuzmanovich: 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: 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: Do these interventions have equal impact or are some more impactful than others? Daniel Kuzmanovich: 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. 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: 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: 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 it'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: 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 exists today in primary care capacity, ran the numbers, and then were 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: 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: A little bit of something is worth a whole lot more than a whole lot of nothing. Just doing one of these things, right? We looked at four categories, broad suite of interventions, just doing one of these things can help. 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: Where do you want organizations to start? Daniel Kuzmanovich: By far in 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: Yeah, Daniel, you actually said at the beginning that there might be a shortage of medical assistants in parts of the country. Daniel Kuzmanovich: It's fair. And that's where we might need to look at technology. Sebastian Beckmann: Yeah. And if you look at that increased MA staffing ratio, that comprises about half of the savings in provider time. Rae Woods: Oh wow. Sebastian Beckmann: But the other interventions together comprise the other half. So if you're able to get one of those right, you're still making a huge impact on provider capacity. Rae Woods: 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, 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: 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 a 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 that administrative work. Daniel, how would you position that to a physician leader? Daniel Kuzmanovich: The way I'd approach this with a physician leader 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: That's right. Daniel Kuzmanovich: 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: Overall, this is an incredibly hopeful 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. 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: 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: That's right. Daniel Kuzmanovich: And so with the specialty construct, it needs a little bit more nuance and 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: Hmm. Can you give me an example of a specialty that might see some benefit here? Daniel Kuzmanovich: 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: 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: 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 it would have to do after horse droppings, which became irrelevant because of the car. Rae Woods: That's right. Sebastian Beckmann: 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: Definitely take models with a grain, if not a jar of salt, but don't get bogged down in 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's 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: Well, Daniel, Sebastian, thanks for coming on Radio Advisory. Daniel Kuzmanovich: Thanks for having us. Sebastian Beckmann: Thanks for having me. Rae Woods: It is so rare that I get to share a truly optimistic message about the future of healthcare. In fact, if you listen to this podcast, you know that I tend to be the pessimist in our conversations. But the good news is that the US can completely avoid a physician shortage. And we can take action now to better support our clinical workforce. You can learn more about our modeling and what you can do at the link in our show notes. Because remember, as always, we're here to help.