Evanston RoundTable, Nov. 20, 2024

Editor’s note: This is the first article in a two-part series.

When health care consultant Michael Millenson phoned Endeavor Health last year to make a dermatology appointment, he was told to wait while the scheduler checked for openings. After a short while, she came back on the line to report the result: nothing. Specifically, nothing this year, nothing next year, nothing as far out as the calendar went. “It was somewhere between distressing and amusing as she checked every doctor, year after year, and found nothing available,” said the former Chicago Tribune health reporter, who is president of Health Quality Advisors, a consulting firm.

“I was looking for a routine appointment, but if it was serious, they probably could have gotten me in earlier,” he added, hopefully.

At my request, he recently tried again, going online to search all Endeavor Health locations in the North Shore area for a routine skin exam. This time he had better luck — slightly. The only appointment available was seven months out. “And that was with a doctor whose name was unfamiliar and apparently had just joined the system,” he said.

While his case may seem extreme, you hear about the issue all the time: People complain they’re unable to see their physician for weeks, months or even (as in Millenson’s case) years.

Shortcuts to care

But as drastic as these delays sound, do they indicate a serious, possibly dangerous problem? There are shortcuts to accessing care, such as adding your name to waitlists or seeing someone other than your regular physician at a given practice. (But that may mean forgoing a connection with a doctor of long standing, said Evanston resident Deborah Geismar, a retired family medicine physician. “Primary care is continuity of care,” she pointed out. “If I’ve seen a patient 20 times, I’ll have a much better chance at getting to the root of a problem more quickly.”)

Immediate care centers also provide an access point for reasonably speedy care. Appointments can frequently be scheduled within a few days. Though often staffed by nurse practitioners and physician assistants rather than doctors, quality of care can be quite good, as I can attest based on a September visit to the care center at 524 Main St. in Evanston. Endeavor Health lists 47 immediate care and walk-in centers, and aside from the Evanston site, there are others in Skokie, Chicago, Deerfield and Gurnee.

“Urgent care has its place,” said Endeavor Health patient Christine Shiel, who visited a site in Mount Prospect when she couldn’t get an appointment with her regular doctor to deal with a serious, persistent and painful cough from chronic asthma. “But it shouldn’t be where you get your primary care from. And they’ll even tell you that — they’ll say, ‘You need to follow up with your primary care doctor.’ But the problem is, you can’t get in to see your primary care doctor.”

Still, even hard-to-see primary care doctors sometimes keep openings in their calendars for urgent cases.

And for a true health emergency, there’s always a hospital emergency room.

Crisis or inconvenience?

So the question remains: Are these delays a mere inconvenience, or an indication of something more serious, such as a crisis of health care access?

“It’s a huge national issue,” said Dr. Mustafa Alavi, co-site medical director of Erie Family Health Center in Evanston and second vice president of the Illinois Academy of Family Physicians. “The primary care workforce is dwindling, and patients need more care.”

Dr. Mustafa Alavi called the decline in the primary care workforce “a huge national issue.” Credit: Mustafa Alavi

That there are delays seems demonstrably true. “’Getting to see my primary care doctor is impossible.’ You hear it everywhere,” said Dr. Nancy Glick, an Evanston physician specializing in infectious diseases.

“I certainly think the crisis is getting worse,” said Geismar. She related that her internist retired in 2019, and she found that most existing Endeavor practices were not taking new patients. “I finally found someone, but it was difficult.”

In a comment on Mark Miller’s recent RoundTable article on Endeavor, Evanston resident Carol Steiner complained, “It takes a year or more to get an appointment with my primary doctor and months with any specialist I am referred to. Twice I have had doctors cancel appointments and both times the appointments offered me conflicted with other appointments. For one it [the wait] was six months for an appointment and the other was a year.”

Evanston resident Richard Wright also commented on Miller’s article, saying, “We have been receiving great care by Northshore (now Endeavor) physicians for many years, while noticing that more and more physicians, including many of our favorites, are leaving Northshore/Endeavor.” In a phone call, he added that it can take “many, many months to see someone with good reviews who’s taking new patients.”

Economics 101

What’s going on? It appears to be a simple matter of supply and demand. As Alavi said, there are more patients and fewer physicians.

As the oldest baby boomers approach 80, age-related heart, cancer and other highly serious and sometimes fatal diseases increase sharply, which drives up demand for health care. “Boomers are living longer, and they can have multiple serious problems, which can require more than the 15-minute limit now imposed at many doctors’ practices,” Geismar said. “Older people need more time.”

On the supply side, the nation is losing doctors to early retirement. “It’s shocking to see how many doctors, particularly in primary care, are exiting the profession altogether, or looking for nonclinical careers where they won’t be applying care directly to patients,” said Dr. Peter Gann, an Evanston resident.

Gann has a nearly half-centurylong perspective on health care issues: He practiced from 1976 to 1991 at the University of Massachusetts Medical Center and taught at Northwestern University from 1992 to 2006. He is professor emeritus at the University of Illinois Chicago, where he still does cancer research and is the author of more than 200 journal articles and research papers.

Asked why doctors are exiting the profession in ever-greater numbers, Gann attributed the exodus in part to loss of autonomy. “Increasingly, physicians haven’t been able to practice medicine in an autonomous way, because the U.S. health system is increasingly controlled by large insurance corporations or large hospital systems which intervene in the decision process between doctors and patients,” he said. “This is true for all physician specialties, but it’s particularly true for primary care.”

He added, “If you look at financing, the way we pay for health care, it’s increasingly taken over by for-profit entities that can enforce very strict controls regarding how long you can spend with a patient and how much documentation you have to provide. You’re pretty rushed during the day if you’re seeing 30 patients and your bosses are telling you that you better not take more than 12 minutes per patient for this type of visit, because if you do, there could be consequences for your pay.”

Private equity triggers ‘serious concern’

Gann’s assertions are backed by a 2022 report from the Nicholas C. Petris Center, a health economics research center, that states, “Emerging evidence about the adverse impact of PE [private equity] investment in healthcare on competition, prices, quality of care, and patient health is a serious concern.”

The report says, “By consolidating healthcare providers, offloading assets, cutting services, and loading acquired companies with debt, PE firms’ move into healthcare is associated with increasingly concentrated markets providing higher cost and lower quality healthcare to patients. PE investment in healthcare has exploded over the last decade, and is projected to grow even more rapidly as we emerge from the pandemic.”

A July 2023 study issued by the Petris Center, the American Antitrust Institute and the Washington Center for Equitable Growth also raises alarms. The report states that private equity takeovers of physician practices increased “more than sixfold” from 2012 to 2021, resulting in larger market share and higher prices.

Dr. Peter Gann, professor emeritus at the University of Illinois Chicago, said a “shocking” number of primary care doctors are retiring early or leaving the profession for something else. Credit: Peter Gann

The New York Times coverage of the study pointed out that “Historically, doctors’ practices have been relatively small, and owned by doctors themselves. But that model has been rapidly declining as the business of medicine has become more complex and the insurance companies that negotiate with doctors over prices have become bigger. Nearly 70 percent of all doctors were employed by either a hospital or a corporation in 2021, according to a recent analysis by the Physicians Advocacy Institute.”

Yet another challenge for practitioners is increasing electronic record-keeping requirements. “Every system is different, they don’t talk to each other, and they’re not designed by doctors but for billing expediency,” Geismar explained.

Data conflict

But all these explanations of access challenges don’t seem to square with data from the American Medical Association. According to the AMA, proportionally there were more doctors practicing in 2023 compared with 20 years before. Specifically, data the AMA sent me shows 30 physicians per 10,000 people nationwide in 2003 vs. 42 physicians per 10,000 people in 2023, an increase of 40%. In Cook County, the numbers were 40 per 10,000 in 2003 vs. 61 in 2023, an increase of 52.5%.

Another report, issued by the National Center for Health Statistics, shows a 9% increase in physicians per capita from 2009 to 2019, from 25.8% to 28.2% per 10,000 population.

Neither study readily provides data breaking those numbers down geographically or by medical specialty. But it seems likely that primary care is not part of that increase. Given the burden of debt most medical school graduates carry, close to a quarter of a million dollars per person on average, it’s no surprise that many residents opt for more lucrative specialty careers rather than primary care.

According to a 2024 scorecard report published by the Robert Graham Center, a Washington, D.C.-based primary care think tank, “The primary care workforce is struggling to meet population needs. Despite a rapidly aging population with higher levels of chronic disease, the number of primary care physicians (PCPs) per person has decreased.”

The report found PCPs declined from 68.4 to 67.2 per 100,000 people between 2012 and 2021, and there has been a 36% increase in the number of U.S. children “without a usual source of care over the last decade and a 21% increase among adults.”

“Demand for PCPs will only increase with time,” the report continues. “The National Institute of Health estimates that the number of people 50 or older with at least one chronic disease will increase by 99.5%, from 72 million in 2020 to 143 million by 2050.”

Primary care = better care

All of this is highly relevant to American health. More primary care is associated with better health outcomes. According to a March 2021 report published by the National Institutes of Health, life expectancy increases when there are more primary care providers nearby. “There are 51 days of life added with every 10 additional primary care providers per 100,000 residents,” Alavi told me.

The Cicero Institute, a Washington, D.C.-based think tank, foresees a looming physician shortage. By 2030, it reports, “the U.S. is projected to have 120,000 too few doctors nationally. Nearly 40% of American physicians will reach retirement age. … [And] 32.2% of Illinois physicians are within retirement age right now.”

The Cicero Institute also reports that “89 of Illinois’ 102 counties are health professional shortage areas,” including Cook County.

All of which suggests the physician shortage, at least in primary care, will only get worse.

Specialty care challenges

Endeavor Health admits patients may have problems accessing specialists, such as the dermatologist Millenson was attempting to schedule.

Like many healthcare providers nationwide, we are navigating an environment where providing access to certain specialties is challenging, particularly medical dermatology, which addresses more complex conditions,” Endeavor spokesperson Spencer Walrath said in a statement he emailed me. “A national shortage of dermatologists has created additional pressure.”

Walrath said that Endeavor is “actively working on several initiatives to improve access, including expanding our care teams, optimizing virtual care offerings, and implementing a waitlist system that allows patients to take advantage of cancellations for earlier appointments.” He added, “We encourage our patients to maintain open communication with their providers to explore all available options for care, including telehealth or seeing other specialists within our network if needed.”

Walrath shared this study reported in the National Library of Medicine: “There are approximately 3.4 dermatologists per 100,000 population, which is lower than what is needed to provide adequate dermatology care in communities.”

Can delays in accessing care be fatal? One study in 2007 found that “Veterans who visited a VA medical center with facility-level wait times of 31 days or more had significantly higher odds of mortality.”

The bottom line may be what Geismar calls “moral injury.” Doctors, she said, “take an oath to do no harm, but it’s becoming harder and harder to do their best for their patients.”

In the face of all this alarming, confusing and even conflicting information, what can be done to increase reasonably timely access to health care?

Part two in the series tomorrow: What can help?