Why primary care physicians are becoming harder to find in Washington

Cliff DesPeaux’s recent hunt for health care has left his head spinning.

The 36-year-old father likes his current primary care doctor in Redmond. But after he and his family moved from Snohomish County to Poulsbo last fall, DesPeaux hoped to find a provider closer to their new home.

After months of calling different clinics, he finally secured two appointments with potential doctors. The first isn’t until March 2025. The second isn’t until June.

“I’m not terribly surprised, but it’s frustrating,” said DesPeaux, who grew up in Kitsap County and is used to some delays in care. He also tried looking for a new pediatrician for his children, but gave up after one local clinic left him waiting for weeks before turning him away. DesPeaux has ended up taking his kids to their regular doctor in Issaquah, but he has to take the entire day off work on appointment days to make the trek.

“It would be simpler if I had a local provider,” he said. “It would just reduce the cognitive load on me.”

The search for health care providers has become common in Washington and spans specialties, from surgery to psychiatry, but the state’s primary care landscape faces a particularly wide range of challenges that continue to worsen. Several factors are related to the long-looming reality of an aging population that’s older, on average, than the U.S. has ever been. This means providers are retiring, while patients are starting to require more complex care.

“It’s not just one thing people are coming in for,” said Dr. Adam Jayne-Jensen, an internal medicine doctor who oversees five UW Medicine clinics in Seattle. “It’s five different things. You’re trying to manage diabetes when they’re there for a cough.”

But other problems feel systemic, doctors say, and are related to the ways the health care industry is changing – while not every aspect, like insurance reimbursement, is keeping up.

A shifting industry

Washington isn’t alone in its challenges meeting patient demands. It’s actually faring better than many other states when it comes to its physician-to-population rates, according to the Association of American Medical Colleges.

As of 2022, the state had about 293 physicians per 100,000 people – a rate that falls a little lower than the national average of 297 per 100,000 but is higher than more than half of the country, including neighboring Idaho, which has about 192 doctors per 100,000.

But while these ratios might provide a glimpse into the state’s ability to meet health care needs, they don’t tell the entire story, said Susan Skillman, senior deputy director of the Center for Health Workforce Studies, housed at the University of Washington.

One reason is because primary care in Washington is not only delivered by physicians – it’s also provided by physician associates and nurse practitioners. So, estimated physician-to-patient ratios likely don’t accurately describe the state of access to primary care, Skillman said.

Solely focusing on rates and comparisons to national averages also implies the doctor shortage is only a supply problem – that if we just recruited more physicians or other providers to the state, the problem would be solved, she said. That isn’t the case.

“It would certainly help if access to primary care providers were better, but then there’s all these other issues,” Skillman said. “What does access require?”

Other factors often complicate physicians’ ability to deliver care and compound retention issues, leading to more burnout and early retirements. Some stressors, for example, include increasing administrative workloads and growing corporate control among consolidated health care systems, according to doctors around the state.

These all contributed to Seattle internist Dr. Nancy Brunsvold’s decision to retire early last September.

“I loved practicing medicine,” said Brunsvold, 60, who left The Polyclinic after working there for 27 years, a few years after Optum took over management. “But every year that went by, the administrative work increased.”

The increase in physician workloads, she said, was in part due to the advent of the electronic health record, which started becoming more common in medical clinics in the early 2000s.

“It just created at least an extra two hours of work daily that was not reimbursed,” Brunsvold said. One study at Massachusetts General Hospital and Brigham and Women’s Hospital found that every half-hour of face-to-face patient time generated 30 minutes of additional computer work for the primary care provider.

“It also created unlimited access to physicians,” Brunsvold said. “There were unlimited emails that I felt I had to stay up on 24/7, which was especially difficult with staffing shortages.”

Benefits of the electronic system include more efficient sharing of medical information between patients and their health care teams and increased accessibility for patients. But before Brunsvold retired, she often worked 10- to 11-hour days without a break, she said.

“I just began to have less stamina for that kind of day,” Brunsvold said.

Managing electronic health records not only includes responding to patient messages, but also reviewing test results, communicating with specialists, addressing nurse reports and refilling prescriptions, said Dr. Martha Hyde, another Seattle area internal medicine physician who retired early.

“With well over 1,000 patients in my panel, it often felt like a tsunami of messages,” Hyde said.

Many primary care providers have also watched their practices change after shifts in management or consolidation of care, Hyde said. While some health care leaders argue smaller practices sometimes need to be absorbed into larger systems in order to survive, others worry the state’s increasing number of hospital consolidations will lead to higher patient costs and worse care.

After Hyde’s local physician-led practice became affiliated with a larger multistate health care system years ago, she said she felt her “voice and experience did not seem to be as valued.”

“While there were advantages to being part of a large company with resources to manage the business end of a rapidly changing health care environment, the intrusion into decisions that affected how I and my partners practiced resulted in stressful working conditions, low morale and frequent staff shortages,” Hyde said.

Keeping pace

The entire health care workforce has struggled to stabilize since the pandemic began, said Dr. Nariman Heshmati, president of the Washington State Medical Association. In the last few years, he’s seen more and more of his colleagues retire, get burned out or leave the industry.

The medical association has grown in membership over the last five years, and now includes nearly 13,000 physicians, resident physicians, medical students and physician associates. But the number of members in primary care who have retired every year has also more than doubled – from at least 40 in 2019 to 93 last year, according to WSMA data.

“COVID was certainly a factor, too,” said Jayne-Jensen of UW Medicine. “People started to fear for their own safety on some level when the pandemic started, and then they were nearing retirement age anyway.”

As health care costs have gone up in recent years, independent providers in particular have struggled with low reimbursement rates among government payers that don’t adequately cover the cost of care.

Last December, the Seattle OB/GYN Group permanently closed its doors after 73 years, largely due to financial challenges exacerbated by low Medicaid and Medicare reimbursement rates, high medical malpractice insurance rates, increased staff salaries and more expensive supplies.

Some practices are now forced to turn away Medicaid patients because they can’t afford to treat them, Heshmati said.

“As a society, we’ve made commitments to take care of our sickest, most vulnerable people,” he said. “But those are turning into empty promises.”

WSMA leaders pushed for a way to get Medicaid rate increases approved during this year’s legislative session, but the bill stalled out in committee.

“All those things can push and push and push, and that causes people to leave, which strains the system more,” Heshmati said. “You had a portion of people who just said, ‘I can’t do this anymore.’ ”

Balancing ripple effects

Some recent changes within clinics or hospital systems have taken steps toward easing feelings of burnout for providers.

At UW Medicine, opening a virtual primary care clinic allowed some providers to partially work from home, Jayne-Jensen said.

“We’ve tried to increase the flexibility of what we can offer providers so they can sustain a career in primary care,” he said.

Some medical schools have made recent pushes to develop new residency programs and invest in training future health care providers, while hospitals have found partnerships with colleges and universities with similar strategies.

Still, the job can be “really challenging,” Jayne-Jensen said.

And as it gets harder for primary care clinics to meet patient demands, other parts of the health care system have begun to strain under increased pressure – like hospital emergency departments.

“If people can’t access primary care services, they don’t get the preventive care they need, or if they’re sick, they’re not treated in a timely manner,” Heshmati said. “Ultimately, they get worse and end up in the ER.”

“We’ve finally hit that point,” he said, “where what was inconvenient is now potentially catastrophic for patients.”