The Primary Care Workforce Supply and Health Reform

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Efforts to implement health reforms that improve access, decrease costs, and improve quality must consider whether the supply of the health care workforce is adequate to achieve such outcomes. The experience in Massachusetts—with an increase on only one side of the demand-supply equation—demonstrates that efforts to improve access to care are hindered when there is not an adequate number of health care providers to deliver that care.¹ 

The Senate Finance Committee bill, “America’s Healthy Future Act,” passed in October 2009, and the U.S. House of Representative’s bill, “Affordable Health Care for America Act,” passed November 7, 2009, include provisions that are designed to increase access to care for the uninsured and reform the delivery system to improve quality and decrease costs.^{2, 3} The delivery system reforms—mainly the focus on accountable care organizations (ACOs) and medical homes—would rely on primary care physicians (PCPs) to coordinate and manage individuals’ care across the health care continuum. While research suggests that the primary care workforce has increased in recent years, it is unclear whether the current system will have the capacity to provide care to a large volume of newly insured individuals should health reform pass.⁴ As reforms are considered and implemented, understanding primary care workforce trends and the implications for the future supply are integral to understanding and anticipating the impact of proposed insurance and delivery system reforms.  

Primary Care Physician Supply 

While there is debate as to the future composition of the physician workforce, there is general agreement that there is currently a shortage of primary care physicians, as evidenced by increased wait times to see physicians.^{5, 6} (See a related HCFO report examining supply projections of the physicians workforce.) Currently, 34 percent of physicians specialize in general primary care and 9 percent specialize in primary care subspecialties.^{7, 8} The number of primary care residency programs has decreased; however, between 1995 and 2006, the number of physicians in primary care residency programs slightly increased. This increase was less than the increase in the number of specialty residents and is in part due to an increased number of international medical graduates (IMGs) and doctor of osteopathy (DO) graduates choosing primary care.⁹ The number of students from allopathic medical schools choosing primary care residencies declined. 

Factors contributing to the maldistribution in specialties include educational debt, salaries, and physician satisfaction. Medical students can accrue up to $200,000 in educational debt and there is a large salary differential between primary care physicians and specialists. Additionally, the current payment system favors procedural services over cognitive services, which are more common in primary care. To earn adequate income, PCPs are compelled to take on more patients than they can comfortably care for, potentially leading to lower-quality care and faster physician burnout and exit from the profession.¹⁰ 

HCFO grantee Richard Kravitz, M.D., University of California, Davis, examined whether physicians’ practice characteristics had an effect on providers’ career satisfaction and their perceived ability to provide care and obtain necessary services for their patients. Kravitz found that physician satisfaction was dependent on their perceived ability to deliver high quality patient care and provide patients with necessary services. These findings suggest that delivery system changes that facilitate the provision of high quality care and coordinate care—such as ACOs and medical homes—may improve physician satisfaction. 

The distribution of PCPs varies across geographic areas, with rural areas facing a greater shortage of PCPs than urban areas.¹¹ Research has shown that areas with a greater proportion of primary care physicians have lower costs than areas with a higher proportion of specialists.¹² New research by HCFO grantee, Michael Chernew, Ph.D., Harvard Medical School, found that while hospital referral regions (HRRs) with a greater supply of primary care physicians have lower health care costs, the rate of cost growth in those areas is not statistically significant from the national average. This implies that increasing the supply of primary care physicians in an area may result in a one-time reduction in costs.¹³ 

The current data on U.S. medical students suggest that the physician workforce demographics are changing, which will likely have implications for the future supply of physicians. For example, a greater proportion of students are female; female physicians are more likely than male students to enter primary care and are less likely to practice in rural areas.¹⁴ Moreover, many female physicians, and younger physicians in general, value work/life balance and therefore prefer to work fewer hours.¹⁵ Consequently, the growing number of women entering the workforce then, may increase the supply of primary care physicians but exasperate the shortage of physicians in rural areas. 

Physician Extender Supply

The shift in focus from specialty care to primary care presents a real opportunity for physician extenders to serve as substitutes for PCPs, thus potentially increasing access to primary care services at lower costs. The term physician extender refers to physician assistants and nurse practitioners who, though their scopes vary, can provide many of the same patient care services as physicians. In recent years, the supply of physician assistants and nurse practitioners has increased, and the number of graduate nursing programs has also increased.¹⁶ These workforces are primarily female, and while the majority of physician assistants specialize, the majority of nurse practitioners work in a primary care setting. Recent trends, however, suggest that both nurse practitioners and physician assistants are choosing to work in more lucrative specialty care settings.¹⁷ In addition, physician assistants are more likely than nurse practitioners to practice in an urban setting.

The scope of practice for each profession differs, limiting the extent to which these health care professionals can serve as substitutes for or complements to physicians. Physician assistants work under the supervision of a physician, providing therapeutic, diagnostic, and preventive services as determined by state laws and supervising physicians.¹⁸ Because physician assistants work as a member of the care team, they are viewed as physician complements rather than substitutes. The scope of practice for nurse practitioners also varies by state, but often includes prescriptive authority and the ability to refer, diagnose, and order tests.¹⁹ The relationship between the nurse practitioner and the physician varies by state. For example, nurse practitioners in 11 states—many of which are rural states—may practice without physician supervision. The scope of practice for both nurse practitioners and physician assistants changes periodically to meet the health care needs of the state; however, such changes are sometimes met with resistance from state medical boards.²⁰ 

To increase access to primary care, policymakers may want to consider changes to scope of practice laws to facilitate the use of physician assistants and nurse practitioners in underserved areas. In states that maintain laws requiring nurse practitioners and physician assistants to work in conjunction with or under the supervision of physicians, telemedicine may allow these professionals to treat patients in locations different than the supervising physicians. 

Current Proposals to Increase the Primary Care Workforce Supply 

With lengthy medical education and training, it takes years to adjust the supply of the health care workforce. Policies are needed to increase the availability of primary care services from fully trained professionals and to encourage current and future medical students to enter primary care. Both the Senate Finance Committee bill and the U.S. House of Representatives bill include provisions aimed at bolstering the health care workforce to ensure that there are enough providers to ensure access to patient care. The Senate Finance Committee bill aims to offer bonus payments to encourage physicians to provide primary care services and increase graduate medical education, particularly for primary care and general surgery, and graduate nursing education training slots. The House bill aims to increase funding for the National Health Services Corp, a program that provides scholarships to medical, dental, nursing, and physician assistant students and tuition loan repayment for fully trained professionals in return for a two-to-four year commitment to serve in an underserved area.²¹ 

Conclusion

Efforts to increase access to health care services, reduce costs, and improve quality hinge on the primary care workforce. Policies that improve the value of such professions as well as increase the supply are integral to achieving such goals. 

For related HCFO-sponsored research, see the grants listed below or visit www.hcfo.org.

PI: Michael Chernew, Ph.D.
Institution: Harvard Medical School
Title: Variation in Health Care Cost Growth
Grant Period: March 1, 2008 – February 28, 2009

The researchers will investigate the factors related to variation in cost growth in the Medicare and commercial sectors. Specifically, the researchers will determine: (1) whether the factors related to the rate of growth in the Medicare program are the same factors that are related to level of cost; (2) whether the factors associated with cost growth in commercial markets are the same as those related to Medicare cost growth; and (3) the extent to which cost growth varies between employers and health plans and what factors are related to that variation in cost growth. While most research and policy initiatives are aimed at managing the level of costs as opposed to cost growth, the researchers suggest that additional attention must be devoted to understanding and developing initiatives relating to the trajectory of cost growth, since the factors related to high levels of costs may not be the same as factors related to cost growth. The objective of this study is to provide knowledge that will support development of cost containment approaches that address cost growth.

PI: James D. Reschovsky, Ph.D.
Institution: Center for Studying Health System Change
Title: Cost and Efficiency in Treating High-Cost Medicare Beneficiaries: The Role of Physician Practice and Health System Factors
Grant Period: March 1, 2008 – August 31, 2009

The researchers will examine key physician practice and market characteristics that may contribute to high costs and inefficient care in the Medicare program. The study is composed of three phases. In phase one, they will analyze the treatment of high-cost Medicare beneficiaries in order to identify key physician, practice, and market characteristics associated with differences between actual and predicted Medicare payments and medical care use. In phase two, they will examine whether the factors associated with greater than predicted resource use affect high-cost beneficiaries’ health outcomes. Finally, the researchers will examine possible sources of geographic cost variations for high-cost beneficiaries and the extent to which these variations reflect differences in patient characteristics or supply-related factors and practice patterns of providers in a particular region. The objective of this project is to identify potential policy levers that can influence cost effectiveness in the delivery of medical care to high-cost Medicare patients.

PI: Richard Kravitz, M.D.
Institution: University of California, Davis
Title: Conditions of Practice and Quality of Care: Physician Perceptions
Grant Period: January 1, 2000 – January 31, 2002

Do physicians’ practice characteristics (the size and complexity of the organization(s) in which they practice) have an effect on providers’ career satisfaction, their perceived ability to provide care, and their perceived ability to obtain necessary services for their patients?  Researchers at the University of California at Davis tested the hypothesis that certain practice conditions facilitate the delivery of perceived high quality patient care, whereas other types of conditions impede perceived high quality care delivery.  The researchers had four objectives to: 1) generate national estimates of physicians’ self-reported career satisfaction, ability to provide care and ability to obtain services for patients; 2) estimate the community-level effects of managed care, physician supply and other factors on these self-reported measures; 3) estimate the effect of individual physician characteristics on these self-reported measures; and 4) create a baseline analytic file for tracking future changes in physician satisfaction and quality of care.  Measures of physician satisfaction, ability to provide care and obtain services for patients are drawn from responses to specific questions on the CTS Physician Survey. In addition to the CTS Physician Survey, they are using the CTS Household Survey and the Area Resource File. The goal of this study is to help policymakers, medical students and physicians, and consumers identify forms of practice organization that are most likely to result in high quality of care.

PI: Suzanne Moore, Ph.D.
Institution: State of New York, Department of Health; Health Research, Inc. 
Title: Alternative Models for Ensuring Access to Primary Medical Care in Nursing Facilitites
Grant Period: July 1992 – December 2005

Will placing medical practitioners on staff at nursing facilities increase the provision of primary care services and improve health outcomes of residents? This project conducted by the New York State Department of Health demonstrated four models for providing primary care in nursing facilities: 1) non-staff physicians in the community provide care on a fee-for-service basis when requested by the facility's nursing staff (the traditional model), 2) a staff physician provides primary care services to all residents, 3) staff nurse practitioners work collaboratively with the facility's medical director, and 4) staff physician assistants work collaboratively with a staff physician. The researchers compared the quality of care, health outcomes and costs associated with each model to determine which are most cost-effective.

1 Halsey, A. “Primary-Care Doctor Shortage May Undermine Reform Efforts,” The Washington Post, June 20, 2009. 
2 “H.R. 3962: Affordable Health Care for America Act,” passed in the U.S. House of Representatives, November 7, 2009. Also see www.govtrack.us/congress/bill.xpd?bill=h111-3962. 
3 “Legislative Language of the America’s Healthy Future Act,” U.S. Senate Finance Committee, October 19, 2009.
4 “Primary Care Professionals: Recent Trends, Projections, and Valuation of Services,” Statement of A. Bruce Steinwald, Director, Health Care, Testimony before the Committee on Health, Education, Labor, and Pensions, U.S. Senate, Government Accountability Office, February 12, 2008.
5 For a discussion about physician supply projections see Nicholson, S. “Will the United States Have a Shortage of Physicians in 10 Years?” HCFO Report, AcademyHealth, November 2009. Also see www.hcfo.org/files/hcfo/HCFO%20Report%20Dec%2009.pdf 
6 Halsey, A. “Primary-Care Doctor Shortage May Undermine Reform Efforts,” The Washington Post, June 20, 2009.
7 National Center for Health Statistics. 2009. Health United States, 2008. Hyattsville, MD.  
8 For this hot topic, the term “primary care physicians” includes family practice, general medicine, internal medicine, and general pediatric physicians. 
9 “Primary Care Professionals: Recent Trends, Projections, and Valuation of Services,” Statement of A. Bruce Steinwald, Director, Health Care, Testimony before the Committee on Health, Education, Labor, and Pensions, U.S. Senate, Government Accountability Office, February 12, 2008.
10 Sepulveda, M. et al. "Primary Care: Can It Solve Employers' Health Care Dilemma?" Health Affairs, Vol. 27, No. 1, January/February 2008, pp. 151-158. 
11 “Primary Care Professionals: Recent Trends, Projections, and Valuation of Services,” Statement of A. Bruce Steinwald, Director, Health Care, Testimony before the Committee on Health, Education, Labor, and Pensions, U.S. Senate, Government Accountability Office, February 12, 2008. 
12 Baiker, K. and A. Chandra. “Medicare Spending, The Physician Workforce, and Beneficiaries’ Quality of Care,” Web Exclusive, Health Affairs, April 7, 2004, pp: w184-97.
13 Chernew, M.E., et al. “Would Having More Primary Care Doctors Cut Health Spending Growth,” Health Affairs, Vol. 28, No. 5, September/October 2009. 
14 “Specialty and Geographic Distribution of the Physician Workforce: What Influences Medical Student & Resident Choices?” Robert Graham Center, AAFP Center for Policy Studies, March 2009.  
15 Salsberg, E. “National Physician Workforce Trends,” Presentation at ACEP Town Hall Meeting, Washington, DC, April 22, 2009. 
16 “Primary Care Professionals: Recent Trends, Projections, and Valuation of Services,” Statement of A. Bruce Steinwald, Director, Health Care, Testimony before the Committee on Health, Education, Labor, and Pensions, U.S. Senate, Government Accountability Office, February 12, 2008.
17 Ibid. 
18  “Physician Assistants." BLS Occupational Outlook Handbook, 2008-2009 Edition. United States Bureau of Labor Statistics. 
19 Christian, S. et al. “Chart Overview of Nurse Practitioners Scopes of Practice in the United States,” Center for Health Professions, University of California, San Francisco, 2007. 
20 Ibid. 
22 “Facts and Figures,” National Health Services Corp, Health Resources and Services Administration, Department of Health & Human Services. Also see http://nhsc.hrsa.gov/about/facts.htm