Supply and Demand Exacerbates PCP Shortage
By Dr. James Palermo // June 18, 2013
HRSA PUTS BREVARD IN 'LOW NEED' CATEGORY
ABOVE VIDEO: FOXNews reports on the fundamental reasons why physicians in training are not choosing primary care and how the evolving U.S. demographics combined with provisions in Obamacare are sure to exacerbate the existing primary care shortage.
According to a recent study out of George Washington University School of Public Health and Health Services less than one-quarter of new doctors go into primary care medicine, and fewer still work in rural areas.
PRODUCTION OF PCPs ‘ABYSMALLY LOW’
In a statement regarding the findings, lead study author Dr. Candice Chen, an assistant research professor of the George Washington University School of Public Health and Health Services, said, “If residency programs do not ramp up the training of these physicians, the shortage in primary care, especially in remote areas, will get worse. The study’s findings raise questions about whether federally funded graduate medical education institutions are meeting the nation’s need for more primary care physicians.”
The study showed that only 25.2 percent of 8,977 physicians who graduated from U.S. residencies from 2006-2008 worked as primary care physicians, prompting Chen to describe the United State’s current rate of production of primary care physicians as “abysmally low.”
HEALTHCARE SUPPLY AND DEMAND ‘PERFECT STORM’
While there’s little debate about a growing primary care physician (PCP) workforce shortage in the United States, it’s less clear whether efforts that include existing workforce policies, such as educational loan forgiveness, easier access to scholarship money and higher payment rates, can boost the supply of practitioners quickly enough to provide adequate access to needed primary care services for the “baby boomers” as they age, and the more than 30 million U.S. residents expected to gain health coverage through the Patient Protection and Affordable Care Act (PPACA) (aka ‘Obamacare’) beginning in 2014.
The Health Resources and Services Administration (HRSA) estimates an additional 17,722 primary care practitioners are already needed in shortage areas across the country to meet a target of one provider for every 2,000 patients. Likewise, other research indicates that another 35,000 to 44,000 adult primary care providers may be needed by 2025 to care for the nation’s aging population.
IT’S ABOUT TIME AND MONEY
It has often been said that when trying to influence a physician make sure that consideration of their time and money are primary components of your argument.
To address the impending PCP supply and demand crisis, focus has been placed by a number of medical schools on accelerating medical curriculum for students willing to commit to a primary care tract. Fast-tracking PCP preparation with three-year med school training addresses the “time” factor.
Many students, burdened with high debt for their medical education, steer clear of a career as a PCP because reimbursement is lower relative to medical or surgical specialties. The 3-year programs are significantly less costly for students, and with the prospect of getting into active practice at least one year earlier, the economic offset is an incentive for some, who may not have considered family medicine, to take the three-year pathway and go into primary care.
PPACA INCREASES PCP MEDICAID AND MEDICARE REIMBURSEMENT
The PPACA increases Medicaid reimbursement rates for primary care physicians (defined as those who specialize in family medicine, internal medicine, and pediatrics, as well as subspecialists in certain circumstances when they provide primary care) to 100 percent of Medicare rates in 2013 and 2014. Implementation of the rule is underway now and it is estimated by the Center for Medicare and Medicaid Services (CMS) that Medicaid reimbursement will increase 34 percent.
Provisions in the PPACA also increase PCP Medicare rates by 10 percent, adding to the monetary incentives for more physicians to pursue careers in primary care and address the looming PCP shortage, which will have a significant impact on Medicare beneficiaries as well.
The monetary incentives may be a minor “carrot” for young physicians deciding which career path to take—primary care or specialty medicine/surgery. However, Health and Human Services administrator, Marilyn Tavenner also suggests, “It will help encourage primary care physicians to continue and expand their efforts to provide checkups, preventive screenings, vaccines, and other care to Medicaid beneficiaries. The funds will be an important tool for states to ensure their primary care networks are prepared for increased enrollment (in Medicaid) as the health care law is implemented.”
But is that likely to be the case in Brevard County?
BREVARD FAR BELOW SHORTAGE THRESHOLD
According to doctor’s office data (2009) from the U.S. Census Bureau’s County Business Patterns and Population Estimates programs, Brevard County has a very favorable 1:1,092 total physician (PCPs and specialists) to population ratio; and according to primary care provider data (2008) from the U.S. Department of Health and Human Services’ leading health indicators, our county has a 1:1,325 PCP to population ratio. Both ratios put Brevard County into the “Low Need” category.
The most recent data online at HealthIndicators.gov and based on 2010 HRSA findings is consistent with the above, showing a PCP ratio of 1:1,320, far below their Health Professions Shortage Area (HPSA) threshold of 1:3,500.
CHALLENGE TO FIND WILLING MEDICAID PROVIDERS
It is projected that the Medicaid expansion provided for in the Patient Protection and Affordable Care Act (PPACA) will add up to 16 million new Medicaid enrollees to the already 60 million people presently on Medicaid. That certainly will strain existing PCP resources. However, finding the “willing” professional resources, especially primary care, to incorporate new Medicaid patients into their practice is clearly recognized across the healthcare industry as another major challenge and threat to one of the core PPACA aims–to meet the healthcare needs of more Americans.
Unfortunately, the law provides for increasing health insurance coverage of more American lives, but does not ensure that those added to the Medicaid rolls, or those already on Medicaid for that matter, will have available to them the professional resources they need.
Although the PPACA includes numerous provisions intended to increase the primary care and public health workforce, the “elephant in the room” that seems to be overlooked is the fact that a significant segment of the existing primary care workforce limits or does not accept Medicaid patients in their practices.
ADMINISTRATIVE HASSLES, RESERVATIONS ABOUT REIMBURSEMENT
Access to physicians for Medicaid patients is particularly challenging because of the historically very poor pay associated with Medicaid coverage, administrative hassles and delays in getting paid. According to a Centers for Disease Control (CDC) report published last year in the journal, Health Affairs, the percentage on average of U.S. office-based physicians accepting new Medicaid patients in 2011 was 69.4 percent, with Florida below that at 59.1.
That percentage is much lower here on the Space Coast. In a random phone survey of office-based primary care physician practices in Brevard County done by SpaceCoastDaily.com, only 2 out of the 40 (5%) primary care physicians contacted presently accept new Medicaid patients.
The monetary incentives discussed above may help address our local physicians’ low Medicaid acceptance, but many physicians have reservations related to what may happen after 2014 when they’ve taken on the responsibility of new lives. The concern is that in 2015 when the provision for the federally funded pay rate increase in the PPACA expires, Congress may come under pressure to continue the funding, but has no statutory obligation and may not extend the increase.
COMMUNITY RESOURCE PROVIDES QUALITY ALTERNATIVE
A very important alternative to private primary care as first-line professional resources for Medicaid recipients is community health centers like Brevard Health Alliance. The PPACA provides $11 billion to expand community health centers across the country that provide primary care to Medicaid patients.
It is clear that long term solutions to meeting the healthcare needs of more Americans will require changing attitudes on the part of all stakeholders and a transformational redesign of medical education, care and payment models to ensure the appropriate level of care at an affordable price. However, whether or not the already implementation challenged PPACA, which promises to create an explosion of publicly insured people, in the midst of already overburdened resources and at reimbursement levels that are in many cases below the cost of providing services, can provide those solutions remains to be seen.