American Medical News
By — Posted May 6, 2013
Washington The stress that 30 million additional insured people will place on the health care system under the coverage expansions that will start in 2014 requires funneling more resources into primary health care training, witnesses told a Senate panel on April 23.
The Health Resources and Services Administration estimates a current shortfall in primary care physicians of 16,000, a number that's projected to rise by 50,000 by 2025, said Sen. Bernard Sanders (I, Vt.), who chairs the Senate Health, Education, Labor and Pensions primary health and aging subcommittee.
With more Americans gaining coverage through the Affordable Care Act's Medicaid expansion and through health insurance exchanges, Sanders asked witnesses how serious the access problem would become.
“It is dead serious,” responded Dan Hawkins, senior vice president for public policy and research at the National Assn. of Community Health Centers. If and when these 30 million people obtain coverage, there is going to be such a huge surge — especially in areas where there are large uninsured populations, such as Texas — that the resulting stress on the health care system “is going to be all but overwhelming,” he said. Many of the newly covered people who will be seeking care in physicians' offices aren't in good health now, and they are postponing care until their illnesses progress to the point that they end up needing more complex and expensive care.
Given these projections, it's imperative to bulk up the work force to meet the anticipated need starting in 2014, Hawkins said. This would involve training more nurse practitioners, midwives and physician assistants, caregivers who could be brought on line in much less time than it would take to train a physician, he said.
“I believe team practice is what works,” Hawkins said. “There are many more community health care centers and other community-based organizations that are ready to engage in partnership with the residency programs and medical schools in the training of community-based primary care physicians of the future.” The American Medical Association has been supportive of legislation to expand Medicare-supported graduate medical education positions as part of an effort to address coming physician work force shortages.
Engaging in these practices won't get rid of the access problem entirely, but it could help to alleviate it, Hawkins said.
Paul R. G. Cunningham, MD, dean and senior associate vice chancellor for medical affairs at East Carolina University's Brody School of Medicine in Greenville, N.C., said he's not waiting for the surge. “We're creating innovation as we speak,” he said, citing several collaborations the university has undertaken with local faith-based and military organizations and a community college to mitigate the coming demand.
There also needs to be a move toward payment models that create a more efficient health care system, said George Rust, MD, MPH, a professor of family medicine and co-director of the National Center for Primary Care at Morehouse School of Medicine in Atlanta. It's about shifting hospital-based care to accountable care organizations and other models under which professionals are looking at how best to achieve community-based positive outcomes instead of filling up hospital beds.
“If we are paying for outcomes rather than for volume, we find that with the appropriate teams in the primary care setting as well as in partnership with hospitals and specialists, we can get more cohesive systems of care that can take care of larger panels of patients and achieve better outcomes,” Dr. Rust said.
Most nurse practitioners practice in primary care environments and are prepared to serve as primary care clinicians, said Deborah Wachtel, a registered nurse and nurse practitioner who spoke on behalf of the American Assn. of Nurse Practitioners. But schools of nursing have been turning away thousands of applicants due to barriers such as budget constraints and faculty shortages, she said. “There are long waiting lists to get into nurse practitioner programs.”
One federal program that's made some headway in boosting the primary care work force is the National Health Service Corps., an HRSA initiative that provides scholarships and repays loans to physicians who agree to practice in underserved areas. Over the past five years, the number of health care professionals in the corps has increased threefold, from about 3,600 in 2008 to roughly 10,000 in 2012. “I have talked with doctors and nurses who say they would never have been able to go into medicine or nursing” without the scholarship program, testified Rebecca Spitzgo, the corps director. She's also the associate administrator of HRSA's Bureau of Clinician Recruitment and Service.
Spitzgo noted that more than 55% of the clinicians who received scholarships through the corps continued to practice in underserved communities more than a decade after they ended their commitments to the program.
But the program has not been able to fund all of the applicants. More than 5,700 apply each year for loan repayments, and for fiscal 2012, the corps was able to provide loan awards for only about 2,000, Spitzgo said. For scholarship applications, “we get about 1,300 of those, and we'll fund about 200.”
Instead of giving physicians subsidies to get them to practice in underserved areas, Sen. Chris Murphy (D, Conn.) asked if the same funds could be used to increase the rates being paid to all physicians serving in that area. “So whether you're in the Service Corps or not, you're going to be rewarded for serving in that area,” he said.
Such an approach already has been adopted by the Centers for Medicare & Medicaid Services, which offers incentive payments for doctors who practice in underserved communities, Spitzgo said. But even with that additional 10% bonus, “we still have shortage areas,” she added.