Addressing Clinician Workforce Shortages in Underserved Areas

Increasing Demand, Increasing Shortages

The demand for primary care services is increasing on multiple fronts as underserved communities face increasing clinician workforce shortages. The United States population is increasing, with the U.S. Census estimating an increase of approximately 5.2 million people between 2013 and 2015.¹ As this growth occurs, the current population is aging, which increases demand for more intensive and frequent health care services. By 2015, 26.8% of Americans will be aged 55 or older, compared with 24.7% in 2010—an increase of nearly 11 million people.² These facts form a backdrop to the implementation of the Patient Protection and Affordable Care Act (ACA), which increases the number of people with insurance coverage, many of whom had lacked coverage and a primary care health home. The Congressional Budget Office (CBO) estimates that the ACA will result in increasing insurance coverage to 20 million currently uninsured people by 2015.³ All of these increases, through a growing, aging, and newly insured population, require a well-trained and appropriately distributed clinician workforce.

However, if current trends continue, provider supply is unlikely to meet demand. This is particularly true of physicians, but there is also concern regarding the availability of other provider types in underserved areas. On the physician side, the shortage is mainly due to medical student enrollment not matching the anticipated growth in need as well as increasingly few medical students choosing primary care residencies and fellowships.^4,5 Estimates of the primary care physician shortage are about 20,000 full-time equivalents (FTEs) by the year 2020,^6,7 if not earlier, depending on the methodology used. Any increases in this primary care physician supply will come slowly. “Because of the long length of time needed to train physicians and to change our education infrastructure, policymakers, educators, physicians, and other stakeholders need to know at least a decade in advance how changes in the health care system and other trends will affect the adequacy of physician supply.”⁸ [p. v]

Fortunately, nurse practitioners (NPs) and physician assistants (PAs) provide a significant level of primary care services across practice environments, and the supply of these valuable clinicians is expected to grow. “The supply of primary care NPs is projected to increase by 30 percent, from 55,400 in 2010 to 72,100 in 2020. The supply of primary care PAs is projected to increase by 58 percent, from 27,700 to 43,900 over the same period.”⁷ [p. 2] However, given current patterns of use, it is unclear how much of the primary care gap these providers will fill. State laws,¹⁰ physician practice patterns and cultural differences can act as barriers to using these providers effectively.

Workforce Picture in Underserved Areas

The areas already experiencing primary care provider (PCP) shortages are likely to be hit hardest by increasing demand from the ACA. The Center for Studying Health System Change notes that “states with the smallest number of PCPs per capita overall—generally in the South and Mountain West—potentially will see the largest percentage increases in Medicaid enrollment…. [while] states with the largest number of PCPs per capita—primarily in the Northeast—will see more modest increases in Medicaid enrollment.”^11,12 [p. 10]

The transformation of PCP services during ACA implementation will affect all clinical practices to some extent, but the impact will be uneven, with safety-net providers facing the greatest challenges. Even if PCPs supply could meet demand at the national level, the distribution of those providers will continue to follow market forces resulting in predictable shortfalls for some regions. Health care providers are already more likely than the general population to live and practice in urban and suburban areas, leaving out the rural communities who need PCP service. Communities with the greatest health care needs, such as communities with high proportions of minority and low-income residents, have fewer clinicians.¹¹

Safety-net institutions face increasing challenges to recruit and retain clinicians in underserved areas. Competition for PCPs has increased from health systems and hospitals, which are often able to offer higher salaries and...