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Healthcare Labor Issue: The Short Supply of U.S. Primary Care Providers

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Healthcare Labor Issue:  The Short Supply of U.S. Primary Care Providers

Introduction

        The United States boasts a higher ratio of health care specialists to primary care providers (i.e., chiefly family practice, pediatrics, and internal medicine) than any developed nation in the world, a trend that continues due to the prospect of higher pay for specialists, the aging of our population, and the lack of institutionally-backed incentives for primary care providers. There are also exists cultural factors that influence decision-making among medical residents, including medical training experiences and inspiration drawn from past medical encounters (i.e. those among family members or mentors). An increasing number of medical residents choose career paths where a surplus of providers already exists, leaving several other specialty and primary care (aka, general practitioner) positions in great demand. This demand is being magnified by the impacts of the Affordable Care Act (ACA), which is dramatically expanding accessibility of care and leading to approximately 35 million Americans with private healthcare insurance under the provisions of this legislation, and thereby rapidly increasing demand for primary care services. However, there also remains a critical primary care provider manpower capacity shortfall that threatens to minimize the positive impacts of ACA in the coming years.

The Primary Care Provider Shortage

        A growing provider shortfall is not insignificant. It is expected to create prolonged patient accessibility timeframes, overwhelmed primary care settings, and reduced effectiveness of care. These results would likely be amplified in health care environments where the gap is wider than average, namely in urban and rural, low-income settings where access to care has historically been lower than average and where long-term treatment programs are less likely to be a viable option due to the health of the patient. While the ACA has implemented several resource-backed initiatives to overcome this provider gap, questions remain with respect to whether or not these measures will be enough to overcome cultural and social factors steering medical residents toward increased specialization.

        There are several factors contradicting ACA-backed initiatives. One clear factor is the current state of medical training schools, which often focus heavily on specialization in the course of providing a well-rounded educational experience (Faulkner et al., 2011). According to Carroll (2013), medical students often spend a disproportionate amount of time in critical and acute trauma care settings that may paint the primary care world as more pedestrian and less impactful. It would stand to reason that medical students go on to practice the types of medicine that they see around them, and this increasingly influences students away from primary care (Carroll, 2013).

        But the more immediate issue influencing medical student choices likely falls at the feet of reimbursement programs in the U.S. that are clearly slanted toward specialty and subspecialty care. This is a strong financial incentive for students who graduate with sizable student debt and years of comparatively low compensation in primary care as compared to specialty areas. For many students and their families, the choice of becoming a primary care provider is a difficult one to economically substantiate given the financial opportunity in specialist fields. For current primary care providers, the increase in health care coverage for millions of Americans will certainly lead to an increase in demand for service within a capacity constrained medical model. Additionally, this demand increase also lead to a commensurate rise in costs as care providers must add personnel, space, and equipment to meet care provision of the expanding population. While the ACA does provide some modest increases in reimbursement for primary care services, these rates remain largely disproportionate to those for specialty services and do not match rate increases and reimbursement seen in specialty care.  In fact, overall reimbursements for primary care are not rising, and in some cases they are being reduced major care coverage providers. According to Adamopoulos (2014), major private insurance providers such as Blue Cross/Blue Shield and United Healthcare are reducing reimbursement rates to new lows that are more closely in line with Medicaid reimbursement rates.

ACA Solutions

        The ACA is an historic piece of legislation that was designed to overhaul the current structure of the U.S. health care system. If nothing else, it is clear from many passages of ACA that its authors anticipated the impacts of a growing supply shortfall with respect to real and anticipated demand escalation within primary care resulting from this legislation. There are several public-sector investments that have been designed to increase the primary care provider work force and to steer medical students toward filling this gap. This may be supplemented by changes in the culture of health care and the demographics of the patients seeking care. The ACA has authorized several major healthcare system infrastructure investment initiatives by the government, including:

  • Investing $14.6 billion in key workforce initiatives: Foremost among these is the expansion of the National Health Service Corps, which should provide more than 15,000 primary care physician jobs over the next ten years (Health Resources and Service Administration).
  • Investing $230 million in medical school grants toward generalist training: Most such grants come in the form of scholarships and financial aid dedicated specifically to educating primary care providers (Health Resources and Service Administration).
  • Massive investments in the Graduate Nurse Education Demonstration: This program is designed to expand the pool of advanced practice registered nurses (APRNs) in primary care settings (Adamapouos, 2014).
  • Incentivizing Hospitals: The ACA provides access to resources for hospitals training medical students and APRNs undergoing residency and internship training.

        These and other ACA-sponsored programs are reasoned responses to the long-shrinking provider capacity in primary care. The ACA has also allocated additional incremental Medicare/Medicaid reimbursements to primary care providers in family medicine, internal medicine, pediatrics or geriatric care (Health Resources and Service Administration). This would represent a compensation for traditionally low Medicaid reimbursements that have encouraged a growing number of primary care providers to avoid accepting Medicaid patients, cumulative economic decisions that have significant impact on further reducing primary care accessibility to a population with increasing demand for these services.

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