Q&A: New designations provide more accurate account of areas with PCP shortages

A project that restructured primary care health professional shortage area designations could improve the distribution of primary care clinicians and resources in the United States, according to a recent analysis in JAMA Network Open.

Despite government incentives, the distribution of primary care physicians in the U.S. remains unequal in rural vs. urban areas.

The Shortage Designation Modernization Project (SDMP) was implemented in 2014 as part of the Affordable Care Act to streamline often inaccurate designations of PCP supply, Christopher A. Scannell, MD, PhD, a primary care physician and recent graduate of the Veterans Association University of California, Los Angeles, National Clinician Scholars Program, and colleagues wrote. Primary care health professional shortage areas (PC-HPSAs) prior to the project were often designated improperly due to time-intensive documentation.

Scannell and colleagues identified changes in PC-HPSAs from 2013 to 2015, including an 8% decrease in non-PC-HPSA designations, a 32% decrease in full-county designations and a 29% increase in partial-county designations. However, they noted that additional research is required to accurately quantify whether the SDMP has effectively redirected resources to under-resourced areas.

Healio Primary Care spoke with Scannell to learn more about the project and its potential impact on primary care shortages.

Healio Primary Care: What did you find most surprising in your analysis?

Scannell: The abrupt change in PC-HPSA designations starting in 2015.

Let me give you some additional background first. I had originally learned about the SDMP from doing a literature search on PC-HPSAs for another project. When I first read about it and started digging around for background literature, I realized there was nothing published in the primary research literature about this policy change. There was also a minimal amount in the research literature on PC-HPSAs. My colleagues and I decided to do a descriptive analysis of how PC-HPSA designations at the county level changed over time to fill in this gap.

When we first graphed out the number of the different types of PC-HPSA designations vs. time, we were really struck by how the number of full-county and partial-county PC-HPSAs switched between 2013 and 2015. This also corresponded to the start of the SDMP, and this is what really grabbed our attention.

Healio Primary Care: How severe is the primary care shortage in the United States?

Scannell: Simply put, we don’t have enough PCPs and we don’t have enough of them in the areas with the greatest need. Based on a 2021 Association of American Medical Colleges report, there will be a projected shortage of somewhere between about 20,000 to 50,000 PCPs by 2034. Or using PC-HSPA status as a guide, which amounts to a population-to-PCP ratio of at least 3,000 to 3,500 in each county, we would need about 14,000 more PCPs to remove these designations. If we recruit even more PCPs and drive this ratio down to 1,500 per county, this change would increase mean life expectancy by more than 50 days and save more than 7,000 lives each year. Unfortunately, there is a national trend of decreasing PCP supply per capita over the last decade, especially in rural areas. This trend is likely driven by a combination of increasing population size, disproportionate physician loss in rural areas, an aging physician workforce and physician burnout.

Healio Primary Care: How has the COVID-19 pandemic affected the shortage? And, in turn, how has the shortage affected the pandemic?

Scannell: These are excellent questions and ones where we are just starting to understand the relationship between these two factors. In terms of the impact of the COVID-19 pandemic on PCP shortage, there is a dearth of quantitative data on the matter and it’s likely too early to tell what the overall change in PCP supply is going to be. Anecdotally, and based on survey and qualitative evidence, the pandemic has contributed to physician burnout, and I would guess that this would cause more providers to leave the profession. In terms of the impact of PCP shortage on the pandemic, early evidence suggests that full-county PC-HPSAs have higher COVID-19 case and mortality rates compared to counties without this designation. Although various medical and socioeconomic markers of vulnerability also often overlap with a county’s PC-HPSA status, PCP shortage can easily be seen as part of the causal pathway where structural factors impede timely access to medical care and can lead to worse outcomes.

Healio Primary Care: How will efforts like the SDMP help address primary care shortages?

Scannell: The SDMP could potentially improve PCP shortages by aligning financial and clinical personnel resource incentives with a more accurate marker of PCP supply. PC-HPSA status did not accurately reflect county-level PCP supply, and this may have led to inappropriate disbursement of resources. Counties that are designated full-county PC-HPSAs are now more reflective of areas with low PCP supply and can hopefully receive the resources they truly need. Additionally, I believe the SDMP can help target smaller geographic areas that are under-resourced by placing more emphasis on facility and population-level need at the sub-county level.

Healio Primary Care: How much will the SDMP impact primary care shortages?

Scannell: This outcome is hard to measure based on the scope of our current analysis. Our primary objective with this paper was to provide a descriptive analysis of changes in PC-HPSA designations at the county level before and after implementation of the SDMP. In terms of measuring its impact on addressing the primary care shortage, I think additional work is needed to measure financial and clinical personnel allocation before and after the policy change. Specifically, we should measure financial outcomes such as the Medicare HPSA bonus payments and clinical personnel outcomes such as providers recruited through the National Health Service Corps to get a sense of the immediate impact of the SDMP. We may also see a change in total PCP distribution as a result of the SDMP, but I think this will be a longer-term outcome that will need to be followed for the next 5 to 10 years.

Healio Primary Care: What other efforts are needed to address the shortage?

Scannell: There are various ways to address both the current and future primary care shortage that is projected to get worse over time. These efforts include bolstering the capacity of both physician and non-physician resources. To increase capacity of the physician workforce, efforts include increasing exposure to primary care training in medical school, increasing the number of primary care-related residency positions, increasing funds for loan repayment programs for those choosing to go into primary care, increasing reimbursement rates for non-face-to-face work and decreasing patient panel sizes or increasing time for patient visits to decrease burnout among PCPs. In terms of bolstering the non-physician capacity, efforts include training more advanced practice providers such as nurse practitioners and physician assistants, creating opportunities for medical assistants to act as panel managers or health coaches, and increasing the potential for more patient self-care using technologic resources such as smartphone apps.

Healio Primary Care: What is the take-home message of your study?

Scannell: The take-home message is that the SDMP helped improve the accuracy of PC-HPSA designations as a reflection of county-level measures of PCP supply and additional work is needed to measure the impact of this policy change, especially the allocation of financial and clinical personnel resources. And hopefully, the long-term effect will be to improve recruitment of PCPs to the areas of high medical and social need to improve access to primary care.

I would also like to add that I am open to collaboration, and I hope any researchers out there who are also studying PCP supply/shortages will reach out and contact me so we can increase the evidentiary base for the field and help policy makers make more informed decisions.

References:

AAMC. AAMC report reinforces mounting physician shortage. https://www.aamc.org/news-insights/press-releases/aamc-report-reinforces-mounting-physician-shortage. Accessed August 5, 2021.

Basu S, et al. Ann Intern Med. 2021; doi:10.7326/M20-7381.

Ku BS, et al. J Gen Intern Med. 2020; doi:10.1007/S11606-020-06130-4.

Scannell CA, et al. JAMA Netw Open. 2021;doi:10.1001/jamanetworkopen.2021.18836.