Physician Distribution: An Old Problem Receives New Attention

Wayne J. Guglielmo

May 14, 2009

May 14, 2009 — From President Obama, to members of Congress, to federal and private agencies concerned with the issue, officials in Washington and beyond are pointing to the need for more physicians and other healthcare workers, especially in primary care. The Association of American Medical Colleges, for its part, has called for a 30% increase in enrollment to meet anticipated demands up through 2025 — demands that would rise dramatically if lawmakers managed to pass some form of universal healthcare.

But as essential as it is, the push for more physicians and healthcare professionals will not by itself solve a related workforce problem: the maldistribution of physicians and other healthcare professionals across the nation, a problem that has left rural, frontier, and some inner-city communities especially vulnerable.

Nowhere are workforce shortages showing up more clearly in these areas than in community health centers (CHCs), the outpatient clinics that receive federal and other money to provide treatment to people regardless of their income or insurance status. Nationally, the current need for primary care providers, including physicians, nurse practitioners (NPs), physician assistants (PAs), and certified nurse midwives, is roughly 1850, according to the National Association of Community Health Centers (NACHC) in Bethesda, Maryland. An additional 1400 nursing slots also remain unfilled.

At a CHC in south central Washington State, for instance, Anita Monoian, chief executive officer and president of Yakima Neighborhood Health Services, has struggled for some time now to fill 5 physician vacancies in her clinic, despite aggressive recruiting. "For a couple of these vacancies, I've been recruiting for more than a year," Ms. Monoian, who is also chair-elect of the board of directors of NACHC, told Medscape Medical News.

Ms. Monoian is fortunate in some ways, since Yakima, a city of about 85,000, is "not as rural as some places that have 1200 people." Still, recruiting for physicians and other health professionals remains a challenge — as it does, to varying degrees, in CHCs across the country.

The difficulty of getting providers to practice in rural, frontier, and even some inner-city communities is not new. "This isn't something that has come up in the last 1 or 2 years," said Tom Morris, associate administrator in the Office of Rural Health Policy, Health Resources Services Administration (HRSA), US Department of Health and Human Services. "It's a longstanding challenge."

And yet there are at least anecdotal signs that the gap between supply and demand in some areas is widening. "There was a time when it would take a community health center 2 to 3 months to recruit physicians and other providers," said Jim Macrae, who as HRSA associate administrator for primary care manages a budget that goes in part to support CHCs across the country. "At worst, it would take 6 months. Now 6 months is the average — and in some cases it's 12 months before they can find someone."

Several factors seem to be driving this trend — a workforce that is aging and needs to be replaced; a shallower pool of international students from which to draw; the extra strain placed on clinics by the recession and worker layoffs; and a new generation of physician recruits who are smart, tech-savvy, and not inclined to settle. "They've set a standard for the quality of life they want, and they're not going to compromise that standard," explained Ms. Monoian, who added that applicants often end up interviewing her.

Simply having more doctors, nurses, and others looking for a job, of course, would mitigate these problems. But even the AAMC has acknowledged that "increasing the number of physicians alone will not improve distribution," since providers would still tend to favor some locations at the expense of others. Beyond the necessary but insufficient step of boosting supply, AAMC makes clear, "effective policies for improving access must be continued and enhanced."

Getting Clinicians Where They're Needed

The economic stimulus measure, signed into law by President Obama in February, will address some of these concerns, especially as they affect CHCs.

Besides $1.5 billion for CHC infrastructure improvements and another $500 million for CHC service enhancements, the stimulus package directs $500 million to deal with distribution-related problems. Of this $500 million, $300 million will go to the National Health Services Corps to place 4100 new primary care physicians, NPs, PAs, dentists, and other healthcare professionals in underserved areas across the country.

As part of this process, NHSC participants are eligible to have their medical school tuition and fees reduced or paid for through, respectively, an NHSC loan repayment or scholarship program. An additional $200 million in stimulus money is slated for the HRSA Title VII Health Professions and Title VIII Nurse Training programs. "This is basically to create the next cadre of providers to serve in rural, frontier, and inner-city communities," the HRSA's Jim Macrae told Medscape Medical News.

Beyond targeting stimulus money, policymakers, say experts, also need to think about workforce distribution, and workforce planning generally, in a more coordinated way. "Many countries have workforce planning that's more formal," said Mark Doescher, MD, MSPH, an associate professor in the Department of Family Medicine, University of Washington School of Medicine, Seattle, and director of the WWAMI Rural Health Research Center. "We really don't have that here."

How might a more coordinated approach work? Dr. Doescher starts by envisioning a continuum, which stretches from the time a student enters secondary school to the time he or she begins their career. By exerting the right influence at key "leverage points" along the way, Dr. Doescher told Medscape Medical News, educators and other "stakeholders" can increase the odds that a student will not only choose primary care but elect to practice their profession in an underserved area.

In secondary school and college, that means enhancing science and mathematics instruction; at the medical school admissions level, it means doing more to recruit applicants from rural communities, who are more likely to return to their communities to practice; and within medical school, it means, among other things, giving students "longitudinal rural experiences," which a number of even urban-based medical schools are doing.

Residency, noted Dr. Doescher, presents a whole different set of leverage points, because students may now be carrying debt, may be training in urban hospitals, and may have crucial family and lifestyle decisions to make. Still, he said, it is possible to exert the kind of influence — like loan forgiveness or providing Medicare financing for community-based rural residencies — that might not only bring providers to underserved communities for 3 or 4 years but help them put down roots.

As Tom Morris of HRSA's Office of Rural Health Policy says: "No one thing will solve the problem. It's a lot of individual activities pointing in the right direction that will make a difference."

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