Primary Care Workforce Primary Care Workforce Health Care Safety-Net Toolkit for Legislators Primary Care Workforce Introduction The primary care workforce delivers essential primary and pre- ventive health care to a population that is increasingly demand- ing these services. Access to appropriate primary care services is important to maintaining and improving health. Those who obtain regular primary care receive more preventive services, are more likely to comply with their prescribed treatments, and have lower rates of illness and premature death, according to research.1 Effective primary care is comprehensive, coordinated, timely, and patient-centered and can result in better health for the patient, fewer avoidable hospitalizations and emergency room visits and lower costs. Despite the benefits of a high-quality primary nology adaptation, provide new challenges for the care system, the reality is that today’s primary care existing workforce. workforce is struggling to meet current demand for services—and the unmet needs are expected to This primer provides an overview of the issues intensify as a result of demographic changes, cov- and challenges facing the primary care workforce. erage expansions due to the Affordable Care Act It also contains policy options and actions that (ACA), and a decline in the primary care physician states have adopted to address gaps and strengthen workforce. At the same time, reforms and quality the primary care workforce’s capacity to meet the improvements, such as health information tech- growing demand for services. “Primary care is a foundational element of the U.S. health care system and is required to meet our Nation’s triple aims of improving quality, containing costs, and improving patient and family experience.” —Agency for Healthcare Research and Quality 2 Health Care Safety-Net Toolkit for Legislators At a Glance: What Legislators Need to Know What is primary care and why is it important? deliver, and establishing reimbursement policies (e.g., The Institute of Medicine defines primary care as “The enhanced Medicaid reimbursement for primary care provision of integrated, accessible health care services services). by clinicians who are accountable for addressing a large majority of personal health care needs, developing a Legislators adopt workforce policies and engage in sustained partnership with patients, and practicing in the workforce planning to ensure an adequate supply and context of family and community.”2 geographic distribution of primary care providers in their state so that their constituents have access to high-qual- As a first contact with patients, primary care refers to the ity primary care services, regardless of where they live. A long-term, comprehensive, coordinated and patient- competent and sufficient primary care workforce offers centered care delivered by a primary healthcare provider. important public health benefits and cost savings. Access to primary care “is associated with more timely care, better preventive care, avoiding unnecessary care, What is a shortage area, why is it important, and how is improved costs, and lower mortality.”3 it determined? Research and policy discussions about the primary care Who provides primary care services? workforce frequently cite the challenge of workforce Primary care providers (PCPs) include physicians, Ad- shortages and poor distribution throughout the coun- vance Practice Registered Nurses (APRNs) such as nurse try—and specifically the mismatch between the need for practitioners, and physician assistants in family medicine, primary care workers to provide adequate access to es- general internal medicine and general pediatrics. Other sential health care services and the availability of staff to health care professionals—such as pharmacists, dentists, meet those needs. The U.S. Health Resources and Services dieticians/nutritionists, certified nurse midwives, and Administration (HRSA) develops shortage designation social workers—deliver or help to deliver primary care criteria to determine if a geographic area, population or services. facility is a Health Professional Shortage Area (HPSA) or Medically Underserved Area or Population (MUA/MUP).4 How and why do state legislators address primary care workforce policy? HPSA designation is used to determine eligibility for State legislators address the primary care workforce in certain federal workforce programs and policies, such various ways that are discussed in greater detail in this as National Health Service Corps, the J-1 Visa Program primer. Examples include regulating and licensing health and the Medicare Physician Bonus program. While the professions, analyzing and requiring data collection on programs vary in terms of eligible providers, they share in workforce supply and distribution, identifying shortage common a focus on attracting primary care physicians to areas and resource gaps, establishing loan repayment or retaining them in underserved areas. programs and other incentives to encourage practice in underserved areas, defining the services a provider can 3 Primary Care Workforce Primary Care Workforce Issues and retirement age—and not enough medical students Challenges and new physicians exist to replace them, let alone The demand for primary care services is rapidly meet the increasing demand for additional pro- outpacing the supply of providers able to deliver viders. Although the number of medical students these services. More than 64 million Americans choosing primary care rather than a specialty has currently live in areas designated by the Health increased in the past four years, it is not enough to Resources and Services Administration as having meet the current and future demand for primary shortages of primary care professionals.5 care. In addition, existing primary care physicians are retiring or leaving for opportunities in other Estimates of the scope of the provider shortage fields. According to a March 2013 article in the vary, but it is generally agreed upon that thousands journal Family Medicine, “Accessible, high-quality, of additional primary care providers are needed cost-effective health care systems are anchored in to meet the current demand. During the coming primary care, yet decreasing production of gradu- decade, tens of thousands of additional primary ate medical education (GME) jeopardizes the 8 care providers will be needed to meet increasing primary care workforce and the nation’s health.” demands. Rural and underserved communities A number of factors contribute to the selection of are especially hard-hit by the shortage of primary primary care training by medical students, includ- care physicians. Only 11 percent of the nation’s ing the perceptions that those in practice have physicians work in rural areas, although nearly 19 heavy workloads, poor quality of work life, and percent of Americans live there.6 lower comparative income relative to specialty care. With passage of the Affordable Care Act, the Congressional Budget Office estimated in 2012 Solutions: Federal and State that between 30 and 33 million additional Ameri- Policies and Actions cans could have access to insurance coverage in To reverse these trends, federal and state policy- 2016 and subsequent years.7 Starting in 2014, makers have adopted policies and programs— millions of the newly insured will be more able to including payment reforms, expanded use of seek medical care in a primary care setting, placing non-physician providers, and expanded training an even greater strain on the primary care work- opportunities—to increase the numbers and prac- force. Increased federal investments in community tice locations of primary care providers to respond health centers and patient-centered medical homes to changing population needs. In addition to will offer enhanced access to primary care services. bolstering the workforce, systemic changes—such At the same time, however, these new primary care as strengthening community health centers and settings will require more primary care providers other models that focus on primary care—empha- to deliver and coordinate care. size the importance of primary care in the overall health care system. This section summarizes some Despite the growing needs, there are not enough key federal and state resources and actions that primary care physicians and other primary care can help to meet the needs for more primary care providers to fill the gaps. Primary care physicians services. in particular are aging—one-quarter are nearing 4 Health Care Safety-Net Toolkit for Legislators Federal Resources more than 16,000 new primary care providers over Federal workforce funds provide a wide range of five years.10 support and assistance to develop the primary care workforce and ensure that people have access to The act re-authorizes existing workforce training primary care professionals. In addition to scholar- programs and invests in public health infrastruc- ships and loan repayment programs for providers ture, programs and state-level workforce analysis who practice in underserved areas, federal initia- and planning. The Prevention and Public Health tives support primary care infrastructure and Fund expands the supply of primary care providers delivery in many ways—from funding streamlined through additional primary care residency slots, pathways to becoming a primary care doctor to and increases the number of training opportunities diversity programs to enhancing national and for physician assistants and nurse practitioners. In state-level