- The United States is staring down a significant provider shortage, raising questions about how to ensure seamless patient care access in a rapidly changing environment.
As of 2016, the healthcare industry lacked 20,000 primary care physicians, according to statistics from the Association of American Medical Colleges (AAMC), and the deficit is only projected to grow.
By 2030, the industry could be short up to 120,000 primary care physicians by 2030, AAMC said in revised estimates for 2018.
The industry will also need between 20,700 and 30,500 more surgeons and 20,300 to 36,800 specialists.
The growing provider shortage stems from changes in the industry landscape. The Baby Boomer generation is aging - and with age comes more chronic illnesses.
Training enough providers to meet these growing demands is also difficult. Although medical school enrollment numbers haven’t yet dipped, some experts argue that fewer students may consider the path in the future because of high costs, the extreme pressure of handling higher caseloads, and extensive student debt.
Placing students who have completed medical school into residencies has also proven a challenge, experts report. There are fewer residence programs than medical school graduates, data from the National Residency Matching Program shows, leaving some new grads without a clear path forward into clinical care.
Additionally, physician burnout is pushing some seasoned doctors to enter early retirement or reduce their hours. The 2016 Physicians Foundation Biennial Physician Survey found that 54 percent of physicians are feeling burnout, and 48 percent plan to combat those feelings by cutting hours or retiring early.
Clinician shortage issues impact some regions more than others. Patients living in rural areas, for example, face more access issues tied to the clinician shortage than patients living in urban or suburban areas.
The nationwide provider shortage creates a considerable patient care access issue. When there are not enough doctors, patients usually experience long wait times for both routine and urgent appointments.
Combatting the complex physician shortage issue will require a multi-pronged effort on the part of individual organizations and industry leaders.
Organizations should consider focusing on utilizing non-physician clinicians, better staff scheduling strategy, and creating incentives for new hires.
On an industry-wide basis, leaders may wish to take broader actions, such as expanding scope of practice for nurse practitioners and physician assistants and supplementing efforts for physician recruitment and education.
How does the provider shortage impact patient care access, satisfaction?
The provider shortage is fundamentally a patient care access issue, but long waits for an appointment or extended travel times to different care sites also have a significant impact on patient satisfaction.
A 2017 Merritt Hawkins survey found that patient wait times have increased by 30 percent since 2014.
The survey of physician practices in 30 mid-sized and large metropolitan areas found that patients face an average appointment wait time of 24 days. This is up from 18.5 days in 2014.
Longer wait times are largely due to the provider shortage, according to Merritt Hawkins President Mark Smith.
“Physician appointment wait times are the longest they have been since we began conducting the survey,” Smith said in a press release. “Growing physician appointment wait times are significant indicators that the nation is experiencing a shortage of physicians.”
“Finding a physician who can see you today, or three weeks from today, can be a challenge, even in large urban areas where there is a relatively robust supply of doctors,” Smith added. “The challenge becomes even more difficult in smaller communities that have fewer physicians per population.”
Long wait times negatively impact patient satisfaction scores, separate data has shown. The 2018 Vitals Wait Time Report found that a reasonable wait time - around 15 minutes, the survey said - is somewhat or very important to a quality care experience.
Thirty percent of patients said they have left a provider because their wait times became unreasonable.
As hospitals and clinics nationwide face pressure to improve patient satisfaction, they are considering all avenues for improving the care experience. Ensuring the organization has enough providers per patient may produce improved patient experiences.
Recruiting non-physician clinicians to enhance care teams
Non-physician clinicians such as nurse practitioners (NPs), advanced practice registered nurses (APRNs), and physician assistants (PAs) present an opportunity to expand care teams and ease the effects of the physician shortage.
A June 2018 analysis from MGMA showed that APRNs and PAs are in higher demand because of the physician shortage. Because more organizations want to hire non-physician clinicians to fill care gaps, nurses have seen average annual salary increases from $48k in 2015 to $57k in 2018.
The job market for PAs has grown by 53 percent, and the average salary for a PA has grown in the past five years to $107,718 in 2018.
Nurse practitioners and their colleagues can bring significant value to organizations embracing team-based care models, said Christy Dempsey, Chief Nursing Officer at Press Ganey.
“We have seen good outcomes when nurse practitioners are able to be autonomous,” she said in a previous interview. “There is also broad understanding that when we are educated and trained as nurses, we understand the value of an interprofessional team and that none of us can do this by ourselves. Because interprofessional teamwork it is so ingrained in nurses and then therefore nurse practitioners, autonomy does not mean that we won’t work without interprofessional colleagues to take care of patients.”
NPs and PAs are trained to conduct most primary care appointments, said Bianca Belcher, MPH, PA-C, Director of the Center for Healthcare Leadership and Management at the American Academy of PAs.
“Both [NPs and PAs] can diagnose, prescribe, and manage patient populations as far as treatment protocols,” Belcher explained. “A lot of times we are the primary treatment option for patients, as well as the formal or informal coordinators of care.”
But not all industry stakeholders agree with expanding scope of practice for NPs and PAs.
A 2013 essay from the American Academy of Family Physicians’ president-elect at the time, Reid Blackwelder, MD, asserted that physician and NP roles are not interchangeable. Because of variable and shorter training periods, NPs may not be ideal candidates for filling care access gaps, Blackwelder wrote.
“There is no question that nurse practitioners, physician assistants and others are each vital parts of our health care team. But they are not physicians,” he said. “Although some tasks and services can be shared, the roles each of us play are not interchangeable. The medical expertise of primary care physicians must be a part of the team-based care patients need and deserve.”
Measuring and then marketing what NPs and PAs do will be central to addressing these critics, according to Joyce Knestrick, PhD, APRN, C-FNP, FAANP, President of the American Association of Nurse Practitioners.
“Within many health systems, the PAs and NPs are not coded to show that they delivered certain services,” she said. “That makes it very difficult for organizations to understand the value that they’re contributing, both from a patient care perspective and from a revenue and reimbursement perspective.”
“We need to collect that data on what we do so that we’re not viewed as a cost center instead of a group that can bring profit,” Knestrick added.
As organizations and industry leaders consider PAs and NPs as solutions to the physician shortage, it will be key to measure and address the potential that these professionals have for fulfilling patient care needs, particularly in primary care.
Employing judicious appointment, shift scheduling strategies
Although non-physician clinicians and other healthcare workers do come with a lower price tag, many cash-strapped organizations still are not in a position to hire more employees. These clinics and hospitals can work to chip away at the challenges of a clinician shortage by scheduling their providers at strategic times and in strategic places.
Organizations can analyze their clinic traffic to identify high-demand timeframes. For example, before- and after-work appointments and lunchtime appointments are likely in higher demand than mid-day clinic appointments. Instead of scheduling an even amount of providers during all time periods, organizations may wish to consider scheduling more providers during high-traffic times.
The Institute of Healthcare Improvement (IHI) recommends organizations look at their provider supply and patient demand for both in-office appointments and phone call or secure message consultation. From there, organizations can identify trends in patient traffic and redistribute their provider schedules.
Organization leaders should track patient traffic not only on a daily or weekly basis, but also on a seasonal basis, IHI says.
“Flu season, allergy season, snow-bird season, and school physicals are all examples of demand-side variation,” IHI explains.
“Every year at most primary care clinics, an increase in demand for appointments during January and February can be predicted as the cold and flu season hits,” the organization continues. “Practices can make arrangements for physicians to add appointments to their schedules during these months or preferably preschedule elective visits into low demand seasons, months, and days. Scheduling elective and pre-scheduled appointments at low demand times anticipates needed openings during times of peak demand (as determined by an analysis of demand data).”
How organizations can recruit more physicians
While non-physician clinicians and better scheduling can close some care gaps, the fact of the matter is that the industry and individual organizations need more doctors.
The Bureau of Labor Statistics projects that the physician and surgeon job market will grow by 13 percent by 2026, but that growth pales in comparison to patient population growth.
The AAMC predicts that the over-65 patient population will grow 50 percent by 2030 and the over-75 population will grow 69 percent. Growth in this high-needs group calls for more doctors who are able to lead chronic care management teams and address the complex health concerns of older adult patients.
Individual organizations are developing hiring incentives that could attract doctors to practice. According to healthcare consultants at the Coker Group, key incentives include better salaries, performance-based payments, student loan forgiveness, or housing programs.
Creating incentives that work is especially important for smaller healthcare organizations located in rural areas.
Experts at the Rural Health Information Hub (RHIhub) state that lower population density, fewer educational and entertainment opportunities, and harsher climates may make rural regions less desirable areas in which to work. Incentives that guarantee housing, competitive salaries, and access to continuing education could compel providers to take up the challenge of practicing in rural areas.
But hiring incentive programs are considerable financial investments for healthcare organizations, especially those located in rural areas that have limited resources.
“Recruiting healthcare providers and acclimating them to a community and facility are expensive, and often lengthy, endeavors,” says RHIhub. “It is important to recruit providers who are well-suited to the community in which they will work, and to be proactive in retaining those providers. This is called recruiting for retention.”
RHIhub suggests that organizations should create standardized hiring strategies, consider long-term organizational goals, and engage in continuous organizational planning. Additionally, hiring personnel should ensure applicants’ priorities align with organization goals, that the organization is in the area the applicant desires, and that the region has school availability for applicants’ families, RHIhub recommends.
Industry-wide clinician recruitment efforts
Some industry leaders are working on preliminary incentive programs to recruit more doctors. NYU School of Medicine recently announced that it will offer full-tuition scholarships to all of its current and future students regardless of need or merit. Offering tuition-free medical school could help students overcome financial barriers to receiving a medical education and incentivize students to pursue a medical degree who otherwise would not have.
However, this unprecedented move is limited in scope and at this time has little evidence for its effectiveness at addressing provider shortages.
Industry stakeholders also argue that the government must do a better job of supporting medical school graduates beginning their careers as residents.
“Medical schools and teaching hospitals are working to ensure that the supply of physicians is sufficient to meet demand and that those physicians are ready to practice in the health care system of future,” said AAMC President and CEO Darrell G. Kirch, MD, said in a statement about the group’s 2018 physician shortage report.
“To address the doctor shortage, medical schools have increased class sizes by nearly 30 percent since 2002,” Kirch continued. “Now it’s time for Congress to do its part. Funding for residency training has been frozen since 1997 and without an increase in federal support, there simply won’t be enough doctors to provide the care Americans need.”
Other experts say the country needs to tap its immigrant workforce and foreign-trained provider workforce.
The American Medical Association (AMA) issued an August 2018 statement calling on the government to process visas faster for foreign-trained physicians, stating that these physicians are essential to closing provider shortage gaps.
“These physicians play a critical role in providing healthcare to many Americans because they tend to choose primary-care specialties and work in areas of the country with higher rates of poverty; they are providing important medical services to communities in need,” AMA wrote in its letter to the US Citizenship and Immigration Service (USCIS). “According to a recent report, about 20.8 million Americans live in areas where at least half of the physicians are foreign-trained.”
However, critics of foreign-born providers filling care gaps state that efforts should be targeted at better placement of US-trained medical residents.
It is not too late for healthcare professionals to address the provider shortage and the patient care access issues likely to come with it.
On an organizational level, leadership can look at the resources it already has, such as NPs, PAs, and community health workers to fill in care gaps, and offer hiring incentives to supplement their workforces. Reexamining provider scheduling and high-demand timeframes will allow organizations to deploy their provider resources in a way that will meet patient needs.
The industry at large should look at similar strategies, such as expanding scope of practice laws for non-physician clinicians, offering support for medical education and residency placement, and supplementing organizational efforts in providing hiring incentives.