December 10, 2008
BACKGROUNDER: RECRUITING AND RETAINING A PRIMARY HEALTHCARE WORKFORCE
By: Saul Spigel, Chief Analyst
Two legislatively created groups are looking at ways to increase state residents' access to quality healthcare. Both recognize that shortages of primary care providers could be an obstacle to achieving this goal.
This Backgrounder briefly describes existing and projected provider shortages and looks at options the state could consider to help recruit and retain trained providers. (By and large, it does not address the healthcare provider education and training system.) The report focuses on primary care physicians (e.g., family practitioners, internists, pediatricians, and ob/gyns) but touches on general practice dentists and dental hygienists, nurses and physician assistants, and others who provide primary medical and behavioral healthcare.
Shortages of healthcare workers from physicians to nurses' aides have been documented in Connecticut and across the nation. The American Medical Association, for example, projects a nationwide physician shortage of between 51,000 and 228,000 by 2020 while the University of Albany's Center for Health Workforce Studies estimates over half a million more registered nurses (RNs) will be needed by 2016.
In Connecticut, the Allied Health Workforce Policy Board's latest report projects a 15% increase in the total number of healthcare jobs between 2004 and 2014. (The legislature created the board in 2004 to track the allied health workerforce and make recommendations on ways to recruit and retain people in these fields.) It predicts the state will need over 1,000 new RNs a year for the next five years to fill demand. OLR report 2006-R-0546 (http://www.cga.ct.gov/2006/rpt/2006-R-0546.htm) contains detailed information on Connecticut healthcare workforce shortages.
The Policy Board's projections do not take into account any increased demand that would occur if more Connecticut residents have access to health services. Two groups the legislature created in 2007 are looking at ways to accomplish this end. The Statewide Primary Care Access Authority is seeking to develop a system that provides primary care services to all state residents. And the HealthFirst Connecticut Authority is considering options for universal health insurance coverage.
Causes for Shortages
These shortages have many causes. Several studies of primary care providers cite personal finances and the practice environment as key causes. (Other causes, which this report does not address, include an aging population's greater need for services, more providers reaching retirement age, and increased credentialing requirements.)
Money. Primary care physicians earn considerably less than specialists. The average 2007 salary of all physicians in family medicine, pediatrics, and internal medicine ranged between $186,000 and $193,000, while the average for anesthesiologists, radiologists, and orthopedic surgeons ranged between $345,000 and $436,000. Average starting salaries for these practice areas were equally disparate—starting specialists earned about twice as much as starting primary care physicians (Ebell, “Future Salary and US Residency Fill Rate Revisited,” Journal of the American Medical Association (JAMA), September 10, 2008, p. 1131-32).
Their relatively lower earnings, particularly in starting pay, make it harder for newly graduated primary care physicians to pay their considerable medical school debt. The average 2007 medical school graduate owed nearly $140,000, a 289% increase over 1987. The average new dentist owed $145,000.
Starting wages for most nonphysician primary care providers appear less of a disincentive, but pay increases tend to be small, especially in facilities that serve a high proportion of Medicaid and uninsured patients. And their salaries in clinical settings are often lower than those the pharmaceutical and insurance industries pay.
Practice Environment. Some aspects of the work environment dissuade medical school students from pursuing careers in primary care and lead practicing primary care providers to leave the field. These include sometimes long, erratic hours; administrative obligations, especially dealing with insurance companies; and malpractice liability.
Medical students recognize and view negatively the increasing demands on primary care physicians “to accomplish large numbers of therapeutic interventions during short visits with chronically ill patients while managing increasing administrative expectations” (Hauer, et. al., “Factors Associated With Medical Students' Career Choices Regarding Internal Medicine,” JAMA, September 10, 2008, pp. 1154-1164).
Practicing primary care physicians appear to agree. The Connecticut State Medical Society (CSMS) recently surveyed state doctors about their job satisfaction and problems they face. While the survey found that, on average, physicians are satisfied with their careers, family physicians, internists, and ob/gyns are less satisfied than those in other specialties. Specifically, these doctors expressed less satisfaction with the balance between their professional and personal lives, the number of hours they worked, and their administrative responsibilities. They are more likely to want to move out of Connecticut and less likely to recommend practicing in Connecticut to others, notably medical students. Pediatricians, though, were more satisfied than most doctors in all of these areas except personal and professional life balance.
The CSMS survey cited professional liability as a key factor in physicians' negative views of Connecticut's practice environment. While this was an issue especially for ob/gyns and general surgeons, CSMS noted that 30% of internists and family doctors reported reducing the number of high-risk patients they served and services they provided, presumably due to legal concerns.
Other healthcare providers are also dissatisfied. The Association of Academic Health Centers (AAHC) recently reported that “job satisfaction in the health professions is among the lowest of many industries.” It cited a (1) 2001 study suggesting that almost 25% of all nurses, and nearly one-third of young nurses, planned to leave their jobs in the next year and (2) 2004 study showing about 25% of pharmacists planned to leave their jobs within one year because of salary, schedule, and benefits. (AAHC, Out of Time, Out of Order: The State of the Nation's Workforce, 2008).
RECRUITMENT AND RETENTION STRATEGIES
Scholarships and Loan Repayments. States operate approximately 75 separate programs that provide scholarships, loans, loan repayments, and other financial incentives to students in healthcare fields and new primary care providers, according to the American Association of Medical Colleges. These programs have various funding sources. Connecticut, like 18 other states, combines state funds, in tandem with National Health Service Corps funds in a loan repayment program. Other states (27) provide incentives solely with state funds and some use both approaches in multiple programs. Connecticut has used state funds to enlarge the capacity of its nursing education programs and provide scholarships for nursing faculty.
Scholarships and loan repayments tied to service obligations are the most popular incentives. Scholarships can attract students, especially low-income students, to primary care; loan repayment may be more effective in encouraging graduates to practice in specific locales. Most programs target physicians (typically family practitioners, internists, and pediatricians), but many are open to dentists and dental hygienists, nurses, and physician assistants. Some states have programs specific to these nonphysician providers.
The incentives typically require recipients to practice full-time in the state, usually in an underserved area, for a period of time. These periods run from one to five years; two years is the median. Loan repayment amounts run between $3,000 to $40,000 a year, depending on the recipient's practice field; $10,000 is the median. (Connecticut pays doctors $15,000 a year for up to four years and nurses $22,500 over two years.) Some states use their own criteria for eligible service sites, some use federally designated health professional shortage or medically underserved areas, and some use a combination of federal and state criteria.
Minnesota is one of the few states to have evaluated its loan repayment program. Begun in 1990 to recruit doctors to rural areas, by 2007 the program supported over 550 doctors, dentists, pharmacists, physician assistants, and nurses in those areas and in high-need facilities like nursing homes, intermediate care facilities for people with mental retardation, and dental practices serving a high proportion of low-income patients. The evaluation found:
1. the programs were effective in recruiting practitioners to high-need locations;
2. most practitioners who completed their service obligations remained in similar practice settings in the state; and
3. placement sites varied in their dependence on the program as a recruitment/retention tool, with smaller primary care and specialty clinics valuing the program the most.
Practice Support. Some states help doctors set up practices in underserved areas. Under New York's recently enacted Doctors Across New York initiative, physicians who commit to practicing for two years in an underserved rural or urban area can receive $100,000 for salary enhancements, signing bonuses, or other direct payments. They can apply directly for the money or do so through a group practice or a healthcare provider. Hospitals and community organizations can apply for funds to fill positions. Any physician is eligible, but internists, family physicians, ob/gyns, pediatricians, pediatricians, psychiatrists, general surgeons, and emergency medical services doctors receive preference. New York budgeted $4.9 million for the program in FY 09, which it expects to support 100 doctors.
Under Arkansas' Community Match Loan and Rural Physician Recruitment Program, a doctor can receive up to $80,000 for four years of service in a medically underserved rural community. Half of the money comes from the state, and half from the community; a third party, such as a hospital, can pay the community's share. A physician who fails to complete his or her obligation must repay any money received plus interest and face license suspension for the rest of the service term.
Provider Reimbursement. Specialists make more money than primary care providers largely because of the way insurers, public and private, pay for care. Fee-for service formulas encourage specialists by paying for each procedure, regardless of outcome; the more procedures a doctor performs, the more money he or she makes. In contrast, primary care physicians, whose principal billable service is patient office visits, cannot see more patients without reducing the time they spend with each. And most payers, including Medicare, the nation's largest payer, pay more for procedure-based services than for “evaluation and management” office visits. For example, in Boston, Medicare's fee for a 30-minute office visit for a patient with a complex medical condition is about $100; in contrast, it pays about $450 for a 30-minutes diagnostic colonoscopy.
Several options have been proposed to better compensate primary care providers. These include:
1. increasing base fees for primary care patient visits and adding a fee to account for the time providers spend coordinating care for patients with multiple chronic illnesses (e.g., talking to specialists or insurers);
2. replacing the visit-based, fee-for-service primary care payment with a comprehensive, risk adjusted, per-patient payment combined with substantial performance-based rewards (using patient experience and clinical measures) to encourage quality and access; and
3. including an outcome based pay-for-performance component in any payment system.
Some physician organizations have proposed a “patient-centered medical home” primary care service and payment model. In this model, one health professional coordinates all of a patient's needed services, including specialty care. The medical home is not a “gatekeeper” that must authorize specialty care for patients; instead it seeks to ensure continuity of care and guide patients and their families through the complex process of making medical decisions. The model calls for paying medical homes for the time their staff spend coordinating care. These coordination payments could be added to existing fee schedule payments or they could be included in a comprehensive, per-patient monthly fee.
Practice Environment Strategies
Attracting Providers to Underserved Areas. Many of the financial strategies outlined above are designed to recruit new providers to shortage areas after they graduate. Some states and institutions start this process during medical school or residency by:
● targeting students who wish to practice primary care in rural settings for medical school admission (e.g., University of Washington School of Medicine);
● creating special programs or curriculum tracks for students who want to practice in underserved areas (e.g., University of Wisconsin School of Medicine and Public Health's Academy for Rural Medicine or University of Illinois-Chicago's UMed Program for urban practice);
● encouraging residents to train in certain settings, like rural areas, or specialties, like family practice. (Texas requires all family medicine residents to be offered a one-month rural rotation and uses physician shortage and medically underserved designation as criteria for distributing state funds that support primary care residencies.)
Some states have established centers or databases to help recruit providers to underserved areas. Virginia's Primary Practice Opportunities program (http://www.vdh.state.va.us/ppova/), for example, provides free services for employers looking to fill positions, providers looking for employment or practice information, and medical school students looking for residencies. The program is a partnership between the Department of Health, Office of Minority Health and Public Health Policy; the Virginia Recruitment and Retention Network; and the Virginia Area Health Education Centers Program.
Helping Foreign-Trained Providers Become Licensed. An unknown number of immigrants living in Connecticut trained as health care providers in their native countries. Helping them to obtain a Connecticut license to practice could alleviate provider shortages.
But several factors present obstacles to licensure for foreign-trained providers. Some may need help with English. They and others may need help navigating the licensing system, which requires proof, and information about the quality, of their education and training, which often involves numerous rounds of paperwork. And some may need additional training to meet Connecticut licensing requirements.
Some jurisdictions are making it easier for foreign-trained providers. Minnesota established a $450,000 pilot program in 2006 to encourage foreign-trained doctors, dentists, nurses, pharmacists, and allied health workers to become licensed. It gave grants to nonprofit agencies to cover the cost of (1) courses to prepare for licensing exams, (2) taking the exams, and (3) mentors to help candidates learn about the U.S. healthcare system. Of the 250 people who initially inquired about the program, 30 received instruction in medical English and 99 enrolled for test preparation. Twelve physicians completed exams, and nine were accepted for residencies. The program was continued in 2007 with a mix of public and private funding.
A collaboration among the Montgomery County, Maryland Health Department, Montgomery College, several hospitals, and the local workforce investment board provides a coordinated approach to address the barriers Latino nurses encounter in obtaining a Maryland license. The program includes support and guidance, academics, practical exposure to the U.S. healthcare system, and mentoring. Participants must have completed two years in a foreign nursing program, be moderately competent in English, and commit to work in the county for two years.
Temporary Staff. Clinics and hospitals in underserved areas often have difficulty filling vacancies, and individual providers in these locales have trouble getting away to fulfill continuing education requirements or just take a vacation. A substitute doctor or other provider, known as a locum tenens, is one solution to these problems.
But state licensing laws can hinder out-of-state practitioners who wish to work as a substitute. Some states' licensing laws provide specifically for locum tenens. Oregon, for example, allows doctors to obtain a locum tenens registration that permits them to work for 180 days over a two-year period. Arizona permits physicians to work as locum tenens for 180 consecutive days, but only once every three years. Maine grants doctors a one-year temporary license in state or national emergencies, during a provider shortage, or to work as locum tenens.
Connecticut does not have a specific locum tenens law. It permits physicians to obtain a one-year temporary license to work in a state facility or a nine-week license to work in a summer camp (CGS 20-12). Nurses and physician assistants can get temporary licenses only for 120 days after they graduate.
Telemedicine. Telemedicine, the electronic exchange of medical information, could permit:
● providers to pursue continuing education opportunities and improve contact with research facilities and specialists;
● more patients to be treated in local hospitals instead of being transferred to larger, urban hospitals;
● mid-level practitioners, like nurses and physician assistants, to provide patient care, education, and monitoring of chronic conditions, thus reducing the need for physicians; and
● the same provider to serve more patients in a broader area.
Several states have established telemedicine programs. Arizona's program, established in 1996, now comprises 150 sites linked directly or indirectly to a network that provides videoconferencing and diagnostic services for over 60 specialties and home health services for certain conditions. The state provides $1.2 million annually to help fund the program, which also charges affiliated organizations a fee.
While most telemedicine programs serve rural areas, they can also work in cities. A Rochester, New York program uses video conferencing to allow school nurses to consult electronically with a primary care clinician about sick children. In 90% of cases, parents with children seen via this system avoided a primary care or emergency department visit.
Licensing, reimbursement, and system implementation costs are the principal obstacles to greater use of telemedicine. Many states, including Connecticut, require physicians who regularly provide patient care through telemedicine to have a full state license. But some states allow limited licenses for physicians who see patients only via telemedicine. Some private insurers reimburse for telemedicine, some do not, and not all reimburse at the same rate they do for face-to-face visits. Medicaid permits reimbursement for telemedicine, but not all states do so.
FOR FURTHER READING
Recent information on primary care provider supply, pay, and job satisfaction can be found at: U.S. Government Accountability Office, Primary Care Professionals: Recent Supply Trends, Projections, and Valuation of Services, February 12, 2008 (http://www.gao.gov/new.items/d08472t.pdf).
Bodenheimer, et. al., “The Specialist-Generalist Income Gap: Can We Narrow It?”, Journal of Internal Medicine, 23(9), p. 1539-41, September 2008
Physicians' Foundation, The Physicians' Perspective: Medical Practice in 2008 (http://www.physiciansfoundations.org/usr_doc/PF_Report_Final.pdf).
An overview of the primary care workforce development system is at:
Salsberg, Making Sense of the System: How States Can Use Health Workforce Policies to Increase Access and Improve Quality of Care, Milbank Memorial Fund, 2003 (http://www.milbank.org/index.html).
The Connecticut State Medical Society survey is at:
National Conference of State Legislatures studies on state experience with dental loan repayment programs (2005), telemedicine (2006), and incentives to encourage health care professionals to work in rural areas (2000) are available at NCSL's health issues website:
More information on the medical home model, with links to articles and reports on the subject from various other sources is at: The Alliance for Health Care Reform—Primary Care Innovation: The Patient-Centered Medical Home: http://www.allhealth.org/briefing_detail.asp?bi=137.
An issue brief on Arizona's telemedicine program is at: