State Legislative Conference Underscores Need for More Primary Care Physicians

The chronic shortage of primary care physicians threatens to slow and considerably complicate health care reform efforts on the state level, forcing states to redouble their recruitment and retention efforts.

That was one of the major themes to emerge from the AAFP's Nov. 14-15 state legislative conference here. Several speakers at the conference described various ways states are bolstering their primary care physician workforces.

"Recruitment and retention are not just a North Dakota problem," said Judy Lee, president of the North Dakota Senate and one of several speakers to address the conference. "It is really common throughout the United States, and we all know some of the reasons why."

Lee described North Dakota as a very rural state; 38 of the state's 53 counties are considered frontier areas. "That means six or fewer people per square mile," said Lee. "We have 371 cities, but only four are over 25,000 (in population), and we only have 15 over 2,500 in (population)."

North Dakota provides a $90,000 loan repayment program for physicians who are willing to work in underserved areas for at least two years, Lee said. Like other states, North Dakota also relies on the J-1 visa waiver program to bolster its supply of primary care physicians. The program provides states with visa waivers for international physicians.

"Most of our rural health facilities across the country would be closed today without those international physicians," said Lee.

She added, however, that the J-1 visa waiver program is a not a permanent solution to the shortage of primary care physicians. In many instances, medical schools train foreign students under the J-1 visa program, and the foreign medical school graduates then return to their native countries after graduation, said Lee.

"There is nothing to tie them to North Dakota," she noted. "What we are doing is training physicians to go elsewhere and not to stay in North Dakota."

Lee told conference participants that "research shows that growing up in rural areas is the single most important factor in getting medical students to choose rural practices." She called for the selective recruitment of medical school students from rural areas.

In addition, Lee said, "We need to recruit students before medical school and before college. Some state medical schools have programs which introduce high school students to the medical profession."

New Mexico, for example, has launched an intensive program that enables high school graduates to earn a combined undergraduate/medical degree within an eight-year period.

"This is specifically designed for students in rural, underserved areas," said Raul Burciaga, J.D., assistant director for drafting at New Mexico's Legislative Council Service.

The state accepts 75 students into the program each year. These students are among the top 15 percent in their graduating classes, with high test scores in math and science. The students also have to demonstrate community involvement and volunteer service.

"The program requires that the students demonstrate a commitment to the program and the state of New Mexico," said Burciaga.

New Mexico has other programs to encourage physician recruitment and retention, as well. The state's higher education department provides up to $35,000 in assistance for health professionals who practice in underserved areas. Another program provides $5,000 a year in tax credits for physicians and other health care professionals who provide care in rural and underserved parts of the state.

Despite the ongoing efforts in North Dakota, New Mexico and other states, the overall supply of physicians is not keeping pace with increasing patient demand, said Candice Chen, M.D., M.P.H., assistant director for the Medical Education Futures Study at George Washington University in Washington, D.C. And the gap between primary care physicians and subspecialists continues to grow, with grave repercussions for patient care, according to Chen.

Massachusetts, for example, enacted a sweeping health care reform measure in 2006 that requires all state residents to carry insurance. The law resulted in a dramatic increase in the number of insured residents, but the state lacks an adequate supply of primary care physicians. As a result, many Massachusetts residents have not been able to access primary care services.

Chen identified graduate medical education, or GME, and not medical schools, as the true levers that shape the composition of the U.S. physician workforce. "GME is really a control point for how many physicians we are going to have and what kind of physicians we are going to have," she said.

Primary care equals both quality and cost savings, she noted, and increasingly, states are adopting primary care as the foundation for their health care reform initiatives.

In many states, Medicaid and the State Children's Health Insurance Program, or SCHIP, are serving as the vehicles for primary care and patient-centered medical homes. One of the ways states are able to make a case for using the medical home model is to target high-cost populations, said Mary Takach, a policy specialist at the National Academy for State Health Policy.

Pennsylvania, for example, was able to launch a patient-centered medical home within its Medicaid program by pointing out that the state spends 80 percent of its health care dollars on 20 percent of its chronically ill Medicaid patients.

Not surprisingly, the Medicaid medical home efforts vary on a state-by-state basis; many start by covering children before expanding coverage to adults, Takach said.