Is unequal primary care workforce distribution a bigger problem than the physician shortage?

The perceived current and future shortage of primary care physicians has been attracting lots of attention from U.S. health policymakers, but a recent policy brief from the Graham Center suggests the U.S. is facing a bigger primary care problem: an uneven distribution of physicians.

That uneven primary care physician (PCP) distribution is felt most acutely in poor and rural communities, according to the policy brief from the Robert Graham Center for Policy Studies in Family Medicine and Primary Care, which is affiliated with the American Academy of Family Physicians.

For example, there are 68 PCPs per 100,000 people in rural areas, compared with 84 per 100,000 in urban areas, according to data from the Agency for Healthcare Research and Quality that's cited in the brief.

"An unequal distribution implies that many areas have relative primary care shortages, especially rural communities and areas of measurable social deprivation," the brief states.

To hit the goal set by the Health Resources and Services Administration of a 2,000-to-1 population-to-physician ratio, the supply of physicians would need to be increased by 2,670 in rural areas and by 3,970 in urban areas, according to the brief.

Further, as more people gain insurance under federal health reform, the unequal distribution problem is likely to become exacerbated.

The obvious question, then, is what's to be done about the nation's unequal distribution of primary care physicians? That's where the brief falls short (though admittedly, it's only a brief) by offering only a generic statement that lacks any hint of a detailed policy prescription.

"New incentives and policies for distributing primary care physicians to areas of greatest need, as well as a larger absolute number of these physicians, will be needed to ensure access for the newly insured," is as far as the authors are willing to go, with no attempt at specifying what those incentives and policies might be.

But the federal government has already established programs designed to funnel primary care physicians to areas of need. For example, the National Health Service Corps (NHSC) and Title VII of the Public Health Services Act are two of the most important federal programs designed to not only increase the number of PCPs across the nation but also boost primary care in underserved areas, Christiane Mitchell, director of federal affairs for the American Association of Medical Colleges, told Medical Economics last year.

Established in 1972, the NHSC provides scholarships and loan repayment for PCPs to work in areas of the United States in which residents have limited access to healthcare. More than 2,400 PCPs served in the program in 2011, up 67% from 2008.

The NHSC's scholarship program is available to students enrolled in an accredited medical school, and it offers to pay for students' tuition, books, and other costs, in addition to a living stipend, while students train to become PCPs. Students must then provide 1 year of service in one of 5,600 "health professional shortage areas" for each year of support they've received through the program.

But while such programs may be having an impact on the primary care distribution problem, they've hardly solved it.

More recently, medical schools have been receiving some much-deserved scrutiny for their failure to produce an adequate number of primary care physicians and rural health providers.

A study in the journal Academic Medicine drew the issue into sharper focus with its conclusion that a lack of accountability among publicly funded graduate medical education (GME) institutions is one key reason why younger physicians are failing to plug the holes created by unequal physician distribution.

GME institutions receive about $13 billion annually in public funds through Medicare and Medicaid, yet they produce primary care physicians at an "abysmally low" rate, despite the shortage problem having been identified "decades ago," HealthLeaders media reported in an article about the study.

"Right now with the Medicare money that goes for GME there is very little requirement around that money other than that you train and report that you train 'X' number of residents," said Candice Chen, MD, a lead author of the study. "There is nothing in the payment that says you need to produce these kinds of doctors or produce doctors who are going into certain areas to serve the need that America has."

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