As per the 2011 ‘Montana Healthcare Workforce Statewide Strategic Plan’ released by the Montana Office of Rural Health, 11 counties had no primary care physicians (PCPs) and another 16 counties had five or fewer PCPs in 2010. We can see no change in this scenario considering the estimates of the Health Resources and Services Administration (HRSA) and the Association of American Medical Colleges (AAMC). HRSA designates a total of 5,991 Health Professional Shortage Areas (HPSA) for primary care as of January 1, 2014 whereas the AAMC foresees a shortage of 45,000 primary care doctors in the United States by 2020. An article published in Great Falls Tribune talks about the shortage of PCPs in rural areas, and gives a clear view on the reasons for the shortage and how the hospitals in those areas manage this shortage.
Reasons for the Shortage
- Fewer medical graduates are choosing the primary care field. A study by the Washington-based Robert Graham Center for Policy Studies in Family Medicine and Primary Care and the George Washington University School of Public Health and Health Services reveals that the average overall primary care production rate was estimated as 25.2% when measuring the number of medical graduates from 2006 to 2008. Data was collected from nearly 9000 physicians who completed residency between 2006 and 2008 to identify their medical specialty choice 3 – 5 years after completing residency. Among 759 sponsoring institutions, 158 did not produce any primary care graduates, and 184 produced more than 80%.
- The Great Falls Tribune article says when the medical graduates see their debt rising, economics often influence their decision regarding specialties and areas of practice. As per the AAMC, the average debt for indebted graduates in the class of 2013 was $169,900.
- The primary care physicians who graduate from medical school and complete residency prefer more populated areas for their practice. Economics plays a major role here too.
- PCPs make significantly less than specialists. According to a report released by the New England Healthcare Institute in 2010, the three lowest paid medical fields are family medicine, pediatrics and internal medicine. Low Medicare reimbursement rates for routine office visits force these physicians to see more patients a day, which results in spending less time with patients and reduced quality care. They also lose a lot of time for documentation tasks associated with medical billing for Medicare and other health insurance plans. The overall result of all this is lower revenue. As per the experts, many medical school students and practicing PCPs do cite the compensation gap while making a decision on a field of medicine and switching their specialties respectively.
- The New England Health Institute report cites greater workloads and job burnout as a reason why PCPs are leaving their field. Primary care encompasses a variety of areas such as acute care, mental health, chronic care, emergency medicine and so on and it requires dedication and time to keep up with the higher standards of care needed in all these areas.
Slower-paced environment and maintaining proper emergency room and clinical coverage are sometimes challenging for PCPs.
How Rural Hospitals Manage the Shortage
- Increasing Demands for Mid-Level Practitioners – Rural hospitals are increasingly turning to mid-level providers including family nurse practitioners and physician assistants for primary care to fill the gaps of PCPs, as per the above mentioned article. The Montana Healthcare Workforce Statewide Strategic Plan says the number of physician assistants in Montana has increased from 150 to 398 during 2000-2011. The Bureau of Labor Statistics estimates 38 percent increase in the demand for physician assistants between 2012 and 2022 whereas the demand for nurse practitioners is estimated to increase by 31 percent from 2012 to 2022.
- Co-ordination with Larger Regional Healthcare System – The rural clinics and hospitals maintain a working relationship with a larger regional healthcare system to manage the lack of PCPs. The specialists from that healthcare system come to the clinics or hospitals regularly to see the patients, the two hospitals take efforts together when an emergency patient needs to be shifted; or doctors from the larger healthcare facility become available for rural hospitals through telemedicine facility.
- WWAMI Program – WWAMI Regional Medical Education Program of the University of Washington School of Medicine in partnership with the four western states (Wyoming, Alaska, Montana and Idaho) identifies the prospective students having interest in rural medicine and encourages them to stay and practice in rural regions. Each state offers subsidies for tuition fees which reduces the educational costs to a great extent.
- Loan Forgiveness Programs – Many states provide these types of programs that offer funds for primary care doctors who practice in rural or underserved areas that will help repay their educational loans. The fund amount, eligibility and selection procedure may vary according to the program.
Primary care physicians face several challenges in 2014 that affect their practices such as the introduction of ICD-10 medical coding system, second stage of meaningful use of EHRs, updated HIPAA rules and the Physician Quality Reporting System (PQRS). PCPs would need a lot of money and also take great effort to keep up with these government requirements and achieve their professional goals. Even though the Affordable Care Act offers a 10 percent bonus to PCPs who provide services to Medicare patients, it will be implemented through 2015 which is too late. In such a difficult situation, PCPs can seek help from a professional medical billing and coding company to streamline their revenue cycle, ensure compliance and gain excellent reimbursement for services provided.