Successful implementation of the Affordable Care Act will provide tens of millions of previously uninsured Americans with healthcare coverage. However, when these individuals seek medical care outside the emergency room or charity clinic setting will there be practitioners to serve them? The answer is clearly no (J Am Med Assoc, Sept 2009). The facts are that this surge in demand for primary care, will markedly exacerbate the already problematic geographic maldistribution of number and type of physician practice across the United States.
According to the American Association for Family Practice (June 2013), there is presently one family practitioner for every 1470 rural residents compared to one physician for every 1190 residents of urban areas. This projects to a deficit of 2,000-3,000 physicians that will be needed by 2020. Even these numbers belie the supply vs demand mismatch. In addition to comparative deficiency by population density, there are well-served and underserved populations primarily determined by market forces of family income and education.
Pundits from the Robert Graham Center and the Health Resources Administration provide three part strategy to encourage a more equal distribution of healthcare professionals and resources.
- Target future physicians who would commit to working in underserved communities at the time of selection and education of medical students.
- Incentivize present practitioners to relocate with financial rewards (“carrots”) and regulatory measures (“sticks”).
- Accept a lower staffing level for these populations, but focus on improved productivity by increased utilization of physician extenders, technology such as telemedicine, and air transport of providers to more centralized outreach facilities.
But these are the sterile pontifications of the ivory tower. You can not debunk the general suggestions to pay doctors more and give them more resources to provide care; however, the devil is in the details. What is lacking is a canvassing of those already in the arena to find out what specifically it would take to relocate their practice. The battles are being fought by those of us actually on the frontlines. We hope that opening a dialogue in this forum can be productive as this issue will not go away. Better that physician input be focused constructively and proactively rather than centered on impeding externally imposed change.
By Norman Silverman, MD, with Ryan McKennon, DO and Ren Carlton