The Definitive Blog

ACA Physician Shortage is Less than Once Feared, but a Real Problem in Some States

A new study appearing in JAMA Internal Medicine suggests that, contrary to initial expectations, the ACA Medicaid expansion did not lead to a significant physician shortage among primary care providers, at least in 10 states surveyed. According to the study, appointment availability increased for Medicaid patients by 5.4 percent from 2012 to 2016, despite a rise in the Medicaid population. While good news, some states faced more serious access barriers than others and the long-term demand for physicians is still projected to outstrip supply.

One of the states hardest hit by physician shortages is Nevada. The state expanded Medicaid eligibility in mid-2013, adding an estimated 210,000 patients, most of which had previously been uninsured. All of Nevada’s 17 counties have healthcare professional shortage area (HPSA) designations covering some or all of the population, up from 16 prior to the expansion. It currently has a physician-to-population ratio of 201 to 100,000, substantially lower than the national average of 251 to 100,000. Most analysts attribute the deficit to rapid population growth combined with inadequate training capacity, especially for specialists. Poor reimbursement also discourages some doctors from accepting new Medicaid patients. The ACA funded higher Medicaid payments for primary care physicians for a two-year period that ended in 2015, and Nevada did not preserve the increase.

California is also facing shortages in its Medi-Cal program, the state’s version of Medicaid. The ACA brought about a surge in enrollment from 2013 and 2015, and a recent analysis found that the number of practices serving Medi-Cal patients dropped from 69 to 64 percent. For primary care and other specialties, the ratio of FTE physicians for every 100,000 Medi-Cal patients was below the recommended percentage on both the state and national level.

Even if the Medicaid expansion did not create a serious physician shortage in many states, the most recent projections indicate it will become a national problem in coming years. The Association of American Medical Colleges (AAMC) predicts that the U.S. will face a primary care physician and specialist shortage of anywhere between 40,800 and 104,900 doctors by 2030, with specialty providers taking up most of the deficit. It attributed the gap to an aging population that will demand greater variety and utilization of health services.

Top 10 States by Fewest Physicians per 100,000

State Physicians per 100,000
Nevada 139.8
Utah 147.4
Mississippi 153.5
Texas 157.4
Arkansas 164.2
Alabama 169.0
Georgia 169.3
Wyoming 169.8
Idaho 171.9
California 173.9

Fig 1 Data from Definitive Healthcare. Excludes dentists, PAs, nurses, and optometrists.

Stakeholders across the healthcare industry are pursuing many different ways to manage existing and projected doctor shortages. Some health systems have begun to rely on nurse practitioners to offer basic primary care, though many states restrict an NP’s ability to operate without a doctor’s supervision. In the study, the primary strategy practices employed to accommodate more patients was to increase wait times. From 2012 to 2016, appointments with wait times of less than one week decreased by 6.7 and 4.1 percent among Medicaid and privately insured patients, respectively. Appointment delays of 30 days or more increased for the privately insured by 3.3 percent as well. Nationally, wait times have increased about 30 percent since 2014, according to one study. However, longer wait times could have a negative impact on outcomes, depending on the specialty and the vulnerability of the patient. Reports on the recent crisis at the VA suggested that some patients with excessive waiting times had higher mortality and hospitalization rates. In addition, longer appointment delays tend to negatively affect patient satisfaction.

Though utilizing nurse practitioners and spreading out patient appointments can help, the best solutions to the doctor shortage problem lie outside the office and tend to be much more difficult to achieve. States with medical schools have focused on increasing residency positions. In theory, doctors are more likely to set up practice or work in the same state in which they did most of their patient training. In Michigan, a local health authority used federal grant money to institute a graduate medical education program in 2012 with residency opportunities at four southeast MI hospitals and several health centers and private practices. The program focuses mainly on primary care, including pediatrics, internal medicine, and psychiatry, and while it only has a few dozen members in each class, it is one of 300 programs located around the state. The University of Kentucky College of Medicine embarked on a similar strategy by setting up a campus in partnership with St Elizabeth Healthcare, whose patient service area suffers from a shortage of providers. Each class will hold 40 students and receive clinical instruction from St Elizabeth Healthcare physicians. A St Elizabeth official said the health system would likely offer each graduating student a position in the organization, helping meet its growing need for doctors.

If the years after the passage of the ACA have demonstrated anything, it’s that providers and health organizations need to be flexible in order to meet clinical and operational challenges. The looming physician shortage is yet another challenge, but key players across the healthcare spectrum are taking proactive steps to mitigate the problem. Some areas may suffer more than others, as has happened under the ACA, but it seems likely that the health industry as a whole will be prepared enough to keep physician shortages from seriously disrupting healthcare delivery.

Stakeholders across the healthcare industry are pursuing many different ways to manage existing and projected doctor shortages. Some health systems have begun to rely on nurse practitioners to offer basic primary care, though many states restrict an NP’s ability to operate without a doctor’s supervision. In the study, the primary strategy practices employed to accommodate more patients was to increase wait times. From 2012 to 2016, appointments with wait times of less than one week decreased by 6.7 and 4.1 percent among Medicaid and privately insured patients, respectively. Appointment delays of 30 days or more increased for the privately insured by 3.3 percent as well. Nationally, wait times have increased about 30 percent since 2014, according to one study. However, longer wait times could have a negative impact on outcomes, depending on the specialty and the vulnerability of the patient. Reports on the recent crisis at the VA suggested that some patients with excessive waiting times had higher mortality and hospitalization rates. In addition, longer appointment delays tend to negatively affect patient satisfaction.

Though utilizing nurse practitioners and spreading out patient appointments can help, the best solutions to the doctor shortage problem lie outside the office and tend to be much more difficult to achieve. States with medical schools have focused on increasing residency positions. In theory, doctors are more likely to set up practice or work in the same state in which they did most of their patient training. In Michigan, a local health authority used federal grant money to institute a graduate medical education program in 2012 with residency opportunities at four southeast MI hospitals and several health centers and private practices. The program focuses mainly on primary care, including pediatrics, internal medicine, and psychiatry, and while it only has a few dozen members in each class, it is one of 300 programs located around the state. The University of Kentucky College of Medicine embarked on a similar strategy by setting up a campus in partnership with St Elizabeth Healthcare, whose patient service area suffers from a shortage of providers. Each class will hold 40 students and receive clinical instruction from St Elizabeth Healthcare physicians. A St Elizabeth official said the health system would likely offer each graduating student a position in the organization, helping meet its growing need for doctors.

If the years after the passage of the ACA have demonstrated anything, it’s that providers and health organizations need to be flexible in order to meet clinical and operational challenges. The looming physician shortage is yet another challenge, but key players across the healthcare spectrum are taking proactive steps to mitigate the problem. Some areas may suffer more than others, as has happened under the ACA, but it seems likely that the health industry as a whole will be prepared enough to keep physician shortages from seriously disrupting healthcare delivery.

Visit the Definitive Blog to read more about CMS programs such as hospital readmission reduction and how length of patient stays affect readmission rates.

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