To strengthen the provision of primary care, the Affordable Care Act (ACA) allotted $230 million to train additional primary care providers, with the expectation that by 2015, 500 more physicians, 600 more PAs, and 600 more NPs will enter primary care. This amounts to a combined increment of 1,700, which will be measured against the combined annual output of approximately 15,000 primary care providers and expected shortages of 52,000 primary care physicians (PCPs) and more than 100,000 specialists by 2025.
Why are there such gaps in supply? The combined number of new physicians, PAs, and NPs has barely kept up with population growth, and it has fallen far behind growth of the elderly population. Despite the recent recession, economic growth topped 30% over the past 15 years, adding to the demand for health care. Increases in the number of women trained as physicians and PAs is reported as another factor because women tend to work fewer hours than men.1
Why is the story so troubling for primary care? Fewer physicians practice office-based primary care, instead practicing as hospitalists or in specialties or working in industry. Medical specialists, who previously devoted as much as one-third of their effort to primary care, are drawn to the unmet needs of specialty patients. Increased recruitment of PAs and NPs into specialty care further complicates the supply issue.2 At the same time, hospitals are recruiting PAs and NPs to fill the void created by too few residents and to serve other roles, further draining primary care. Yet all of this was easily anticipated. Why, then, have shortages been allowed to evolve? The answer is pipeline, preceptors, and political will.
Pipeline Only 30% of today's 4 million 18-year-olds will graduate from college. While applications to medical schools have increased, they have barely kept pace with the recent growth of medical school places, and matriculants are heavily skewed to higher-income families. Applicants to PA schools have increased much faster, tripling over the past decade while matriculants increased by 50%, but as for medical schools, PA matriculants are increasingly skewed to higher-income families.
Preceptors Training in medicine and nursing faces another barrier: growth of NP programs has been slowed by too few qualified faculty and preceptor sites. Similarly, accreditation of new PA programs beyond the 61 that are currently in process appears to have slowed, likely due to concern over the availability of preceptor sites, preceptors, and adequate numbers of qualified site visitors. Even under current circumstances, students have diminished patient contact hours and fewer opportunities to perform essential procedures.
Medical education is facing similar constraints. In part because the traditional urban academic centers are saturated with students in the health professions, medical schools are relying more on preceptors and clinical training sites in widely dispersed communities. Confronting these same limitations, many new medical schools have organized their teaching around this dispersed preceptor model. The problems of too few preceptors and patients are still greater for residencies. Without more residencies, too few will be available for the increasing numbers of medical students who soon will be graduating, and these students will have to compete for positions with US citizens and foreign nationals who trained abroad. Clearly, education in the health professions is in desperate need of investment.
Political will But is there the political will to invest? The answer is a limited “Yes” for primary care but a resounding “No” for specialties. In addition to the funds to train 1,700 more primary care providers, the ACA also allows the reallocation of unused residency positions, principally to primary care trainees, and it provides $1.8 billion to support the National Health Service Corps, which offers financial aid for primary care providers who agree to work in shortage areas. What the ACA does not do is remove the caps on residency training or provide support for PA or NP programs at levels that could allow meaningful increases in their capacity. Nor have most state licensing boards acted to enable PAs and NPs to practice to the limits of their training.
In a system in which access is assured-indeed, expanded through measures in the ACA—utilization can be constrained either through rationing or by limiting the availability of providers. Examples of the latter include the licensing of hospital and nursing home beds and limitations on the training of physicians. Support for constraining physician supply is bolstered by an exaggerated belief that the health care system suffers from waste and inefficiency and that correcting it requires fewer physicians, particularly specialists.3 However, faced with the inevitable shortages of both primary care providers and specialists, PAs and NPs are gravitating into specialties, while primary care, which was to be the cornerstone, is threatened. The time has come for the nation to reassess its health care goals and recalibrate its workforce strategies.
1. Chen MK, Chevalier JA. Are women overinvesting in education? Evidence from the medical profession. J Human Capital.
2. Cooper RA. New directions for nurse practitioners and physician assistants in the era of physician shortages. Acad Med.
3. Cooper RA. The war on waste. Oncology.