Expansion of health insurance coverage has been the central focus of the debate about curing what ails the health care system in the United States. But not everyone agrees that the problem is strictly a matter of insurance.
“If every American alive today had health insurance, millions still wouldn’t be able to access the primary care that ensures better overall health and reduces health care costs,” according to Daniel Hawkins, Senior Vice President for Policy and Programs of the National Association of Community Health Centers (NACHC). “That’s because provider locations and career choices don’t match up to the need. If we want to fix our health care system, we need to be having the right conversation.”
Number Needed to Serve
Hawkins recently participated in a conference call to discuss the findings from a study conducted by NACHC in partnership with the Robert Graham Center and the George Washington University School of Public Health and Health Services. The report, Access Transformed: Building a Primary Care Workforce for the 21st Century, offered projections on the number of primary care providers—physicians, NPs, PAs, and certified nurse-midwives (CNMs)—that will be required to meet the needs of the approximately 56 million Americans that NACHC classify as “medically disenfranchised” (ie, those who lack access to health care due to shortages of primary care providers in their communities).
Community health centers alone—which serve 18 million patients across the country—currently face a workforce shortage of more than 1,800 primary care providers and almost 1,400 nurses. In order to expand the reach of health centers to 30 million patients by 2015, NACHC projects that an additional 15,585 primary care providers—a little more than one-third of whom would be PAs, NPs, and CNMs—and between 11,553 and 14,397 nurses would be required.
Reaching all medically disenfranchised Americans is an even more daunting goal. In order to adequately serve 69 million patients—including all of those who are disenfranchised—health centers would need at least 51,300 more primary care providers and as many as 44,500 additional nurses.
Currently, centers employ about 7,500 physicians and 4,300 NPs, PAs, and CNMs. “Those numbers represent a 70% increase over the past seven years,” Hawkins said. “But the need is greater still.”
When questioned as to whether the US is dealing with a shortage of primary care providers or a maldistribution of them, Hawkins acknowledged that gauging strictly by volume, the US would need about 3,000 additional primary care providers to meet current needs. However, close to 90 million people live in designated shortage areas, and from their perspective, location is everything.
“Speaking for people who live in underserved areas, it doesn’t matter to me that there may be more physicians than necessary at the community or county down the road—where I live, there’s a shortage,” Hawkins said. “Unless public policy is going to engage in a forced march of those individuals from overserved to underserved areas, the only way that we can really address this problem is to grow primary care.”
Funding Is Essential
So how can the US expand primary care, particularly into areas with the biggest needs? The answer, according to the report, largely involves funding. Many programs that focus on attracting clinicians to underserved areas have experienced budget cuts in recent years—a trend that would have to be reversed if the primary care workforce is going to expand sufficiently, according to NACHC.
“Perhaps most importantly, programs like the National Health Service Corps [NHSC] need substantial additional funding,” Hawkins said. His organization estimates that the NHSC would need an increase from its current funding level of less than $125 million to $770 million by 2015 in order to produce the provider workforce needed by health centers alone.
Hawkins was joined in the tele-conference by Gary Wiltz, MD, Executive Director and Clinical Director of Teche Action Board in Franklin, Louisiana. As a medical student, Wiltz benefited from an NHSC scholarship. His three-year commitment to work in an underserved area in exchange for the financial assistance has turned into 26 years (and counting) at the Teche Action Clinic in Louisiana’s Bayou country.
“The [NHSC] program has proven to be effective,” Wiltz said. “It’s so popular right now that, from the [most recent] stats we were able to gather, they’re funding only one scholarship recipient per seven applicants.”
According to the NHSC Job Opportunities List for fiscal year (FY) 2008, almost 4,900 positions went unfilled because of the lack of funding to support them. The administration’s request for FY2009 funding for NHSC, at $121 million, continues the trend of declining federal appropriations for the program.
“Also needing expansion are programs that train nurse practitioners, nurse-midwives, and physician assistants,” Hawkins said.
The NACHC report noted a decline in support for federal Health Professions and Nurse Training Programs (Titles VII and VIII of the Public Health Service Act). For FY2009, no appropriations have been requested for Title VII, while the administration’s request for Title VIII, at $156 million, is almost one-third less than the previous year’s funding. In addition, it was proposed that the $62 million Advanced Education Nursing program be eliminated.
Beyond funding for training programs, the report mentions some of the obstacles to full utilization of PAs and NPs as another area in need of improvement if workforce needs are going to be met. “State scope-of-practice standards set boundaries by which key primary care providers, namely NPs and PAs, can deliver care,” according to the report. “State policymakers must consider how these standards encourage or discourage primary care professionals to locate in and form teams in underserved areas.”
Eternal Conundrum of Reimbursement
During the teleconference, Hawkins, Wiltz, and Lil Anderson, Chair of the NACHC Board and President and CEO of RiverStone Health in Billings, Montana, also discussed reforming the reimbursement structure to recognize the importance of primary care. Reimbursement is a perennial issue, but in a troubled economy, can change be achieved?
“This is not going to be something that’s easily done,” Hawkins admitted.
“As we are in the process of having another national debate on health care reform, part of that debate needs to be about changing our health system from paying for illness care … to paying for prevention and primary care,” Anderson added. “That’s going to take a lot of time, [and] that is an investment that is going to be difficult to convince Congress and the American public to pay for. But it truly is the only way to change the system that we’re in right now, which really reinforces people to get care in the most expensive arena.”
Hawkins outlined a variety of reimbursement components in which reforms could be made, from reducing the use of services that are “questionable at best” to providing bonuses for the delivery of high-quality care. He also talked about the medical home concept and the proposal by its leading proponents to provide compensation for the types of follow-up and patient communication that are not usually reimbursed.
“Putting together those couple of innovations with a fee-for-service payment for the care actually provided to patients during a visit … could significantly boost revenues and payments to primary care providers,” Hawkins said. “And yet, we are convinced that in so doing it would reduce overall spending.”
NACHC estimates that a reduction in emergency department use by persons who do not have a true emergency and whose needs could be addressed in a primary care setting could produce a savings of $18 billion per year. In the case of staffing health centers to meet the needs of 30 million patients, NACHC says the return on investment could be as high as $80 billion dollars annually—“not to mention over 450,000 new jobs,” according to Hawkins.
The full report—which includes projections of how many primary care providers are needed in each state—is available at the NACHC Web site (www.nachc.com).