How some states are addressing doctor shortages
How some states are working to address a shortfall of primary care doctors:
A package of bills moving through the Legislature is aimed at addressing California’s medical provider gap. The legislation would allow nurse practitioners, optometrists and pharmacists to expand the types of services they can provide patients. The proposals face heavy opposition from doctors, who favor training and placing more primary care physicians in rural and other underserved communities. Opponents also worry such changes would create two classes of medical care — one for people who have access to doctors and another for people who don’t.
Among the steps Delaware officials have taken to address the primary care physician shortage is a loan repayment program for primary care providers who commit to work in underserved areas. The program, funded by the state and federal governments, provided more than $360,000 in loan repayments to seven primary care providers in fiscal 2013. Officials say they are looking at expanding it.
Gov. Rick Scott funded an additional 700 residency slots this year, but Florida will still need additional residencies and fellowships just to bring the state up to the national average per capita. Scott also recently signed into law a long-debated bill that expands the drug-prescribing powers of optometrists. The state now allows optometrists to prescribe oral medications to treat eye diseases. House Republicans repeatedly used the shortage of primary care physicians and nurses in the state as a reason not to expand Medicaid under the federal Affordable Care Act.
A state medical society succeeded in killing or gutting bills this year that would have given more medical decision-making authority to psychologists, dentists and advanced-practice nurses. That included one bill that would have allowed trained dentists to give flu shots and other immunizations. The dental society plans to bring the issue to lawmakers again but focus narrowly on flu shots. The group contends dentists should be prepared to respond to a future flu pandemic. They plan to make the case that the Affordable Care Act will increase the number of patients eligible for free flu shots and that the number of professionals who can give them also should increase.
State officials and professional associations representing primary care physicians and other health providers are reviewing the state’s primary care providers and where they are concentrated. Shortly after the federal health care law was signed in 2010, state officials determined that Indiana had not been properly tracking the density of primary care physicians and needed to do a complete review, said David Roos, executive director of Covering Kids and Families of Indiana.
Efforts in Kansas to address medically underserved areas of the state began nearly a half-century ago at the University of Kansas, where a scholarship program is aimed at recruiting new physicians to start their practices in rural areas. Kansas has expanded those efforts in recent budget years, including legislation this year to increase the scope of study that would be eligible for the scholarships in return for serving in rural areas. Legislators also have expanded the laws to give pharmacists the ability to perform certain wellness functions, including administering vaccines.
The state has not yet taken steps to deal with an influx of patients, but a recent study showed Kentucky’s 10,475 doctors were not enough to keep pace with current patient loads. A report from Deloitte Consulting said Kentucky needs some 3,790 additional physicians, including primary care doctors and specialists, plus 612 more dentists, 5,635 more registered nurses, 296 more physician assistants and 269 more optometrists to meet current demand. The report’s recommendations included expanding the use of telemedicine, particularly to put patients in contact with specialists.
Three bills in the New Jersey Legislature would give non-physicians more authority. The bills would let advanced-practice nurses determine causes of death if doctors are not available, let psychologists prescribe medications and let advanced-practice nurses prescribe drugs without the same oversight required for doctors. None of the bills has gotten far, and the Medical Society of New Jersey opposes all three.
According to a state legislative report, New Mexico residents could have trouble accessing medical care due to the potential need of 2,000 physicians, 3,000 registered nurses and as many as 800 dentists. State lawmakers didn’t act this year on a plan that would have allowed dental therapists to practice in the state. An association representing dentists opposed the measure, although supporters said therapists would help address the state’s shortage of dentists.
The New York health department’s 2013-14 budget includes $8.5 million for programs that place physicians in underserved areas. Doctors Across New York began in 2008 and has awarded $8.9 million to support practices and $7.6 million for loan repayments. So far this year, it has provided 26 awards totaling more than $2.5 million over two years.
North Dakota has a program that reimburses family doctors for student loans up to $90,000 for a two-year commitment to work in a rural or other underserved area. A community match is required. A related program gives similar loan repayments up to $30,000 to physician assistants and nurse practitioners for a two-year-commitment to work in rural or other underserved areas, again with a community match required.
The governor wants to target graduate medical education funding toward training in primary care. Under a budget proposal still being debated, medical schools would receive about $200 million over the two-year budget period that begins in July. The state would then work with medical deans on a plan to prioritize training in primary care services, with the idea that dollars would be more focused in that area in the 2015 budget year.
South Dakota has a program that reimburses doctors double the University of South Dakota School of Medicine’s resident tuition for the most recent four-year-period if they agree to practice for three years in underserved rural areas. The current amount is about $138,000. A related program also gives double tuition reimbursements to physician assistants, nurse practitioners and nurse midwives who agree to practice in rural areas for three years, while a third program gives a $10,000 payment to nurses, therapists, lab professionals and others who practice in a rural area for three years.
So far, no Wisconsin bills have dealt specifically with increasing the number of physicians or granting medical decision-making authority to pharmacists and other health care workers. But the budget-writing committee of the Republican-controlled state Legislature unanimously approved a measure to shift more money toward residency programs in the state. Supporters said the bill will encourage new doctors to remain in Wisconsin.