The Numerous Initiatives for Mitigating the Physician Shortage
Author: Treven W. Cade
In tandem with previous articles focused on legislative pursuits to combat the physician shortage such as the different iterations of the Resident Physician Shortage Reduction Acts and the Consolidated Appropriations Act of 2021 (HR 133), are the different ways states and the federal government have begun addressing the physician shortage. One may have a keener understanding of what predicated these bills and the initiatives already in practice. As the efforts of H.R.133 must be enacted by 2025, the success of the bill and others like it, to be analyzed and understood later, will prove crucial in paving the way for future legislation, such as the Resident Physician Shortage Reduction Act.
Inadequate medical care or maladaptive practices from physicians are not the sources of this shortage. Rather, it is aspects of the medical vocation such as student loan debt, work compression, physician burnout, and early retirement that riddle most of the workforce. Because of this, solutions to our physician shortage will generally rely on ways in which the work of a physician can be eased or delegated elsewhere. One such example from a state initiative in Florida was to broaden the scope of work allotted to Advanced Practice Registered Nurses (APRNs) and Physician Assistants (PAs). APRNS and PAs are rapidly growing fields in healthcare (Nastasi “How State-Level Reforms . . .”). Working with these patient care team members to distribute patient care work safely and effectively more equitably may prove monumental in decreasing physician work compression. With this sort of legislation, if the residency cap slots were increased, per the Resident Physician Shortage Reduction Act, the effect would be twofold: more physicians would practice, and the growing pool of APRNs and PAs could be tapped into to assist the physicians much more closely.
A second initiative within Florida is a sentiment that will most certainly become a prominent healthcare faculty in our present time and the near future: telemedicine. This legislation allows for broader use of telemedicine by “[allowing] out-of-state providers to provide telehealth services in Florida without obtaining a license in the state” (Nastasi “How State-Level Reforms . . .”). This provision could allow for areas heavily impacted by the physician shortage to ease their tensions by having telehealth provided elsewhere. Legislation that pushes to increase telemedicine is especially pertinent after enacting the Affordable Care Act, as it increased telemedicine across the country (Dall). In essence, this legislation “[reduces] the burden of receiving licensure in multiple states. Suppose a practitioner receives a license in any member state. In that case, they can receive licensure in all other member states with little or no additional effort” (Nastasi “Curing the Physician Shortage”). This geographic flexibility is perhaps the most significant contribution telehealth can have to overall healthcare in America, as it allows physicians to come into contact with patients across stateliness. It also could assist with Health Professional Shortage Areas (HPSAs), as they have a severely limited number of physicians; tapping into the workforce of other states could prove helpful. As our country continues to experience the physician shortage, legislation such as this will be crucial for patients to receive time with a physician that they could not have in their state.
Another effort in line with HPSAs is an initiative being pushed by some states and aims to increase the quality of care and incentive to practice in rural HPSAs. The HRSA designates HPSAs, and 59% of these are in rural areas (“Health Professional Shortage Areas . . .”). One such example of these legislative efforts is in Iowa, where they “enacted a law in May 2019 that will provide opportunities for residency students to participate in rural rotations for exposure to rural areas of the state” (ASTHO Staff). The effect of this legislation could be twofold: first, this will generally increase the medical care received in rural areas, and second, it could potentially incentivize these residents to continue practicing in rural areas. The second initiative in Washington State aims to increase the quality of care in these shortage areas by “[establishing] the International Medical Graduate Workgroup, consisting of governor-appointed members that represent the department of health, health insurance carriers, community, and migrant health centers” (ASTHO Staff). Before the onset of the physician shortage, most healthcare legislation was focused on improving the quality of care rather than the number of physicians. It is a sentiment that cannot be lost when attempting to increase the physician pool.
The last of the state initiatives listed here are loan repayment programs targeted towards health professionals. Offering two examples, Alaska and Hawaii seek to improve and expand their healthcare facilities through these repayments. Alaska’s bill, in particular, “would provide student loan repayments and direct incentive payments to eligible healthcare professionals, as defined by the Health Care Professional Workforce Enhancement program” (ASTHO Staff). One cause of the physician shortage is medical graduates going into specialty care; therefore, incentives such as these will be crucial when the residency cap slots are increased to incentivize residents into those slots.
Moving away from state initiatives to federal, we wanted to highlight other legislation outside of the Resident Physician Shortage Reduction Act and H.R.133. As stated in our previous article, H.R.133 was passed recently. It contained the Consolidated Appropriations Act of 2021, which was the first time the residency cap slot was increased since its halt in 1997, per the Balanced Budget Act. With the numerous Resident Physician Shortage Reductions Acts that have died in Congress, albeit proposing a 15,000 increase to the cap rather than the 1,000, the passing of the Consolidated Appropriations Act is a refreshing change. However, it does not mean the former will have an easier time being passed. Fortunately, while we wait to see the future of this legislation, there have been multiple other federal initiatives that wish to ease the impact brought about by the physician shortage. Likewise, if these initiatives prove successful, our legislation may be more prone to pass more legislation regarding healthcare. In particular, regarding H.R.133 will be fully enacted in 2025 with measurable, the next set of legislation will most likely be pushed through after its completion. However, H.R.133 has not been the only federal healthcare legislation in the works.
Besides the multiple Resident Physician Shortage Reduction Acts and H.R.133, two recent bills have been discussed on the federal level that has prioritized the easing physician shortage: Senate Bill 192 and Senate Bill 884. Before developing upon these bills, the common themes are an emphasis on community health programs, increased funding, and most importantly, redefining the concept of the physician to incorporate a variety of different healthcare workers. Some of these bills have only been introduced, and some have been discussed in Congressional committees. However, they all showcase different measures that have been initiated by our legislature and could show what kind of efforts may be advocated for in the future, especially after the enactment of H.R.133 in 2025.
Beginning with Senate Bill 289, it was introduced and focuses on rural areas and hopes to provide extra opportunities to these general areas that are impacted by the physician shortage. In essence, it resembles some of the state legislation that focused upon HPSAs. Specifically, Senate Bill 289 proposes to provide extra opportunities for community health centers through a reauthorization of funding. Specifically, quoting the bill itself, it is an amendment to “the Social Security Act to support rural residency training funding that is equitable for all States” (“S.289 . . .”). The areas most impacted by the physician shortage and already feeling its effects are these rural HPSAs; therefore, focusing on community infrastructure is a necessary step to contain more healthcare workers when residency cap slots are increased.
The second of the federal initiatives, HR 884, aims to classify clinical psychologists as physicians for their specific work in their field. This is along the same lines as the state initiative that delegated parts of the physician workload to APRNs and PAs: in essence, these pieces of legislation seek to expand the definition of what a physician is, and in this case, the definition has expanded to clinical psychologists. With a higher priority given to mental health, classifying clinical psychologists as physicians could prove superficial to decrease the projected shortage; however, it will most likely not decrease the physician workload as similar state initiatives have done.
In tandem with H.R.133 and the Resident Physician Shortage Reduction Acts, these efforts showcase the state and federal initiatives to combat the physician shortage. With the proposals of H.R.133 needing to be fully enacted by 2025, these initiatives will perhaps be the leading efforts in the forthcoming legislation. Especially if these efforts prove successful, they will highlight the measures that could be taken in the future. For example, the Consolidated Appropriations Act of 2021 added 1,000 caps to the residency slots; therefore, its potential success could pave the way for the Resident Physician Shortage Reduction Act, increasing the cap by 15,000. In the meantime, the combined efforts of these initiatives highlight where legislation and healthcare facilities are heading to curve the physician shortage.
“S.289: Rural Physician Workforce Production Act of 2019.” Congress.gov, Text - S.289 - 116th Congress (2019-2020): Rural Physician Workforce Production Act of 2019 | Congress.gov | Library of Congress.
ASTHO Staff. “State Policy Approaches to Address Healthcare Workforce Shortages.” Astho, June 12, 2019. https://www.astho.org/StatePublicHealth/State-Policy-Approaches-to-Address-Healthcare-Workforce-Shortages/06-12-19/.
Dall, Tim et al. “The Complexities of Physician Supply and Demand: Projections From 2018 to 2033.” AAMC, June 2020. https://www.aamc.org/system/files/2020-06/stratcomm-aamc-physician-workforce-projections-june-2020.pdf.
“Health Professional Shortage Areas: 2017 Postcard.” NCSL, August 8, 2017. Health Professional Shortage Areas, 2017 postcard (ncsl.org).
Nastasi, Vittorio. “How State-Level Reforms Could Alleviate the Looming Physician Shortage.” Reason Foundation, March 10, 2020. https://reason.org/commentary/how-state-level-reforms-could-alleviate-the-looming-physician-shortage/.
Nastasi, Vittorio and Sal Nuzzo. “Curing the Physician Shortage: State Level Prescriptions for a National Problem.” The James Madison Institute, PolicyBrief_Physician_Shortage_Feb2020_v03_web-2.pdf (jamesmadison.org).