CRYSTAL CITY, VA. — Suppose the federal government has designated your part of the state as a physician shortage area, but charges haven't gone up and you still have lots of openings for new patients in your practice. Does that mean there's really not a problem getting care? Not necessarily, according to Carol J. Simon, Ph.D.
The usual symptoms of a “demand-driven” physician shortage are waits to see providers, new patients being turned away, and rising prices, Dr. Simon said at the 2008 Physician Workforce Research Conference. However, “we don't find a lot of systematic evidence of demand-driven shortage in [federally] defined primary care shortage areas. What we do find … is a lot of evidence of inadequate demand—inability to pay and inability to access the care that patients may need.”
To find out more about access problems, Dr. Simon, vice president at the Lewin Group, a health care consulting firm, and her colleagues sent surveys to 2,834 primary care physicians in five states: California, Georgia, Illinois, Pennsylvania, and Texas. About half the physicians surveyed were pediatricians; 15% were African American or Hispanic. The response rate was 69% (n = 1,967).
According to their preliminary findings, 49% of respondents overall were accepting all new patients, while 44% accepted some and 7% accepted none. But those numbers changed when looked at by the type of area surveyed. For example, in areas designated as having a primary care shortage, 71% of physicians were accepting all new patients, compared with only 34% of physicians in areas of high population growth and 52% of physicians in poor areas.
As to the growth in physician incomes, the data were not consistent with a lack of providers, Dr. Simon said at the meeting, which was sponsored by the Association of American Medical Colleges and Harvard Medical School. Over a 3-year period, physician incomes dropped an average of 4% per year in shortage areas, compared with a 5% annual increase in high-growth areas and a decline of 1.6% per year in poor areas. Physician incomes as compared with the national average also were not consistent with shortage designations: incomes of physicians practicing in designated shortage areas were found to be at 89% of the national average, compared with 107% for physicians in high-growth areas and 78% for physicians in poor areas.
The researchers also looked at a particular example of delayed follow-up care: follow-up exceeding 4 weeks for mild persistent asthma. There was little difference between the amount of delayed follow-up that occurred in the designated shortage areas and high-growth areas, but poor areas had a slightly higher percentage (see box). “It's hard to tell whether this is evidence of capacity issues or [of] scheduling difficulties,” said Dr. Simon.
The results seem to suggest that in designated shortage areas, “the immediate need may be to bolster willingness and ability to pay for care—that is, [increasing] insurance coverage and incomes,” she said. “Increasing supply alone in the absence of a basis for paying for care could threaten the financial viability of system providers.”
In areas with high population growth, “there is indeed evidence of [lines], longer follow-up times, practices closed to new patients, and upward pressure on income and prices,” she said. “Here, increasing supply will promote access to services and mitigate cost increases. Clearly we're seeing pressure in some areas not historically defined as shortage areas.”
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