Program to get doctors to high-need areas falling short, study says

A decades-old federal program that offers doctors incentives to practice in disadvantaged communities has had little effect on physician density or patient mortality, a recent analysis concludes.

Publishing in the journal Health Affairs, researchers looked at data from the Health Professional Shortage Area, or HPSA, program, zeroing in on physician density and mortality. Introduced in 1965, the HPSA program designates areas in need of more physicians and offers bonuses, loan repayment, visa waivers, higher reimbursements and other benefits to doctors who choose to practice and serve Medicare patients in specific communities.

The researchers analyzed outcomes in HPSAs and areas without the designation between 1978 and 2015, matching 844 shortage counties with similar counties with enough providers. Using a variety of statistical methods designed to sift through dense demographic factors, the analysis yielded few clues that HPSA leads to higher physician numbers or reduces deaths. Some small effects were seen, but the changes were statistically insignificant, the researchers write.

Overall, 73 percent of counties with shortages still had physician shortages a decade after designation. Meanwhile, those without shortages continued to amass physicians. Counties with too few providers would need a 134 percent rise in physician density to match those without shortages, the researchers write.

Nor were age-adjusted mortality rates affected by the program, even when researchers looked at longer time frames and neighboring counties.

Although the study covered only 40 percent of the nation’s counties and didn’t cover all geographic areas equally, the researchers say they identified a “significant proportion” of counties with shortages.

The data excluded providers who aren’t medical doctors, such as nurse practitioners or physician assistants, among the fastest-growing medical occupations. One 2018 study forecast that by 2030, about two-thirds of advanced medical practitioners entering the workforce would be nurse practitioners or physician assistants.

Substituting such practitioners for medical doctors in underserved areas is one potential way to reduce shortages, the researchers write. Another is to target newer physicians and encourage them to start their careers in shortage areas, reflecting the reality that most established doctors don’t veer far from the place where they first go into practice.

“The incentives needed to displace physicians must over-compensate for their baseline inertia and preferences,” the researchers write. Given projected physician shortages, they conclude, “a focus on redistributing physicians may redirect resources that could be better spent solving the long-term workforce challenge.”