II. Workforce: The primary care physician workforce is shrinking and gaps in access appear to be growing.

Many areas of the country face a shortfall of primary care physicians. The availability of primary care physicians is an important component of access. From 2012 to 2020, just 20% to 21% of all physicians completing their residency, or 1 in 5, were practicing primary care two years later. Overall, about 1 in 3 US practicing physicians are PCPs, so the data point to a national need to strengthen the PCP pipeline to prevent the shortage from worsening.¹⁵

In 2020, rates of physicians entering primary care differed substantially across states (Figure 2), with higher percentages of new primary care physicians in western and rural states like Maine and Alaska. Tracking the percentage of physicians entering the primary care workforce in a state over time will help state officials develop policies that attract and maintain their PCP workforce.

There is wide variation in the proportion of clinicians working in primary care by state (Figure 3). Along with primary care physicians, NPs and PAs are core members of the primary care workforce. In general, the states with a high percentage of primary care physicians also had high percentages of NPs and PAs – with some exceptions. Specifically, Iowa and North Carolina have a high density of primary care physicians but lower percentages of NPs and PAs. In Montana and North Dakota, there was a lower density of primary care physicians but a higher density of NPs and PAs.

Figure 3. Percentage of Physicians, Nurse Practitioners, and Physician Assistants Working in Primary Care by State in 2020

NICOLE SEAGRIFF, DNP, APRN, FNP-BC

On-Site Medical Director, Norwalk and Stamford, Conn., The Community Health Center, Inc. Clinical Program Director, National Nurse Practitioner Residency Program, Associate Faculty, Weitzman Institute

Nicole Seagriff,
DNP, APRN,
FNP-BC

Did your nurse practitioner residency influence your decision to practice primary care?

When I was a student the Yale School of Nursing about 11 or 12 years ago, I had a clinical rotation at the Community Health Center and then applied to the NP residency program. I’ve been practicing at the Community Health Center ever since. We see similar results among our alumni of the residency program. During the pandemic, colleagues and I surveyed our alumni and found that 92% of respondents were still working as an nurse practitioner in clinical practice, and that 74% were still practicing as primary care providers — the majority of that group were still at a federally qualified health center.

Are you part of a primary care team?

Yes, we’re very fortunate to have an amazing team-based focus. We have huddles in the morning and our teams are all co-located. We work closely with medical assistants, nurses, and ancillary supports like registered dietitians, certified diabetes care and education specialists, podiatrists, chiropractors, and of course — one of our closest collaborators — our behavioral health team.

Regulations related to scope of practice, which many states expanded for NPs and PAs during the COVID pandemic,¹⁶ and the availability of training opportunities, may impact the primary care workforce by state. For example, one study found that states that allow for NP autonomy see an increase in the number of NPs and in health care utilization among rural and vulnerable populations.¹⁷ Indeed, the states in this analysis with a high percentage of NPs working in primary care, such as Oregon, Idaho, and Nebraska, also have less restrictive scope-of-practice laws.¹⁸ Yet, states with very restrictive scope-of-practice laws such as California and Oklahoma also have high rates of NPs working in primary care, indicating that multiple factors determine entry into primary care for advanced practice clinicians. Furthermore, the lack of a uniform national data set that lists advanced practice clinicians’ current specialties limits a complete understanding of workforce data for NPs and PAs.

DAVID C. DUGDALE, MD

Medical Director, Value Based Care, UW Medicine, Professor of Medicine, University of Washington School of Medicine

David C. Dugdale,
MD

Can you describe your training in internal medicine and how it works today?

I was trained in internal medicine from 1982 to 1985. It was very traditional hospital-based training with some outpatient care in hospital-associated outpatient departments. In the past 15 years, probably the most common training experience for internal medicine clinicians and post-training career trajectory has been into hospital medicine. But there’s a subset of internal medicine trained doctors who go into primary care internal medicine like me, and we tend to miss out on exposure to community based models. I think many training programs have recognized this, and now make residency opportunities available that didn’t exist when I was being trained. But it still probably wouldn’t have the same type of exposure as our family medicine colleagues, who have emphasized a more community-based approach.

How has your primary care career been meaningful?

The unbound nature of primary care, the open-ended commitment brings certain positives with it that I think many other clinicians simply don’t experience. I have valued the intimate knowledge of people’s lives and circumstances as they relate to my trying to do the best job I can vis-a-vis their health care. I think, for the most part, that holistic view isn’t hardwired into the field in other specialties.

Primary care access continues to lag in underserved communities. Another way of assessing whether every household in every community has access to primary care is measuring the number of primary care physicians per 100,000 population in medically underserved areas (MUAs). An MUA is an area designated by the Health Resources and Services Administration (HRSA) as having too few primary care providers, high infant mortality, high poverty levels, or a large elderly population.¹⁹ Living in MUAs, which are found in both rural and urban areas, has been associated with poor health outcomes, at least partially due to lack of adequate access to health care.^{20, 21}

Between 2012 and 2020, the number of PCPs in MUAs remained static, but the PCP supply in non-MUAs rose, increasing the gap in the number of PCPs per 100,000 people by 5%. As of 2020, there were approximately 55.8 PCPs per 100,000 people in MUAs, well below the rate of 79.7 primary care physicians per 100,000 in areas that are not MUAs. As shown in Figure 4, rates for both MUAs (red dots) and non-MUAs (green dots) vary substantially across the nation.

For some states, the gap in PCPs per 100,000 people between MUAs and non-MUAs is large (signified by the length of the arrows). Generally, non-MUAs have more PCPs than MUAs. Although efforts by organizations such as community health centers play a central role in providing access to patients in medically underserved areas, the data demonstrate that much of the country still falls short in meeting these critical access needs.

Figure 4. Primary Care Physicians per 100,000 People in MUAs and non-MUAs by State

Notes

15. The Number of Practicing Primary Care Physicians in the United States. Agency for Healthcare Research and Quality; 2018. https://www.ahrq.gov/research/findings/factsheets/primary/pcwork1/index.html
16. COVID-19 State Emergency Response: Temporarily Suspended and Waived Practice Agreement Requirements. American Association of Nurse Practitioners; 2022. https://www.aanp.org/advocacy/state/covid-19-state-emergency-response-temporarily-suspended-and-waived-practice-agreement-requirements
17. Xue Y, Ye Z, Brewer C, Spetz J. Impact of state nurse practitioner scope-of-practice regulation on health care delivery: systematic review. Nurs Outlook. 2016;64(1):71-85. doi:10.1016/j.outlook.2015.08.005
18. State Practice Environment. American Association of Nurse Practitioners. Accessed August 16, 2022. https://www.aanp.org/advocacy/state/state-practice-environment
19. Scoring Shortage Designations | Bureau of Health Workforce. Health Resources and Services Administration. Accessed September 22, 2022. https://bhw.hrsa.gov/workforce-shortage-areas/shortage-designation/scoring
20. Brown TM, Parmar G, Durant RW, et al. Health professional shortage areas, insurance status, and cardiovascular disease prevention in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study. J Health Care Poor Underserved. 2011;22(4):1179-1189. doi:10.1353/hpu.2011.0127
21. Liu J. Health professional shortage and health status and health care access. J Health Care Poor Underserved. 2007;18(3):590-598. doi:10.1353/hpu.2007.0062