Primary care is an essential part of health in our time. Those who partner with primary care providers (PCPs) throughout their lives tend to stay healthier as they age, heeding suggested preventive behaviors and taking timely interventions as needed. These patients manage their health with a practitioner who understands their unique health history and can be connected to the right specialists when needed.
Access to primary care diminishes health disparities, lowers the overall costs of healthcare by mitigating health issues, reduces unnecessary care, and is a sign of a healthy and thriving healthcare system. Unfortunately for citizens of the United States, the healthcare system is expensive and faltering. According to the Commonwealth Fund, of the 11 most affluent countries in the world, the U.S. healthcare system ranks dead last.
Although reasons for the country's last-place ranking are complex, the widespread lack of access to primary care is one of the major factors. As a shortage of primary care providers looms on our collective horizon, the lack of access to healthcare has the potential to get much worse. Unfortunately, the South is going to be the most heavily impacted.
There is a looming nationwide lack of primary care physicians (PCPs). By 2030, the Association of American Medical Colleges (AAMC) predicts a deficit of between 14,800 and 49,300 PCPs. The U.S. Health Resources and Services Administration (HRSA) puts the PCP shortage at 23,640 by 2025. When looking at HRSA’s predictions for the supply and demand of PCPs, on average, the U.S. will need 7 percent* more PCPs than will be available in the workforce.
Many experts agree that APRNs and other advanced-practice providers may be part of the solution. By illustration, the AAMC predicts that if APRNs are utilized moderately in upcoming years, it will help to diminish demand for PCPs. If APRNs are used heavily, AAMC predicts that there could be a PCP surplus as early as 2024. Utilizing APRNs fully depends on the state in which they practice—a complex issue in the South, which largely restricts its nurse practitioners and other advanced practice nurses.
*This figure includes all reported states and regions in HRSA’s report, except for the District of Columbia. DC is predicted to have a 167.5 percent adequacy of PCPs, and inclusion of this figure in the averages skews the overarching picture of PCP supply/demand nationwide. When included in averages, it brings the average adequacy rate from -7 percent to -4.1 percent. It has been omitted from averages for purposes of clarity.
The South far outstrips other regions in its looming shortage of physicians. In fact, the HRSA predicted an average of 17.6 percent inadequacy by 2025 in the South, By comparison, the Midwest is expected to have an average 8 percent inadequacy, and the West, 6.2 percent. The Northeast is predicted to have a 4 percent PCP surplus.
In the South, upcoming shortages will range between 8.3 and 32.9 percent depending on the state—all above the national average. Of the 16 states included in this analysis, only Maryland is expected to have a surplus of primary care physicians by 2025, with an adequacy rate of 4.7 percent. Of all the states listed, the following five states are those that will have the most acute need for PCPs in the South in the upcoming years:
Keep reading to learn more about the detailed picture of the shortages in these five states, as well as how APRNs in each state might be able to relieve these deficits.
At a projected PCP deficit of almost 33 percent by 2025, Mississippi will have the greatest need for physicians in the next ten years. According to the HRSA, primary care physician supply in Mississippi will grow minimally between 2013 and 2025. Already at a deficit in 2013, Mississippi will have a much higher demand for PCPs, swelling from from 2,010 to 2,220 by 2025—a growth rate of 10.4 percent. With a 9 percent differential between supply and demand in this period, HRSA predicts Mississippi will need an additional 730 PCPs to fill the gap.
The Robert Graham Center (RGC) predicted that an additional 298 physicians will be needed for the state between 2010 and 2025. By 2030, that rate rises to 364: 132 PCPs needed due to patient aging, 165 due population growth, and 67 because of a larger population of insured.
In Mississippi, nurse practitioners (NPs) have a reduced scope of practice. Although free to prescribe drugs and Schedule II-V controlled substances following an approved educational program, NPs must work in collaboration with a supervising physician as per written practice guidelines to practice primary care in Mississippi.
Because NPs in Mississippi do not have full practice authority, their impact on the PCP shortage will be limited. What's more, HRSA predicts a 640 NP surplus by 2025—healthcare professionals who could help reduce the PCP shortage.
HRSA projects that by 2025, Alabama will require more than 30 percent more PCPs than it currently has. Demand for PCPs in Alabama between 2013 and 2025 is expected to increase by 9.3 percent. As demand for physicians rises during this period, supply will diminish. HRSA predicts that the supply of PCPs will dwindle from 2,720 to 2,680—a deceleration rate of 1.5 percent. The decrease in supply combined with an increase in demand will result in a predicted PCP deficit of 1,190.
The RGC predicts that between 2010 and 2025, 499 new PCPs will be needed to maintain the status quo level of care in Alabama. Projections through 2030 raise that number to 612: 185 new PCPs due to aging, 324 due to population growth, and 103 due to insurance access.
Like Mississippi, NPs in Alabama have a reduced scope of practice. NPs are not recognized as PCPs and they are subject to collaborative practice agreements. They can only prescribe medicine based on collaborating physician-approved protocols. Because NPs in Alabama must work closely with physicians, NP capacity to alleviate PCP shortages in Alabama will be limited.
What's more, if the supply of NPs continues on the HRSA predicted trajectory, the number of NPs in Alabama will also be inadequate to overcome deficits in the region. By 2025, HRSA predicts that there will be a 100 NP surplus in Alabama—not enough to overcome the RGC or HRSA predictions for the number of PCPs required, but adequate to partially alleviate the deficit.
Between 2013 and 2025, HRSA predicts that Kentucky will experience a 27.3 percent lack of PCPs. Similar to Alabama, dwindling supply and increased demand contribute to this large gap. Over the 12 year period in HRSA’s predictions, demand for PCPs will increase from 3,330 to 3,520, a growth rate of 5.7 percent. Supply will decrease from 2,660 to 2,560, a deceleration rate of 3.8 percent. The gap between PCP supply and PCP demand in Kentucky during this period will total 960.
RGC predicts that to maintain the status quo, Kentucky will need to add 510 physicians to the workforce between 2010 and 2025. More than 600 new primary care physicians will be needed by 2030, with more than half needed due to population growth, followed by aging and insurance utilization.
In Kentucky, NPs have a reduced scope of practice for the first four years of practice and a permanently reduced scope of practice for prescribing controlled substances. Although NPs are recognized as primary care providers and can independently treat and diagnose, they can only prescribe legend drugs through a collaborative agreement with a physician during their first four years of practice. After the first four years, NPs are free to prescribe legend drugs independently, but must retain a collaborative agreement for the prescription of Schedule II-V controlled substances.
The collaborative agreement between NPs and physicians is minimal in comparison to other states. NPs in Kentucky may have more impact on the PCP shortage than where the reduced scope of practice is more strict. HRSA predicts an NP surplus of 400 in 2024; the predicted number of new NPs will not be enough to fill in the gap completely, but it can help make a dent.
HRSA predicts Oklahoma will experience a 26.3 percent deficit of primary care physicians in 2025. While supply between 2013 and 2025 is predicted to increase 1.3 percent from 2,290 to 2,320 PCPs, demand is going to rise much faster. Between 2013 and 2025, HRSA predicts supply in Oklahoma will increase from 2,830 to 3,150, a growth rate of 11.3 percent. As demand rises 11 percent faster than supply, HRSA predicts there will be a deficit of more than 800 physicians in Oklahoma in 2025.
Because the RGC predicts to maintain the status quo healthcare access, the RGC prediction for 2025 is more modest, stating that 367 PCPs will be needed. Even when extended to 2030, RGC reports that 451 new primary care physicians will be needed: 54 due to aging, 293 due to population growth, and 104 due to insurance.
NPs in Oklahoma are subject to restricted practice. While they are recognized as PCPs in Oklahoma and can provide comprehensive healthcare independently, they are subject to career-long medical direction by a supervising physician when prescribing medication. Similar to other states where NPs can provide care independently but are subject to collaborative agreements with or supervision by a physician, there are limits the extent NPs will be able to mediate the impact of the impending PCP shortage, unless the state practice authority changes.
According to HRSA, there will be an NP surplus of 400 NPs in 2025. However, even if these NPs had a full scope of practice, numerically there are not enough in-state NPs to overcome the PCP shortage in Oklahoma completely, but it would help alleviate the shortage.
The state of Arkansas can anticipate a 24.5 percent inadequacy of PCP supply in 2025. Supply is projected to grow minimally during that period, bringing PCP numbers from 1,1810 to 1,820. However, similar to the rest of the South, demand is going outpace supply. HRSA predicts that demand in Arkansas will grow 11.6 percent between 2013 and 2025, bringing the needed number of PCPs from 2,160 to 2,410. The number of PCPs needed to bridge the gap will be 590.
RGC’s status quo maintenance projections predict that Arkansas will need 330 new PCPs in the workforce in 2025. When extended to 2030, this number jumps to 410: 115 PCPs due to aging, 221 due to population growth, and 74 due to insurance.
NPs are not recognized as PCPs in the state of Arkansas and practice with a reduced scope. While NPs do not need direct supervision from a physician, they must have a collaborative agreement with a physician. NPs in Arkansas can gain independent prescriptive authority following the successful completion of an advanced pharmacology course, so long as they maintain their collaborative agreement with a physician. Similarly to other states where NPs have reduced the scope of practice, the required collaboration with a physician will diminish NP capacity to overcome PCP deficits in the state.
Despite the limitations, numerically, HRSA predicts that with an NP surplus of 590 by 2025, there will be the exact number of NPs required to overcome the PCP deficit and more than enough to maintain status quo levels of care.
The story of the rest of the South is quite similar to the one of the five states listed above: demand is outstripping supply by large margins, NPs have reduced or restricted scope of practice, and predicted NP surpluses will not always overcome the lack of PCP supply. If access to primary care provides a window into the health of a healthcare system, the future of healthcare in the South is looking quite sickly.
Policymakers and leaders in healthcare need to consider the impact of limiting the scope of practice for NPs and need to figure out how to attract more advanced-practice practitioners into the region. Only then can they hope to overcome the impending PCP shortages for the citizens of the South.