States with the most restrictive scope-of-practice laws have an inadequate supply of primary care clinicians to serve a high concentration of dual-eligible beneficiaries.
Objectives: To determine whether enough primary care providers are in close proximity to where dual-eligible beneficiaries live to provide the capacity needed for integrated care models.
Study Design: Secondary data analysis using dual-eligible enrollment data and health care workforce data.
Methods: We determined the density of dual-eligible beneficiaries per 1000 population in 2017 for each of 3142 US counties. County-level supply of primary care physicians (PCPs), primary care nurse practitioners, and physician assistants was determined.
Results: One-third of the 791 counties with the highest density of dual-eligible beneficiaries had PCP shortages. Counties with the highest density of dual-eligible beneficiaries and the fewest primary care clinicians of any type were concentrated in Southeastern states. These areas also had some of the highest coronavirus disease 2019 outbreaks within their states.
Conclusions: States in the Southeastern region of the United States with some of the most restrictive scope-of-practice laws have an inadequate supply of primary care providers to serve a high concentration of dual-eligible beneficiaries. The fragmented care of the dually eligible population leads to extremely high costs, prompting policy makers to consider integrated delivery models that emphasize primary care. However, primary care workforce shortages will be an enduring challenge without scope-of-practice reforms.
Am J Manag Care. 2021;27(5):In Press
Twelve million people are enrolled in both Medicare and Medicaid. Known as “dual-eligible beneficiaries,” they account for 20% of Medicare beneficiaries and 15% of those receiving Medicaid, but account for one-third of total expenditures for each program.1 Most qualify for Medicare on the basis of age or a disability, and all dual-eligible beneficiaries have incomes below or near the federal poverty level. This population suffers disproportionately from chronic conditions and fragmented care.1
To help overcome historically fragmented and uncoordinated care, CMS has developed integrated care delivery models, including the Program of All-Inclusive Care for the Elderly, the Medicare Advantage Dual-Eligible Special Needs Plans, and the recent Financial Alignment Initiative. Although these models largely rely on adequate access to primary care, there are well-documented shortages of primary care physicians (PCPs).2 We investigate whether dual-eligible enrollees are concentrated in different areas of the country and whether primary care clinicians, including PCPs, nurse practitioners (NPs), and physician assistants (PAs), are geographically colocated in these areas. Without an adequate primary care workforce available, implementing integrated care delivery models for dual-eligible beneficiaries may be in vain.
We conducted a cross-sectional analysis using data on the geographic locations of dual-eligible beneficiaries and primary care providers. Enrollment data from the Office of Medicare-Medicaid Coordination were used to calculate the population density of dual-eligible beneficiaries,3 defined as the number of dual-eligible beneficiaries receiving full or partial Medicaid benefits per 1000 population in each of the 3142 US counties. We categorized counties according to dually eligible beneficiary density quartiles.
To determine the county supply of PCPs, we used the Health Resources and Services Administration 2017 designation for whole-county Health Professional Shortage Areas (HPSAs). HPSA data came from the Area Health Resources Files (AHRF), which are commonly used to identify county-level socioeconomic, demographic, and health workforce characteristics. AHRF data were also used to identify PAs in each county. Because the HPSA designation only considers PCPs, to identify primary care NPs (PCNPs) we used methods previously developed, based on National Provider Identifier numbers from CMS.4 We calculated the county-level number of PCNPs and PAs per 1000 population and categorized them into the highest (ie, ≥ 75th percentile) and lowest (ie, < 25th percentile) supply density quartiles.
There were substantive regional variations in dual-eligible beneficiary density and in primary care workforce supply, as shown in the Figure [panels A and B and panels C and D]. Panel A shows that one-third (n = 271) of the 791 counties with the highest density of dual-eligible beneficiaries were designated as HPSAs and were more likely to be rural and located in the Southeast region of the country. Many of these counties were also encumbered by high poverty rates and a heavy burden of chronic conditions.5,6
Panel B reveals that in nearly half (n = 128) of the 271 counties with both a high-density dual-eligible population and a PCP shortage, the density of PCNPs was the highest. That is, the distribution of PCNPs was within the highest quartile of the overall supply of PCNPs in the country. Conversely, in 52 of these counties, the number of PCNPs per 1000 population ranked in the lowest quartile. The majority of counties with high-density dual-eligible beneficiaries and PCP shortages also ranked in the bottom quartile of the PA supply (panel C).
Although we found that the highest supply of PCNPs was located in many counties with a high concentration of dual-eligible beneficiaries along with PCP shortages, we also found counties in the same regions with the lowest supply of PCNPs and the lowest supply of PAs. Panel D shows that 23 (8%) of high-density dual-eligible counties with HPSA designations ranked in the lowest quartile for both PCNPs and PAs. These counties had very high poverty rates, 14 were rural, and most were in Southeastern states, including Texas, Louisiana, Alabama, Georgia, and South Carolina. These counties are essentially “primary care deserts”—they had the highest density of dual-eligible beneficiaries and the fewest primary care clinicians of any type.
Finally, in the face of the competing challenge of the coronavirus disease 2019 (COVID-19) pandemic, we observed the prevalence of infection rates in counties with a high density of dual-eligible beneficiaries to understand the challenge of coordinating care for these beneficiaries. Using cumulative, total confirmed COVID-19 cases reported in each county,7 we found that 11 of these primary care desert counties also ranked in the top quartile of COVID-19 cases per capita within their states. Although there have been issues regarding test accuracy for confirming COVID-19 infections, results of serologic surveys have shown that confirmed cases represent a significant undercount of actual infection rates.8
We also found that areas with shortages of primary care clinicians were those where there were high concentrations of poverty at the county level (data not shown). These findings align with those of other investigators who have reported that low-income populations in the Southern and South Central areas of the United States experience access barriers and worse health outcomes compared with similar low-income individuals in other regions.9
Improving the care for dual-eligible beneficiaries through integrated care delivery models is a vital policy initiative. Although CMS urges states to adopt these new models, primary care workforce shortages in the United States will likely hamper the effectiveness of these initiatives and limit their ability to expand their scale. Federal, state, and local stakeholders need to develop systematic approaches that address barriers that restrict provider roles in caring for patients in need.
For decades, the federal government has relied on programs to try to increase the number of PCPs in underserved areas, such as loan payment programs, recruiting rural students to become physicians,10 or giving bonus payments to PCPs for services delivered in HPSAs. The Affordable Care Act also implemented primary care incentive programs for both PCPs and nonphysician primary care providers. However, dual-eligible beneficiaries and others in underserved areas continue to have inadequate access to care.
The disproportionate impact of the pandemic further reinforces the need for integrated care delivery and financing between Medicare and Medicaid, particularly in areas where the dual-eligible population is concentrated. Notably, in response to the COVID-19 pandemic, CMS has temporarily eased supervision restrictions on NPs and promoted telemedicine to reduce care access barriers faced by vulnerable populations.
The quality of care provided to vulnerable populations, such as dual-eligible beneficiaries, by PCNPs and PAs has been proved to be comparable with that delivered by PCPs.11-13 However, at the state level, scope-of-practice regulations often restrain the flexibility of having care furnished by nonphysician providers. All PAs are required to practice in collaboration with a physician,14,15 and as shown by our results, the density of PA supply highly overlaps with the density of PCP supply. This limits their capability to fill gaps in areas with a shortage of PCPs.
Our study reveals that some regions of the United States need to improve the distribution of the primary care workforce to serve dual-eligible beneficiaries and to provide adequate care. We found that most of these areas were in Southeastern states, which impose the most restrictive scope-of-practice regulations that limit the capacity of NPs. Such restrictions may also increase NPs’ reluctance to locate in these states. Thus, a first step to expand access to care is to lessen the state-imposed restrictions on scope of practice for NPs.
Amid the COVID-19 pandemic, Florida, Tennessee, Kentucky, Louisiana, New Jersey, New York, Wisconsin, and West Virginia all lifted the restrictions on NPs’ scope of practice. However, because most of these regulatory changes are temporary, in response to the pandemic, a more permanent broadening of licensure scope is required. NPs are unlikely to relocate to these regions unless the easing of restrictions is more enduring.
At the local level, we observed that some counties were able to recruit NPs to practice locations where PCP shortages existed with a high concentration of dual-eligible beneficiaries. Although other counties were not able to successfully recruit NPs, they were frequently in the same states as counties that did, even in states with restrictive scope-of-practice laws. This finding suggests that there may be local leaders in some health systems who have surmounted constraining barriers, such as scope-of-practice restrictions, to successfully recruit PCNPs to fulfill a primary care need. It would therefore be helpful to reach out to these health care system leaders to understand how they addressed this issue.
Local stakeholders in states with large dually eligible populations should take advantage of the resources available for expanding access to primary care. Successful approaches at local levels in other parts of the state may be available. In 2017, the National Academy of Medicine published “Vital Directions for Health and Health Care,” which is a framework for better health and well-being, high-value health care, and strong science and technology to help guide policy makers to improve health care in the United States.16 Using this framework, North Carolina health care leaders recently convened a symposium to examine actions needed to achieve more affordable quality care and to assess the state’s capacity to improve care.17 Other states or local leaders can use this framework to guide reforms to augment the primary care workforce and deal with workforce challenges with vulnerable populations, such as dual-eligible beneficiaries.
The current pause in nonurgent health services due to the pandemic is having more devastating economic effects on rural clinics and hospitals,particularly in the Southeast. These are places that have already experienced a serious loss of physicians and hospitals, even before the COVID-19 crisis.18,19 Further, many primary care practices are having financial difficulties because the pandemic has created a barrier to non–COVID-19 office visits. Many have furloughed health care workers because the loss in practice volumes has created unanticipated financial strain. Disrupted and delayed routine care for dual-eligible beneficiaries, most of whom have chronic conditions, will likely result in relapses of conditions and/or exacerbations after relapse. The pandemic reinforces the need to grow the primary care workforce in the Southeastern region to address the pent-up service demand that awaits the resumption of normal care patterns. Because of the inelastic supply of PCPs, an expanded scope of practice may be an essential strategy to attract advanced nonphysician primary care providers, such as PCNPs, who can help coordinate the care for dual-eligible beneficiaries with costly chronic conditions.20
This will likely disrupt the current ways of organizing, sustaining, and growing the workforce. Without policy changes to strengthen the primary care workforce, vulnerable populations like dual-eligible beneficiaries will continue to endure fragmented care in areas with preponderant primary care shortages.
Primary care workforce shortages will likely hamper the effectiveness of integrated delivery models for dual-eligible beneficiaries and limit the ability to expand policy scale. These shortages will be an enduring challenge in states without scope-of-practice law reforms. Dual-eligible beneficiaries’ inadequate access to primary care cannot be addressed without systematic state-level approaches.
Author Affiliations: Division of Health Services Management and Policy, College of Public Health (WYX, SMR), and Division of General Internal Medicine, College of Medicine (WYX, SMR), The Ohio State University, Columbus, OH; Center for Interdisciplinary Health Workforce Studies, College of Nursing, Montana State University (PB), Bozeman, MT.
Source of Funding: None.
Author Disclosures: Dr Retchin discloses that he receives fees and equity for his service as a member of the Board of Directors for Aveanna Healthcare, a large pediatric and adult home health care company. He also notes his service as a Commissioner on the Medicaid and CHIP Payment and Access Commission, for which he receives per diem payments and expenses for attendance at commission meetings. The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.
Authorship Information: Concept and design (WYX, SMR, PB); acquisition of data (WYX); analysis and interpretation of data (WYX, SMR, PB); drafting of the manuscript (WYX, SMR, PB); critical revision of the manuscript for important intellectual content (WYX, SMR, PB); and statistical analysis (WYX, SMR).
Address Correspondence to: Wendy Y. Xu, PhD, The Ohio State University, 208 Cunz Hall, 1841 Neil Ave, Columbus, OH 43210. Email: firstname.lastname@example.org.
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