Efforts to attract physicians to underserved areas aren't working, says study

A federal program created to attract physicians to medically underserved areas of the United States has not achieved this intended effect or reduced mortality rates in these regions, a new Yale study finds. The researchers say new approaches may be needed to address health care disparities across the country.

The findings were published in the journal Health Affairs.

Previous research has shown that people tend to seek out health care within their own community; the farther people have to travel to access that care, the less likely they'll do it. So the lack of adequate numbers of physicians—an issue that affects more than 40 million Americans—can contribute to health care access disparities; areas with shortages of health care professionals, studies show, tend to have higher mortality rates than regions that do not.

To address this problem, the U.S. government launched the Health Professional Shortage Area (HPSA) program in 1965. It offers incentives—such as student loan forgiveness and higher Medicare reimbursement—to physicians who practice in areas identified as having a critical shortage of health care providers.

Though the HPSA program has existed for nearly 60 years, there is limited research on whether it has achieved its intended effect.

For the study, researchers compared health data from U.S. counties designated as HPSAs with similar counties that met the qualifications for HPSA status but, for a variety of reasons, were never classified as such.

"The way this program works is that state-level actors need to petition federal officials for the HPSA designation, which was an approach that made sense in 1965 when technology was different and local officials were in a better position to know what areas were in need," said lead author Justin Markowski, a Ph.D. candidate at Yale School of Public Health. "However, because states engage with the HPSA process differently, there are counties that could be designated as HPSA but are not."

This approach allowed the researchers to compare underserved counties that did and did not receive HPSA benefits and assess whether HPSA incentives were effective.

Their findings revealed that the program has not had much of an impact.

"Our study showed that the program has had little effect on underserved areas, yielding no significant changes in physician density or county-level mortality rates," said Chima Ndumele, an associate professor of public health at Yale School of Public Health and faculty advisor on the project.

In fact, 73% of counties designated as HPSAs continued to experience physician shortages in the 10 years after their initial designation.

"The HPSA program has been great at identifying in-need counties, but not great at ameliorating that need," said Markowski. "We've really not moved the needle on this."

The study's findings also suggest that improving existing incentives may not be the answer. While the government has expanded the incentives for physicians to practice in these medically underserved areas, the study found no evidence that mortality rates or physician density have improved at any point in the program's history.

The researchers propose two alternative strategies to the current HPSA program. The first is to focus these incentives toward new medical school graduates.

"We know that physicians and health care practitioners in general don't really want to move once they've established their care. And when they do, they typically move out of HPSAs if they were originally in one," said Markowski. "Attracting young providers before they establish practices somewhere else is one potential solution. We don't know what goes into that decision-making process for young physicians, and that's an avenue for new research."

The second proposal is that the U.S. offer other types of health care professionals, such as nurse practitioners and physician associates, a wider scope of practice and more autonomy if they work in underserved areas.

Ultimately, it's about thinking outside the box, said Markowski.

"The federal government just released a significant amount of new funds for HPSA programs, but our findings underpin the idea that we need to think carefully about how we use those dollars," said Markowski. "We need to do better about getting physicians to these areas and we need to try other approaches."