Primary Care Deserts and Their Risks

Primary care is the door to the medical system. General physicians connect patients to specialists, prescribe medications, administer vaccines, recommend screenings, and make referrals for surgeries.

The primary care door is jammed shut for 75 million people. They live in counties without adequate medical services. To provide sufficient access to general medicine, these counties would need to hire an additional 13,000 physicians.

Medical deserts struggle to attract practitioners due to high patient loads and fear of poor compensation. The Health Resources and Services Administration (HRSA) has attempted to recruit practitioners to areas that lack health services for decades. Since 1965, they have designated Health Professional Shortage Areas (HPSAs), regions that lack correctional, medical, or mental health facilities or in which a certain demographic, such as Medicare beneficiaries, struggles to access health services.

The HRSA distributes resources to deficit areas via federal programs, like the National Health Service Corps, the Indian Health Service Loan Repayment Program, the Rural Health Clinic Program, and the HPSA Bonus Payment Program. These programs aim to resolve health care deficits by incentivizing doctors to practice in shortage areas. Doctors that practice in HPSAs are eligible for bonus payments, student loan repayment, and other perks. Federally-funded programs receive over one billion dollars collectively per year to promote health equity; still, they have not cleared the longstanding gap in primary care access.

Justin H. Markowski and colleagues evaluated the impact of HPSA designations on access to primary care. They tracked each county’s HPSA designation history, as well as county-level mortality and physician coverage over the span of 50 years. They used mortality data from the Centers for Disease Control and Prevention and physician location data from the HRSA.

Current methods of federal support have not remedied the primary care shortage.

Most of the counties that received an HPSA designation (73%) have remained primary care deserts for a decade or more. Additionally, the differences in mortality and physician coverage between deficit and non-deficit areas have grown since 1970.

Primary care doctors in HPSA areas may refuse to see Medicare recipients due to low reimbursement rates. This refusal to see Medicare recipients prevents patients from receiving timely surgeries. HPSA programs have attempted to settle this issue by providing incentives for surgeons that operate on Medicare beneficiaries, as well as general practitioners who see Medicare patients. Still, patient referrals are often delayed.

Surgeries such as hip replacements or hernia repairs can be treated electively if patients receive timely referrals. If not, these surgeries may become emergency operations with a higher risk of complications.

A recent study found that Medicare beneficiaries in primary care shortage areas were more likely to need emergency surgery, have serious complications, and be readmitted to the hospital after surgery than those living outside of shortage areas. Bonus payments for general practitioners and surgeons have not expedited referrals to necessary surgeries, putting Medicare patients in harm’s way.

Current methods of federal support have not remedied the primary care shortage. Markowski and colleagues recommend that HPSA-dependent programs work to attract new medical graduates to shortage areas; medical centers in shortage areas should offer competitive salaries and benefits, flexible work arrangements, and emphasize their access to increased Medicare provider reimbursements. They also suggest that HPSA areas utilize physician assistants and nurse practitioners in primary care to address the gaps in care. Others call on Medicare to create payment plans in well-known medical deserts for practitioners that incentivize timely referrals and surgeries.