JeVonna Caine, one of OK Policy’s 2013-14 Research Fellows, is pursuing a Masters of Public Health in Health Administration and Policy from the OU Health Sciences Center, while also working at the State Department of Health in the Health Planning & Grants department. She has an extensive background in community health education and research with previous positions at Georgetown University and Youth Services of Tulsa.
With the influx of insurance enrollment through the Patient Protection and Affordable Care Act (aka ACA, aka Obamacare), nationwide uninsured rates are at their lowest since 2008. This signals an impending increase in the demand for primary care services. However, Oklahoma is currently ranked 48th in the nation for access to primary care physicians (PCPs). Oklahoma needs to do better to grow the supply of primary care physicians, but we still put up significant barriers. Work-related stress, declining reimbursements and increasing administrative requirements all discourage medical students from training to be PCPs, particularly in rural communities.
PCPs are overworked and underpaid
Primary care physicians in Oklahoma face substantial demand but comparatively little pay. Oklahoma would need to add some 1,300 PCPs just to meet the national average. In rural areas, where the shortage is most significant, some PCPs describe being on call every other night – not a schedule many doctors would willingly choose or be able to sustain if they did. They are also comparatively underpaid: over a career, PCPs will earn $1.5 to 2.8 million less than their counterparts who go into specialty areas.
PCPs are discouraged by declining Medicaid payments
Similarly, declining Medicaid reimbursements offer more headaches and financial losses for PCPs who accept Medicaid. The Health Care Authority, which oversees Oklahoma’s Medicaid program, must make millions in cuts in its budget this year. The federal matching funds for Medicaid are declining, thanks to Oklahoma’s sprightly economy, but state lawmakers have chosen not to provide state funds to cover the loss. Budget cuts mean provider reimbursement rates will drop, which will, according to OHCA’s Board Chairman, disproportionately impact rural providers. It’s not a secret that rural populations have less health access and depend more on Medicaid. Any cuts to Medicaid reimbursement could create major accessibility problems in rural Oklahoma.
PCPs are burdened by increasing required administrative tasks
Providers are also burdened by increasing administrative requirements. In an effort to curb prescription drug abuse, Gov. Fallin’s administration pushed hard in the past legislative session for a bill requiring physicians to use the state’s Prescription Monitoring Program (PMP), a state-of-the-art tool for providers to track the prescribing and purchasing of controlled substances. Many health care providers fought against the legislation, arguing that the checking the system is an ineffective use of time. While the bill requiring prescribers to use the PMP failed to pass this session, it will likely come up again next year.
Similarly, the Affordable Care Act requires all Medicare-serving physicians to adopt Electronic Health Records (EHR) by 2015 or face reimbursement penalties. While EHR offers greater efficiency and interfacing capabilities, the increased time consumption, especially during early use, and high costs are discouraging to many physicians. In Oklahoma, the EHR implementation rate among office-based physicians is 36.9 percent, compared to a national average of 48.1 percent. Anecdotal reports also suggest that the EHR requirement is driving some older physicians into retirement.
The way forward
It is, in short, very difficult to make primary care attractive to medical students – particularly in rural areas. This is unfortunate, because there’s never been greater need, and that need is only going to grow.
If the state continues to cut funding to Medicaid services, the progress the state has made in health improvements could be stalled, and the ultimate goal of a healthier state will not be realized. The number of primary care physicians will remain low, exacerbating the disparity between supply and demand while limiting access to care for the state’s neediest populations.
However, the state has a few options growing forward. Continuing to invest in the next generation of primary care physicians would build a better health care provider supply. More responsible fiscal planning could create a more stable state budget, which in turn would lessen the likelihood of provider cuts. The substantial state-level variation in adoption of electronic health records indicates that more can be done to encourage PCPs to go digital. And finally, accepting federal funds to expand health coverage to low-income Oklahomans would be a net savings to the state and would inject billions in federal funds into our health care system.
Oklahoma’s primary care physician supply is in dire straits, but it doesn’t have to be this way. By acting intelligently to incentivize primary care in the state, policymakers can relieve some of the pressure on existing care providers, especially in rural areas.