According to the Association of American Medical Colleges, the United States will face a shortage of as many as 121,900 physicians by the year 2032. The shortage may be particularly severe in a state like Florida where more than 20 percent of the population is over 65 years old.
In a recent policy brief published by the James Madison Institute, my coauthor, Sal Nuzzo, and I discuss several state-level policy measures to address provider shortages, expand access to care, and lower costs for patients.
The U.S. Department of Health and Human Services has already designated 282 primary care Health Provider Shortage Areas (HPSAs) in Florida, which cover a population of more than six million Floridians. An estimated 1,636 additional primary care physicians are required to remove existing HPSA designations. The shortage is projected to grow to over 3,000 physicians by 2025 and up to 4,671 physicians by 2030.
States are beginning to embrace telemedicine as a tool to address the looming physician shortage. Indeed, telemedicine is one of many emerging trends in health care delivery with tremendous potential to expand access and achieve cost-reductions, but it should not be perceived as a panacea for issues in the health care industry. Addressing the growing physician shortage will require states, including Florida, to expand the scope of practice for non-physician providers, pursue comprehensive licensing reform, eliminate certificate of need requirements, and embrace future technological innovation.
Expanding Scope of Practice for Non-Physician Practitioners
In contrast to physicians, the supply of non-physician providers including advanced practice registered nurses (APRNs), physician assistants (PAs), and pharmaceutical workers is growing rapidly. However, scope of practice laws prevent these workers from practicing to the full extent of their training and education by limiting the range of services they are allowed to provide or requiring them to work under the supervision of physicians.
Fortunately, wide variation in scope of practice laws and supervision requirements across states suggests that there is ample room for reform without compromising the quality of care. In fact, the vast majority of research on the subject suggests that expanding the role of non-physician providers improves access with no negative effects on quality.
A report from the Institute of Medicine strongly recommended expanding the role of APRNs to meet the growing need for primary care providers. The report specifically cited the importance of nurses in expanding access and improving the quality of care.
The Florida legislature is currently considering legislation (HB 607) that would allow APRNs and PAs to practice independently and expand their scope of practice by authorizing them to sign documents that otherwise require the signature of a physician. Another bill (HB 389) under consideration would expand pharmacists’ scope of practice to include testing and initiation of treatment for influenza and streptococcal pharyngitis.
Removing Barriers for Out-of-State Telehealth Providers
The terms telehealth and telemedicine broadly refer to the delivery of health care services via telecommunication or digital communication technologies. Widespread adoption of these technologies would help address physician shortages by allowing patients to receive care without the physical presence of a health care provider. However, the patchwork of licensing requirements for out-of-state providers limits the potential impact of telemedicine.
In 2019, Florida lawmakers passed significant reforms to allow for wider use of telemedicine. The legislation created a registration process that allows out-of-state providers to provide telehealth services in Florida without obtaining a license in the state. While allowing providers licensed in other states to practice telemedicine is a major step in the right direction, registration still presents an unnecessary barrier to out-of-state providers.
Rather than create new requirements, Florida and other states could join interstate licensure compacts to reduce the burden of receiving licensure in multiple states. If a practitioner receives a license in any member state, they are able to receive licensure in all other member states with little or no additional effort. However, there are no existing compacts for physician assistants or pharmacists, and the compacts that do exist rely on widespread adoption to be effective.
Alternatively, states could recognize licenses from other states. Such a policy would not be detrimental to the quality of services as licensure standards for health care providers are largely comparable across states. In fact, many states, including Florida, already have license reciprocity programs to recognize out-of-state licenses held by veterans, active-duty service members, and military spouses. Expanding out-of-state license recognition to all new residents and out-of-state providers would increase competition, expand access, reduce costs, and promote the adoption of telemedicine by expanding the health care labor market.
Eliminating Certificate of Need Requirements and Bans on Specialty Hospitals
Certificate of need (CON) laws require health care providers to demonstrate an unmet need before constructing new facilities, expanding existing ones, or offering new services. The 1974 National Health Planning and Resources Development Act mandated states to implement CON programs for many facilities and services under the theory that unregulated competition would lead to over-investment in facilities and equipment. However, ample research has found that CON laws actually increase costs and reduce access to care by limiting competition and supply. Consequently, several states have eliminated their CON programs following the repeal of the federal mandate in 1987.
Florida repealed most of its CON laws in 2019 but maintained requirements for nursing homes, skilled nursing facilities, hospice programs, and intermediate care facilities for the developmentally disabled. The legislature also stopped shy of eliminating Florida’s ban on specialty hospitals that restrict their services to cardiac, orthopedic, surgical or oncology care. Florida lawmakers are currently considering legislation (HB 6059) that would eliminate this ban.
Considering that a shortage of physicians will raise costs and limit access to care, policies such as certificate of need laws that unnecessarily exacerbate these problems should be eliminated. CON laws for nursing homes and hospices are particularly detrimental in Florida given the relatively high elderly population in the state.
Embracing Innovative Technologies
Technological innovation has the potential to transform the health care industry and reduce the impact of physician shortages, but our laws are often slow to respond to change. While it is impossible to know what innovations lie around the corner, technologies including artificial intelligence (AI), unmanned aerial vehicles (UAVs), and telepharmacy services are already demonstrating their potential. Rather than trying to force compliance with outdated regulatory schemes, states should embrace these technologies and avoid limiting future innovation through excessive regulation.
A growing body of evidence suggests that artificial intelligence could be used to diagnose a variety of diseases more accurately than physicians. For example, an algorithm developed by Google researchers outperformed six radiologists at screening for lung cancer in a study published by Nature Medicine. While this technology is a long way off from replacing physicians, it could become an essential aid to physicians in the near future. States should be cautious to avoid limiting the potential of AI in health care settings through overregulation.
UAVs, or drones, could be useful for delivering medical supplies to remote areas, especially during natural disasters. In fact, they are already being used in some developing countries to deliver blood, vaccines, and other life-saving medical supplies. However, deploying UAVs in the United States is more complicated because of the patchwork of laws and regulations governing airspace and will likely require collaboration between federal, state, and local authorities. Nevertheless, states like Florida should be leaders in coordinating with federal and municipal authorities.
Telepharmacy technologies could expand access to care, particularly in rural communities, by allowing patients to interact with pharmacists remotely. There are several types of telepharmacy services including remote consultation, remote dispensing, and automated dispensing machines. In a remote counseling setting, a pharmacist provides guidance to patients via a video or audio link to ensure the safe and proper use of medications. Remote dispensing is another option, wherein a pharmacist manages several remote sites staffed by pharmacy technicians. This model allows for wider access in rural areas where traditional pharmacies staffed by in-person pharmacists may not be feasible. Finally, automated pharmacy dispensing machines, allow pharmacists to interact with patients and remotely dispense medications via video or audio link. The machines are typically stocked with common prescriptions (non-narcotics) and provide 24-hour access to pharmacy services without significant labor costs. The Florida legislature is considering legislation (HB 57) that would allow certain hospitals to place these machines in their emergency departments for use by patients upon discharge.
As the country’s population continues to grow and age, the demand for health care services will outpace the supply of physicians. States can address the looming shortage by pursuing a broad range of reforms to expand scope of practice for non-physician providers, eliminate certificate of need laws, recognize out-of-state licenses, and embrace future technological innovations. Taken together, these measures would alleviate the growing strain on our health care resources, expand access to care, and reduce costs for patients.