What Nebraska’s Physician Shortage Says About the Emerging Healthcare System Nationwide
I read with interest a report issued earlier this month by a work group at the University of Nebraska Medical Center, which focused on the widespread, challenging physician shortage in the state of Nebraska. The report, entitled “The States of the Healthcare Workforce in the State of Nebraska,” revealed that while there has been an 11 percent increase in the number of physicians in the state over the last 10 years, there are 13 counties that still do not have a primary care physician, according to a press release published by the University of Nebraska Medical Center (UNMC).
According to the April 4 press release published by UNMC, that finding was one of a number of key findings in the 64-page report. Among those challenges, the report found “the reality that nearly one-fifth of physicians in Nebraska are more than 60 years old, and thus likely to retire in the near future”; found that “18 of 93 Nebraska counties have no pharmacist”; and found that “demographics in many counties are becoming more diverse, but the current health workforce doesn’t necessarily reflect the populations being served.”
Inevitably, physician assistants and advanced nurse practitioners (PAs and APNs) are filling in the gaps in Nebraska. “Since 2007, there has been a large increase in the number of active physician assistants (PAs) in the state,” the report noted. “There are 908 PAs (or 47.3 PAs per 100,000 population) versus 598 (33.5 {As per 100,000 population) in 2007—a 52-percent difference in number of PAs. PAs currently provide a total of 35,878 work hours, equating to 897 FTE PAs. Half of the PAs are 40 years old or younger, and over 70 percent of PAs are female.” Further, the report stated, “Analysis of the distribution of PAs by county showed that 16 counties in Nebraska do not have an active PA.”
Meanwhile, the reported noted that, “In 2017, there were 1,148 nurse practitioners (NPs), 36 certified nurse midwives (CNMs), 49 clinical nurse specialists (CNSs), and 308 certified registered nurse anesthetists (CRNAs). The number of NPs rose from 767 to 1,148 in 2007-2017—a 50-percent increase. For CNMs, the increase was from 22 to 36 professionals.”
Importantly, the report’s authors state, “Our results highlight the substantial deficit in the supply of physicians across counties in Nebraska, particularly for the primary care specialties of internal medicine, OB/GYN and pediatrics. In addition, nearly one in five physicians in the state are older than age 65, and thus are likely to retire in the near future. In contrast, the number and rates of physician assistants and nurse professionals have grown substantially over the last decades and provide wide-ranging geographical coverage in Nebraska. The greater reliance on physician assistants and nurse practitioners,” they wrote, “has helped to offset the inadequate supply of primary care physicians.” Even so, they added, “[T]here remains substantial variation in the rate of nurse professionals across the state, with relatively low numbers of RNs, LPNs and APRNs in west and central Nebraska.”
Can healthcare IT be part of the solution?
Of course, Nebraska is far from alone among states with widely dispersed, broadly rural populations; Nebraska’s situation mirrors the situations of nearly all of those states. What’s more, with both the physician and nurse cadres aging these days, all of those states are facing accelerating challenges in providing high-quality care to their populations, including those sub-populations living with single or multiple chronic illnesses—particularly diabetes, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and coronary artery disease (CAD).
But here’s the thing: the potential for leveraging important technologies is quite considerable in states like Nebraska. We all know that the adoption of telehealth technologies, strategies, and care delivery are advancing rapidly everywhere in the U.S., but particularly in states like Nebraska, which have a few large metropolitan areas, with medical specialists, imaging centers, and academic medical centers and other teaching hospitals, along with vast rural areas that have shortages of all physicians, including primary care physicians, as well as of mid-level professionals.
But there’s more: as value-based care delivery and payment move forward, the need to shift as much administrative burden, as well as, as many clinical and other tasks that can be shifted off primary care physicians, will only increase. As a result, multidisciplinary care team-based models are moving forward, even in less-advanced (until now) managed care markets. And the leveraging of clinical information systems will absolutely be a critical success factor in that regard. Not only will electronic health records need to be hyper-accessible and super-usable; all of the clinical decision support tools and the tools needed to optimally care-manage patients with chronic illnesses, will need to be architected for use by those multidisciplinary care teams, with data beautifully organized for use by the physicians, physician assistants, advanced nurse practitioners, registered nurses, licensed practical nurses, nurse case and care managers, social workers, psychologists, pharmacists, therapists, and all others connected to those care teams. And that architecture will perforce have to include dashboards for use by physicians and care managers, to evaluate patients’ health statuses and outcomes; data analytics for executive and leadership use; and as much operational software and revenue cycle management technology as possible, for financial and operational success in an increasingly value-based operational world.
What’s more, key technologies will be part of the solution to managing the care and health of patients when they are in their homes and navigating their daily lives, as well—as it will need to be. But there’s great opportunity there, as patients/consumers connect themselves to mobile technology that can in turn be connected to the formal clinical information systems that help clinicians and care managers enhance and improve their patients’ clinical outcomes and health statuses. OpenNotes, too, could prove valuable in engaging patients in their care, including in enhancing what is often described as “patient compliance” (a terrible term, really, but it’s the one commonly used and understood) in relation to physician instructions and prescriptions—not to mention support and education from care and case managers to patients/consumers.
In fact, it’s impossible to think about the future of healthcare delivery in states like Nebraska and not think about the role of healthcare information technology. And that puts healthcare informaticists and other healthcare IT leaders in a unique position, as facilitators—at the highest level—of change and change management, in healthcare delivery, on behalf of the patients whom we’re all saying should be at the center of all this.
So when it comes to physician shortages, the aging of physicians and nurses, and all the broad staffing and care access challenges that face communities and regions in states like Nebraska, let’s keep in mind that healthcare IT leaders can be heroes in all this—and need to help their colleagues move forward, into the challenging, exciting, rapidly changing, emerging healthcare system of the mid-21st century. Nebraska, you’re not alone. Nor will your solution be yours alone.