Evaluation of Policy Options for Increasing the Availability of Primary Care Services in Rural Washington State

Purpose

The Washington State legislature has recently considered several policy options to address a perceived shortage of primary care physicians in rural Washington. These policy options include opening the new Elson S. Floyd College of Medicine at Washington State University (WSU) in 2017; increasing the number of primary care residency positions in the state; expanding educational loan–repayment incentives to encourage primary care physicians to practice in rural Washington; increasing Medicaid payment rates for primary care physicians in rural Washington; and encouraging the adoption of alternative models of primary care, such as patient-centered medical homes.

To inform comparisons between these policy options and others suggested by local experts, the Washington State Institute for Public Policy contracted with the RAND Corporation to project their effects on Washington State's rural primary care workforce through the year 2025.

Methods

To identify policy options for simulation, we conducted 39 key-informant interviews between November 2015 and March 2016. Interviewees included representatives of the legislative and executive branches of the Washington State government, professional associations, medical educational institutions, Medicaid managed care plans, and rural hospitals. Our interview protocol queried respondents' perceptions of primary care and other medical service shortages, current and past programs intended to alleviate these shortages, and additional ideas for increasing the availability of primary care services in rural Washington.

Using our interview notes, we generated a logic model displaying relationships between factors influencing the supply of primary care physicians and primary care services in rural Washington State. The logic model guided our selection of policy options for quantitative simulation.

For quantitative analyses, we used three separate empirical models. First, we constructed predictive models, drawing from national data sets, to forecast changes in the supply of primary care physicians in each Washington county. These predictive models, tailored to historical trends in provider supply and other characteristics of each county, established what we called our base-case projections—i.e., what would happen in the absence of new policy interventions. Second, we used longitudinal and cross-sectional inferential models, again drawing from national data sets, to estimate the effects that policy options would have on the supply of primary care physicians at the county level. We then applied these effect estimates to each Washington county and calculated cumulative effects of each policy option from 2017 to 2025. Third, we used a microsimulation model, tailored to Washington State, to estimate the effects of changing Medicaid payment rates on the supply of primary care services. Finally, we used previously published estimates of the effects of new care-delivery models (medical homes and nurse-managed health centers [NMHCs]) on workforce composition to estimate the impact of expanding these models in rural Washington State.

Findings

Key-Informant Interviews

There was a lack of consensus regarding the degree of primary care shortage in rural areas of Washington. Some of this disagreement stemmed from differences between respondents' definitions of primary care shortages.

Interviewees agreed that the major policy options initially proposed for modeling (opening a new medical school, increasing the number of primary care residency positions, increasing loan-repayment incentives, increasing Medicaid payment rates, increasing the adoption of medical homes—all in rural Washington) had the potential to increase the supply of rural primary care physicians. However, multiple interviewees expressed skepticism that opening a new medical school, without a corresponding increase in rural primary care residency positions, would increase the supply of primary care physicians in rural Washington.

Although we did not prespecify improving the quality of education in rural kindergarten through grade 12 as a policy option (and did not solicit it with a dedicated interview question), there was surprisingly widespread agreement that an effective long-term strategy to increase the number of rural primary care physicians would be to improve rural education in kindergarten through grade 12. Some interviewees also noted that primary care providers tended to cluster around rural hospitals because they enjoy the clinical backup and camaraderie that hospitals provide. They suggested that stabilizing struggling rural hospitals might therefore be a policy lever to preserve rural access to primary care providers, who might relocate if nearby hospitals close. Given these observations, we added two scenarios to the list of policy options for quantitative modeling: increasing the quality of high school education and preserving rural hospitals.

Base-Case Projections of the Rural and Urban Primary Care Workforce

Our predictive models estimated declines in the number of primary care physicians per 100,000 population in both rural and urban areas from 2013 to 2025: 3.66 fewer primary care physicians per 100,000 population in rural counties by 2025, 4.14 fewer in urban counties, 5.07 fewer outside Seattle, and 3.22 fewer within Seattle. These estimated declines were driven largely by recent increases in the percentage of primary care physicians ages 55 and older, many of whom are likely to retire by 2025.

In contrast, we projected increases from 2013 to 2025 of 5.38 to 7.79 nurse practitioners (NPs) and 1.84 to 3.08 physician assistants (PAs) per 100,000 population in Washington State.

Table 1 lists the policy options we considered, the details of the scenarios we used to evaluate those options, and the projected effects of those options based on the parameters in those scenarios.

Table 1.

Projected Effects That Policy Options Would Have on Washington State's Rural Primary Care Physician Workforce in 2025

Policy Option	Scenario Detail	Predicted Effect
Open the Elson S. Floyd College of Medicine at WSU.	Sixty students enroll in 2017 and 2018; 80 students enroll per year thereafter.	The number of primary care physicians per 100,000 population increases by 0.39.
Increase the number of primary care residency positions in Washington State.	All existing Washington State primary care residencies outside Seattle expand by 100 percent in 2017.	The number of primary care physicians per 100,000 population increases by 2.00.
Increase the availability of educational loan–repayment incentives.	Thirty new full-time primary care NHSC positions open in 2017 in rural Washington.	The number of primary care physicians per 100,000 population increases by 1.03. a
Improve the quality of high school education in rural Washington State.	Proficiency rates on standardized tests of math and of reading and language arts increase by 0.2 standard deviation.	The number of primary care physicians per 100,000 population increases by 0.80. a
Preserve rural hospitals in Washington State.	One rural acute-care hospital of average size is closed.	The number of primary care physicians per 100,000 population decreases by 0.87. b
Increase Medicaid fee-for-service payment rates in rural Washington State.	In 2017, Medicaid fee-for-service payment rates increase permanently by 25 percent.	Physician productivity increases by 1.06 primary care physician–equivalents per 100,000 population.
Increase the adoption of medical home practice models.	In 2017, 50 percent of existing rural primary care physicians adopt medical home practice models.	Physician productivity increases by 3.30 primary care physician–equivalents per 100,000 population.
Increase the adoption of NMHCs.	In 2017, 1 percent of existing rural primary care physicians join new NMHCs.	Physician productivity increases by 3.84 primary care physician–equivalents per 100,000 population.

a

The estimate from cross-sectional model assumes that equilibrium is reached by 2025.

b

The estimated effect occurs four years after the date of hospital closure.

Open the Elson S. Floyd College of Medicine at Washington State University

We estimated that opening the new medical school in 2017, beginning with 60 students and reaching a steady-state enrollment of 320 students in 2022, would be associated with increases in 2025 of 0.39 primary care physicians per 100,000 population in rural Washington counties, 0.59 in urban counties, 0.76 in Seattle, and 0.39 in Washington counties outside Seattle. These estimated effects of the new medical school offset approximately 11 percent of the projected decrease in rural per capita primary care physician supply by 2025, 14 percent of the projected decrease in urban counties, 12 percent of the projected decrease within Seattle, and 15 percent of the projected decrease outside Seattle.

Increase the Number of Primary Care Residency Positions in Washington State

We modeled residency policy options ranging up to a 100-percent expansion (i.e., a doubling of primary care residency sizes outside Seattle). The estimated effects of 100-percent primary care residency expansion (adding 36 primary care residents) were larger than the estimated effects of opening the new medical school at WSU, without residency program expansion. However, none of the modeled residency scenarios had an estimated effect sufficient to offset the predicted decline in the number of rural primary care physicians (or primary care physicians outside Seattle) per 100,000 population. For the 100-percent residency size expansions, estimated effects ranged from 1.11 primary care physicians per 100,000 population (27 percent of the projected decrease) in urban counties to 2.00 primary care physicians per 100,000 population (55 percent of the projected decrease) in rural counties by 2025.

Increase the Availability of Educational Loan–Repayment Incentives

To estimate the effect of expanding state-funded loan-repayment incentives in rural areas, we analyzed relationships between the number of National Health Service Corps (NHSC) primary care positions and primary care supply in rural counties. We found that, for each new primary care NHSC position opened per 100,000 county population, the estimated increase was 0.24 primary care physicians per 100,000 county population. Therefore, we estimated that doubling the number of primary care NHSC positions in rural Washington State (by adding 30 more such positions to rural counties, with approximate cumulative population 700,000) would produce an increase of 1.03 primary care physicians per 100,000 population.

Improve the Quality of High School Education in Rural Washington State

Because we lacked longitudinal data on high school quality (measured as proficiency rates on standardized tests of mathematics and of reading and language arts), we fit cross-sectional models that estimated the effect of increasing proficiency rates on these standardized tests by 0.2 standard deviations among high schools in rural Washington counties. We estimated that this improvement in high school quality would be associated with an increase of 0.80 primary care physicians per 100,000 population in rural Washington, or approximately 22 percent of the projected decline in per capita rural primary care physicians expected by 2025. However, because these models were cross-sectional and the time required to improve school performance is unclear, we cannot estimate the number of years required to achieve this estimated effect.

Preserve Rural Hospitals in Washington State

We intended the rural hospital scenario to give a sense of the effects of closing an average-sized rural hospital, without specifying a particular year of hospital closure. This scenario was motivated by interviewees' concern that rural hospital closure would decrease the supply of local primary care physicians. We estimated, using our models based on national data, that the closure of an average-sized rural hospital would be associated with a same-county net decrease of 0.87 primary care physicians per 100,000 rural population four years later.

Increase Medicaid Payment Rates for Primary Care Physicians in Rural Washington State

Using the RAND Health Care Payment and Delivery Simulation Model, we estimated the effects that increasing Medicaid fee-for-service payment rates to primary care physicians in rural counties of Washington State by 10 percent and 25 percent, beginning in 2017 and continuing thereafter, could have on primary care physician productivity. We estimated that, by 2025, a 10-percent payment-rate increase would yield an effective increase of 0.40 primary care physicians per 100,000 population (offsetting approximately 11 percent of the projected decline in the number of primary care physicians), and a 25-percent payment-rate increase would yield an effective increase of 1.06 primary care physicians per 100,000 population (offsetting approximately 29 percent of the projected decline).

Increase the Adoption of New Practice Models, Such as Medical Homes and Nurse-Managed Health Centers

Informed by previously published analyses of survey data, we estimated the effective increases in productivity per primary care physician (measured by panel size) associated with 50 percent of current rural Washington primary care physicians adopting medical home practice models. In such medical homes, primary care services are reallocated from physicians to NPs and PAs. This increase in medical home adoption would result in an effective increase of 3.30 rural primary care physicians per 100,000 population, offsetting 90 percent of the projected decline by 2025. Achieving this level of medical home adoption would require an additional 2.87 NPs and 2.90 PAs per 100,000 population.

We also estimated the effects that 1 percent of rural primary care physicians joining newly created NMHCs in 2017 would have on productivity per primary care physician. This increase in NMHC adoption would result in an effective increase of 3.84 rural primary care physicians per 100,000 population, offsetting the projected decline completely by 2025. Achieving this level of NMHC adoption would require an additional 6.42 NPs per 100,000 population. This additional NP requirement is likely to be met by the projected increase in NPs by 2025, which ranges from 5.38 to 7.79 new NPs per 100,000 population, based on recent increases in the numbers of newly trained NPs nationwide.

Medical homes and NMHCs can be implemented in many ways, and they represent examples of a general point: Reallocating primary care services from physicians to NPs and PAs, either working independently or in teams with primary care physicians, can counterbalance the projected decline in the number of rural primary care physicians. Moreover, even without taking any new policy actions, we project that Washington State will experience increases in the numbers of NPs and PAs per capita that are sufficient to staff these new practice models.

Conclusions

Our analysis was not designed to determine whether primary care shortages currently exist in rural Washington, and key informants disagreed on this question. However, if there are shortages of primary care physicians and services in rural Washington, these shortages are likely to worsen in the coming decade. We estimate that the number of rural primary care physicians per capita will decrease by approximately 3.66 per 100,000 by 2025—a 7-percent reduction from 2013 levels. By comparison, we estimate that urban areas of Washington State will experience a reduction of 4.14 primary care physicians per 100,000—a 5-percent reduction from 2013 levels.

None of the policy options modeled in this report, on its own, will offset this expected decrease by relying on primary care physicians alone. However, combinations of these strategies, or partial reallocation of rural primary care services to NPs and PAs via such new practice models as medical homes and NMHCs, with resulting increase in per-physician panel sizes, are plausible options for preserving the overall availability of primary care services in rural Washington through 2025.