There is a growing need for more primary care providers in New Jersey, with the counties most at risk facing significant health challenges and formidable barriers to expanding the medical workforce, according to an expert analysis.
“In New Jersey there are counties that have a severe shortage of primary care providers which we call ‘health care deserts,’” said Judith Schmidt, a nurse with extensive training who is CEO of the New Jersey State Nurses Association. The shortage could result in escalating health issues and unnecessary hospitalizations, she added.
A report by Rutgers University’s New Jersey Collaborating Center for Nursing released this spring found that primary care doctor-to-patient ratios exceed the national median in 13 of the state’s 21 counties; Cumberland, Ocean, Salem and Sussex counties have roughly half the number of providers needed to meet this target of 90 primary care physicians, or PCMDs, per 100,000 residents. Hudson and Passaic counties also fall drastically short.
Cumberland and Salem counties also have the lowest per-capita income and the worst health outcomes, the center noted, factors which other research has shown are intertwined. A separate study by Rutgers University’s Senator Walter Rand Institute for Public Affairs found that 21% of Cumberland County residents claimed to be in “poor or fair health,” the highest rate among the five South Jersey counties — which also included Burlington, Camden, Gloucester and Salem — polled by Rand for its study.
Salem, Sussex and Ocean counties also have large percentages of elderly residents, a population the nursing center report says requires more primary care services in general than younger groups. By 2030, this senior group is expected to grow by as much as 5.7% in Sussex; elderly residents are slated to increase 3.3 % in Salem and 0.4 % in Ocean, among the lowest increases statewide. By that year, at least one in five residents will be over age 65 in 13 New Jersey counties.
Primary care essentially involves promoting health, preventing disease and managing chronic conditions to avoid flare-ups or complications; the work involves family doctors, internal medicine experts, those trained in obstetrics and gynecology or pediatrics, as well physician assistants and nurse practitioners — plus a suite of other nurses, lab technicians and support staff. Hundreds of thousands of New Jerseyans receive this care from federally qualified health centers (FQHCs) or practices made up of advanced practice nurses (APNs).
Heading toward crisis?
“I think we’re heading toward a primary care shortage — a crisis actually,” said Linda Y. Flake, president and CEO of Southern Jersey Family Medical Centers, which operates eight facilities for low-income patients scattered across four counties. Flake said it has taken years for her organization to hire doctors for some locations.
“Competition for physicians is based on supply and demand, but we haven’t been able to compete favorably,” said Flake, explaining that federally qualified health centers like the system she runs struggle to offer salaries comparable to those available at health care facilities serving wealthier populations.
“Where there’s upper-middle-class people there’s going to be providers,” she said, “and where you have a large number of people who are uninsured or on Medicaid, you’re going to have less providers.”
Multiple factors are fueling the shortage of primary care doctors — which has been building for years in urban and rural areas nationwide — including the relative attraction of other medical specialties, like cancer and cardiac care, which generally command better pay and respect. But experts agree filling the primary care gap is critical to protecting the public health, and many believe it becomes more urgent as the massive baby-boom generation ages.
As for a solution, it depends on whom you ask.
Among those concerned about the problem are physicians themselves. They would like to lessen the heavy cost of medical school in order to expand the pool of primary care clinicians; for example, tuition at Rutgers New Jersey Medical School is now more than $60,000 annually. In addition, CEOs like Flake are hoping for a significant hike in reimbursement rates — some of which were set nearly two decades earlier — to generate new revenue.
“These are hard problems but we need to focus on them,” said Larry Downs, president and CEO of the New Jersey Medical Society.
Arguing for more authority for nurses
Some health care advocates would like to expand the authority of specially-trained advanced practice nurses, or APNs, so they can prescribe medications without formal physician oversight, a legal reform which supporters say would also save nursing practices time and money that could instead be invested in patient care.
Under current law, they must sign a “collaborating agreement” with a physician and pay that doctor a monthly fee in order to write prescriptions; the MD must review at least one patient chart per year for each nurse they oversee. Collaborating doctors are not legally liable for the APNs they contract with and the nurses must have their own malpractice insurance.
Nurses say the time and expense involved in these contracts is unnecessary and have pushed for legislation to end the use of this agreement, also known as joint protocol. Doctors, however, have largely opposed eliminating this change, suggesting it could harm patient care and eliminate an incentive to provide team-based treatments. A bill dating back to 2012 would eliminate joint protocol; the latest version passed the Senate health committee in June.
“We don’t think the solution is to waive a legislative wand and make all the nurses into doctors,” Downs of the medical society said of the legislation, which would only apply to nurses with at least two years experience and specific training, including pharmacology. “There’s really no replacement for the training of doctors.”
But some 22 states — including New York and Pennsylvania — have adopted similar reforms to eliminate this oversight, designed in part to enhance their primary care workforce by allowing APNs to work more independently. According to the nursing center report, further empowering these nurses could help fill the gap in two-thirds of the New Jersey counties that now lack primary care providers.
“We just need to move forward” with the legislation to eliminate collaborative agreement requirements, said Meschell Mansor, an advanced practice nurse who oversees five other nurses at a Gloucester County nursing practice that sees poor homebound patients, mostly elderly.
New Jersey had more than 27,300 licensed doctors in 2018, according to the Association of American Medical Colleges’ annual workforce profile, including at least 24,000 primary care providers. That places the Garden State 11th among the states for the number of doctors per patients and 18th for the ratio of primary care physicians, suggesting the shortage could be more severe elsewhere. (New Jersey has more than 100,000 licensed nurses, including APNs.)
The profile also illustrates the vulnerability of the physician workforce. One-third of doctors in New Jersey were over age 60 in 2018 — placing the state third nationwide for large percentage of elderly clinicians. New Jersey falls in the bottom third nationwide for medical school enrollment per population and the number of graduates who set up practice here.
The cost of medical school
“There are structural issues that contribute to the (primary care) shortage,” Downs said, ticking off the high cost of medical school, the debt accumulated by those who attend and the limited reimbursement rates for primary care services.
Representatives from the medical society have met with state officials to discuss increasing certain Medicaid reimbursement rates, Downs said, which are among the lowest in the nation for some services. Physicians are also eager for the state to restore full funding for the Primary Care Loan Redemption Program, which provides up to $120,000 to graduates of certain clinical health care programs to offset their education costs in return for providing primary care in an underserved community for at least two years.
“As a state there needs to be more investment in making this a friendlier place to practice for physicians,” Downs said, “and part of it comes down to economics.”
While the primary care loan program, which dates to 1991, in the past had at least $1.5 million in annual state funding, Gov. Phil Murphy cut this to $255,000 in the current budget — an 83% reduction.
His office noted there is only limited participation in the program, which is run by Rutgers University; as of March, there were 57 participants — a mix of doctors, dentists and advanced practice nurses and another 15 were in the pipeline. No one has been blocked for lack of funds and those enrolled will get the funds they were promised, the administration said.
“The recommended decrease for Fiscal Year 2020 program impacts a relatively small number of individuals. Historically, even when considering the waiting list, the program has not attracted a large number of applicants,” Murphy officials wrote in budget documents.
Nurses are more focused on ending the joint protocol requirement and the nursing center report argues that doing so would help fill this primary care gap. According to its analysis, if APNs were freed from this requirement and empowered to prescribe medication on their own there would then be enough primary care providers to meet the national per capita average in nine of the 13 New Jersey counties that now fall short.
Escalating illnesses, possible hospitalizations
“Residents of these counties are unable to obtain the needed primary care that could prevent escalating illnesses and possible hospitalizations,” said Schmidt of the New Jersey State Nurses Association, which has long supported eliminating collaborative agreements. “APNs would be able to provide the much-needed resources to these communities if barriers to full practice authority were removed.”
Advanced practice nurses hold graduate degrees and are trained to diagnose and treat acute and chronic illnesses; take health histories; order and interpret lab tests and x-rays; and provide physical examinations, immunizations, and supportive counseling. They must pass an exam to receive state certification. But to order medical devices or prescribe medications — a critical part of medical care — they currently need a collaborative agreement.
Mansor, the APN in Gloucester County, spends $7,200 a year on these agreements for herself and her staff. And she said it’s not easy to find a willing doctor; since 2008 she has had one retire and another encounter legal trouble and is now on her third collaborator. She occasionally calls him for advice, but also consults a range of other experts regularly — without any formal agreement.
“I could take that money and offer more benefits (to my employees), or nursing education,” Mansor said. “There’s a lot more I could do with that money.”
“The collaborative agreement is just causing barriers,” she added. “We could do a lot more without it.”