HPSA Program Did Not Affect Physician Shortages or Health Outcomes

Although health professional shortage area (HPSA) designations aim to improve access to care by alleviating staffing challenges, a Health Affairs study found that most HPSA counties remained physician shortage areas for at least ten years after their designation.

Poor distribution of physicians in underserved areas may be a driver of geographic disparities in healthcare access. The HPSA program encourages healthcare professionals to relocate to shortage areas by providing incentives such as student loan forgiveness or higher Medicare reimbursement.

Stakeholders have voiced concerns about the program, including questioning whether the algorithms effectively identify shortage areas, whether the incentives are strong enough to impact physicians’ decisions about where to practice, and whether the incentives are sufficient to address geographic inequities.

Furthermore, the significant number of shortage areas may reflect a nationwide shortage of physicians rather than unequal distribution.

Researchers out of Yale University used a publicly available data set of primary care HPSAs, the CDC Wide-ranging Online Data for Epidemiologic Research Compress Mortality files, Area Health Resources File data, and US census data to assess the impact of the HPSA program between 1978 and 2015.

They focused on the annual age-adjusted mortality rates and physician density in counties with an HPSA designation to measure the program’s effect.

The sample included 844 HPSA-designated counties and 844 matched control counties. Throughout the study period, HPSA designations had higher average mortality rates and lower physician density.

The primary analysis found no effect of HPSA designation on population-level mortality.

In HPSA-designated counties, the mortality rate went from 1,056 deaths per 100,000 county residents in the four years before HPSA designation to 989 deaths per 100,000 county residents in the four years after HPSA designation. Similarly, in the matched control counties, there were concurrent changes from 1,054 to 991 deaths per 100,000 residents. The adjusted difference-in-difference estimate was -5.92 deaths per 100,000 residents, which was statistically insignificant.

HPSA did not impact physician density either. The adjusted difference-in-difference estimate was a statistically insignificant -1.93 physicians per 100,000 county residents. In addition, 73 percent of HPSA-designated counties were still experiencing a physician shortage ten years after its designation.

Secondary analyses yielded similar results, finding no association between HPSA designation and changes in mortality rates or physician density.

The findings suggest that HPSA designations do not improve access to primary care physicians at the county level. Given this, the overall approach of the HPSA program may need to be adjusted, the researchers wrote.

However, changes like increasing the financial incentives could be hard to justify as there is slim evidence that the program is working or that better incentives would boost its effectiveness.

Other initiatives may be better off addressing the nationwide staffing shortages and focusing on long-term workforce challenges. For example, some states have expanded the role of advanced practice nurses and other healthcare professionals to meet the needs of residents in underserved areas.

To minimize primary care provider shortages and improve the efforts of the existing HPSA program, policymakers should consider refocusing HPSA-dependent programs toward attracting new medical graduates and encouraging them to practice in HPSAs, the researchers said.

Additionally, other types of healthcare providers should be able to serve as physician substitutes in underserved settings or the scope of practice of nurse practitioners or physician assistants could be expanded in these areas.