Primary care as delivered by physicians is an integral part of a quality, accessible, and affordable healthcare system. For decades, stakeholders have reported shortages or impending shortages of these types of physicians. With the enactment of the federal Affordable Care Act, Michigan’s decision to expand Medicaid, the aging Baby Boomers, and other policy, demographic, and cultural factors, now is a good time to reexamine the existing network of primary care physicians in Michigan.

Primary care physicians include physicians that serve as the first contact for patients and provide continuous and comprehensive treatment of all types of health conditions. Primary care physicians often take responsibility for the health of their patients even if they are further referred to specialists and may coordinate care for their patients on an ongoing basis. Primary care physicians typically serve in one of the following medical fields: family or general practice, internal medicine, pediatrics, obstetrics and gynecology, general surgery, or psychiatry.

Shortages of primary care services compromise patient access to sufficient and continuous health care and may drive prices for health care services upward. Additionally, the presence of more primary care physicians in a community is associated with a lower mortality rate indicating that quality of care may also be compromised if sufficient primary care is unavailable.[1]

Even though Michigan has a seen faster growth over the last decade in its share of primary care physicians relative to the population, many reports still point to existing and impending shortages. For example, because of the effects of the aging population, population growth, and insurance expansion, Michigan may need 12 percent more primary care physicians by 2030.^[2] However, other reports show that Michigan doctors are reporting available capacity for new patients and as few as only 12 percent are too full to accept new patients.^[3] These conflicting reports may support another view: that rather than a shortage, physicians are maldistributed nationally and statewide. This assertion proposes that Michigan has a sufficient total number of physicians but they are not practicing in places where they are most needed.

The United States Department of Health and Human Services’ Health Resources and Services Administration (HRSA) calculates shortage areas to indicate where primary care physician needs are greatest. The designations are based on geography, population characteristics, or facility designations. HRSA estimates that in 2015, Michigan has 299 shortage areas and that Michigan’s supply of primary care physicians only met 63.3 percent of need by the covered population. Wayne, Chippewa, and Montcalm counties have the highest number of shortage areas in the state.

To further assess the needs for primary care physicians in Michigan, CRC compared the actual ratio of active primary care physicians by field of practice in each county to a research-based ideal range. This analysis uncovered vast variation across counties in the sufficiency of their supply of primary care physicians. The shortages were not geographically isolated to certain parts of the state, but the northern half of the Lower Peninsula had a greater frequency of shortages. For example, statewide, Michigan has roughly the same share of internists as the national average, but within Michigan, these shortages are heavily concentrated in the northern half of the Lower Peninsula and the eastern half of the Upper Peninsula. Similarly, counties where the ratios of pediatricians and general surgeons to the population are below suggested targets are almost exclusively in the northern half of the Lower Peninsula and across the Upper Peninsula. In contrast, Oakland and Washtenaw counties have at least ten times the ideal physician-to-population ratio for pediatricians.

Overall, four counties had actual ratios of physicians-to-population that consistently fell below the recommended ranges for all the primary care fields CRC examined: Cass, Keweenaw, Lake, and Oscoda. Seven counties fell below suggested ranges in every field except family or general medicine: Alcona, Antrim, Gladwin, Kalkaska, Presque Isle, Roscommon, and Schoolcraft. The majority of these counties are located in the northern half of the Lower Peninsula. In contrast, 19 of Michigan’s counties had physician-to-population ratios that always fell within or above the suggested ranges.

Primary care physician shortages and maldistribution are caused by a variety of factors, typically stemming from demographic changes, state and federal policy, and the training, professional, and cultural environments for medical students and active physicians. Policies that address Michigan’s shortages and maldistribution should be designed to target these causes. The most promising solutions typically seek to either increase the supply of primary care physicians or decrease the demand for their services. Examples of state-level policy options that address primary care physician supply include:

• Addressing Medicaid reimbursement rates and provider payment systems to reduce the compensation differentials between primary care physicians and subspecialist physicians;
• Loan forgiveness programs for physicians who agree to practice primary care in high need areas;
• Working with medical schools to ensure that students more likely to enter primary care are applying and being admitted and developing programs to give medical students exposure to opportunities for practicing primary care and serving in underserved areas;
• Increasing graduate medical education funding and targeting funds to generate more primary care positions for residents; and
• Working with universities and local communities to develop strategies to retain medical students and residents in Michigan post-training.

Policies that alleviate the demand for primary care physicians can also be effective in ensuring Michigan residents receive adequate health services. These options include:

• Increasing the use of medical homes in the state, thereby creating a system where various providers coordinate services and can see more patients effectively;
• Expanding scope of practice requirements to allow non-physician clinicians to practice within the scope of their training to safely deliver healthcare services, as supported by evidence; and
• Investing in public health initiatives to improve the health of Michigan residents and reduce the need and demand for physician care.

Primary care is an integral part of an affordable and effective health care system. Policymakers, in collaboration with health care providers, universities, and other stakeholders can play an important role in coordinating a well-researched and integrated plan to help alleviate the state’s primary care physician shortages. The future of our public’s health relies on primary care services, provided from a variety of provider types, and needs the support of policymakers and citizens alike to reinstate a sense of value in primary care.

[1] Starfield, Barbara, Shi, Leiyu, Grover, Atul, and James Macinko. “The Effects of Specialist Supply on Populations’ Health: Assessing the Evidence.” Health Affairs, W5-97, 2005. content.healthaffairs.org/content/early/2005/03/15/hlthaff.w5.97.citation
^[2] Petterson, S.A.; Cai, A.; Moore, M.; Bazemore, A.; State-level projections of primary care workforce, 2010-2030. September 2013, Robert Graham Center, Washington, D.C.
^[3] Michigan Department of Community Health Survey of Physicians, Survey Findings 2012. Prepared by Public Sector Consultants Inc., January 2013.