Accepted for Publication: May 25, 2021.
Published: July 30, 2021. doi:10.1001/jamanetworkopen.2021.18836
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Scannell CA et al. JAMA Network Open.
Corresponding Author: Christopher A. Scannell, MD, PhD, Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, 1100 Glendon Ave, Ste 900, Space #23, Los Angeles, CA 90024 (ude.alcu.tendem@llennacsc).
Author Contributions: Dr Scannell had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Scannell, Quinton.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Scannell, Jackson.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Scannell, Jackson.
Obtained funding: Scannell.
Administrative, technical, or material support: Scannell, Tsugawa.
Conflict of Interest Disclosures: Dr Scannell reported receiving support from the National Clinician Scholars Program, University of California, Los Angeles (UCLA) and the VA Office of Academic Affiliations through the National Clinician Scholars Program. Dr. Quinton reported receiving support from the National Clinician Scholars Program, UCLA. Dr. Tsugawa reported receiving grants from the National Institutes of Health (NIH)/National Institute on Minority Health and Health Disparities and the NIH/National Institute on Aging for other work not related to this study. No other disclosures were reported.
Disclaimer: The information, content, and/or conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by the US Department of Veterans Affairs, US Health Resources and Services Administration, US Department of Health and Human Services, National Institutes of Health, or the US government.
Additional Contributions: We thank Janelle McCutchen, PhD, MPH, from the US Health Resources and Services Administration for sharing her institutional knowledge about the PC-HPSA designation process and Shortage Designation Modernization Project implementation and providing feedback concerning our research findings. We would also like to thank Carlos Oronce, MD, MPH, from the National Clinician Scholars Program, UCLA for his insightful feedback on the manuscript. They did not receive compensation for their contributions to this work.
Received 2021 Mar 16; Accepted 2021 May 25. Copyright 2021 Scannell CA et al. JAMA Network Open. This is an open access article distributed under the terms of the CC-BY License.This cross-sectional study evaluates whether the Patient Protection and Affordable Care Act (ACA) Shortage Designation Modernization Project is associated with changes in primary care health professional shortage area (PC-HPSA) designations.
Primary care physician (PCP) supply in the United States is unequal and diverging, with PCP density in urban counties double that of rural counties, and more than 50% of rural counties losing PCPs in the past decade. 1 To help reverse this pattern, the federal government provides incentives, such as loan repayment programs, bonus payment programs, or programs to recruit noncitizen foreign medical graduates, for physicians practicing in primary care health professional shortage areas (PC-HPSAs), which are federally designated areas with inadequate PCP access. 2 A county may be designated a partial-county PC-HPSA if populations or facilities with high needs exist at a subcounty level or a full-county PC-HPSA if the entire county meets a minimum population-to-PCP ratio of 3000 to 1 with high need or a ratio of 3500 to 1 in the absence of high need. 3 These designations are time intensive to document and thus are updated infrequently, leading to inaccurate designations and misaligned incentives for physicians. 4 The Shortage Designation Modernization Project (SDMP) was implemented in 2014 to streamline designations as part of the Patient Protection and Affordable Care Act. 5 Whether SDMP implementation is associated with changes in PC-HPSA designations and whether these changes accurately reflect county-level physician supply are unknown.
In this cross-sectional study, we used the Health Resources and Services Administration Area Health Resources Files and extracted county-level PC-HPSA designations, population, and PCP counts (originally derived from the American Medical Association Physician Masterfile) from 2010 to 2018. Data were analyzed from November 2020 to April 2021. The University of California, Los Angeles Institutional Review Board deemed this study exempt from review and waived the requirement for informed consent based on the use of publicly available, deidentified data. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline was followed.
Temporal trends in PC-HPSA designations and population-to-PCP ratios were examined. Segmented regression analysis for 2 periods, before SDMP implementation (2010-2013) and after SDMP implementation (2015-2017), excluding the implementation year (2014), was used to examine the association between SDMP implementation and population-to-PCP ratio. Covariates included year and county PC-HPSA designation and their interaction with the policy change. Projected population-to-PCP ratios in 2015 were compared in the presence and absence of the SDMP. All statistical tests were 2-sided, with a significance threshold of P < .05 and were conducted using Stata/SE, version 16.0 (StataCorp, LLC).
There were 3137 counties with complete data across the observational period (538 non-PC-HPSAs [17%], 1334 partial-county PC-HPSAs [42%], and 1265 PC-HPSAs [40%] beginning in 2010). County-level designations changed between 2010 and 2018, with many full counties redesignated as partial-county PC-HPSAs after SDMP implementation ( Figure 1 ). The number of non–PC-HPSA and full-county designations immediately before (2013) and after (2015) SDMP implementation decreased by 8% and 32%, respectively. The number of partial-county PC-HPSAs increased by 29% ( Figure 2 A), with an increase in the median population-to-PCP ratio for full-county PC-HPSAs greater than the minimum required ratio of 3000 to 1. The population-to-PCP ratio for partial-county or non-PC-HPSAs remained constant ( Figure 2 B). Segmented regression estimates aligned with the descriptive findings: a significant increase was found in the population-to-PCP ratio in full-county PC-HPSAs after implementation of the SDMP compared with before implementation (difference: 293 person-to-PCP increase [95% CI, +176 to +410]; P < .001). No other significant findings were found.