Shortage of Primary Care Physicians and the rise of midlevel providers


Since the passing of the ACA, the healthcare workforce has dealt with an immense influx of newly insured patients requiring medical attention. It is estimated that 32 million people will be newly insured by 2019 as a result of the ACA (Carrier, Stark, & Yee, 2011). There is a gross inadequacy in professional healthcare worker distribution across different healthcare settings which may leave our nation ill-prepared for this new patient population. The biggest discrepancy exists in the fact that specialists outnumber general practitioners by nearly two to one (Barton, 2010). Whereas this trend is supported by the increased reimbursement rates received by specialists, it actually negatively affects the healthcare workforce by encouraging the emergence of specialists when in reality generalists are more direly needed. The ACA attempts to make up for these discrepancies by establishing incentives for primary care practitioners. An estimated $3.5 billion was invested by the ACA into the primary care provider bonus from 2011-2016, in which Medicare paid a 10% bonus over the established physician fee schedule for general care provided by primary care physicians, nurse practitioners, clinical nurse specialists, or physician assistants practicing family medicine, internal medicine, geriatrics, or pediatrics (Stone & Bryant, 2012).

One way in which primary care practices have been making up for this shortage of physicians is by utilizing physician extenders such as advanced nurse practitioners and physician assistants. The increasing independence and scope of practice of these midlevel providers also make these healthcare professionals a valuable resource that may help increase access to primary care. These midlevel providers often perform duties which overlap with those of physicians, including assessment, diagnosis, and treatment of patients, and both practice with “considerable clinical autonomy” (Morgan, Short, & Strand De Oliveira, 2011). Whereas the utilization of these midlevel providers in combined workforce planning appears to be part of the solution to the physician shortage, it has met several barriers in practice. These barriers include “lack of data on some professions, professional interest in protecting turf, competing agendas, and entrenched habits of state bureaucracies and professional organizations” (Morgan, Short, & Strand De Oliveira, 2011).

In the state of Florida, these midlevel providers have not yet achieved “full practice” status. Currently 21 states and the District of Columbia have granted nurse practitioners such freedom. In those full-practice states, NPs can treat patients independently, as well as open their own practices without physician supervision (Simmons, 2015). One crippling limitation on the nurse practitioner’s scope of practice in Florida is that she cannot prescribe controlled medications, and for that reason only physicians can see patients with complex mental health or behavioral issues in our pediatric primary care practice. Reimbursement rates for services rendered by midlevel providers are 80% of the physician fee schedule. However, considering the fact that these midlevel providers’ salaries are approximately half that of a physician, as well as that there are many more midlevel candidates than physician candidates applying for positions, hiring midlevel providers may be one of the best solutions to combating the current shortage of primary care physicians and increasing patient access to care. Additionally, areas that have shortages of primary care, dental, or mental health providers are designated as Health Professional Shortage Areas (HPSA) by the Health Resources and Services Administration (HRSA). Practices in those designated HPSA areas can qualify as National Health Service Corps (NHSC) sites, and healthcare providers employed by them then become eligible for student loan forgiveness. Our site is a designated NHSC site, and we have a great advantage in recruiting midlevel providers seeking loan repayment.

In conclusion, efforts must be made to encourage the education of more general practitioners, be they physicians, physician assistants, or nurse practitioners. The demand for these general healthcare professionals will only increase, and we need to be well-prepared to provide these services to the growing patient population. By involving midlevel practitioners in workforce planning and utilizing them at the peak of their education and productivity, physicians will be freed from these duties and therefore will be made available to tackle more complex cases which require their extended physician education and expertise. It is therefore crucial that the remaining states, including Florida, that have not yet granted midlevel providers “full practice” status reevaluate their decisions in order to increase patient access to greatly needed quality medical care.

About the Author:


Sonda Eunus, MHA

Sonda Eunus is the Founder and CEO of Leading Management Solutions, a healthcare management consulting company ( Along with a team of experienced and knowledgeable consultants, she works with healthcare practice managers to improve practice operations, train employees, increase practice revenue, and much more. She holds a Masters in Healthcare Management and a BA in Psychology.




Barton, P.L. (2010). Understanding the U.S. Health Services System. (4th Ed.). Chicago: Health Administration Press. ISBN-13 978-1-56793-338-3.

Bryant, N., & Stone, R. (2012). The impact of healthcare reform on the workforce caring for older adults. Journal of Aging & Social Policy, 2012, 24:188–205.

Carrier, E., Yee, T., Stark, L. (2011). Matching supply to demand: addressing the US primary care workforce shortage. National Institute for Healthcare Reform.

Morgan, P., Short, N., & Strand De Oliveira, J. (2011) Physician assistants and nurse practitioners: a missing component in state workforce assessments. Journal of Interprofessional Care, 2011, 25: 252–257.

Simmons School of Nursing and Health Sciences. (2015). Where can nurse practitioners work without physician supervision? Retrieved from:


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