Former CDC director issues special report on the U.S. physician shortage

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The United States faces a shortage of physicians, a crisis which is only expected to worsen as baby boomers grow older—the population of individuals 85 years of age or older is expected to triple over the next three decades. Recent projections estimate worsening shortages, both across disciplines and geographic areas. Rochelle Walensky, MD, MPH, former director of the U.S. Centers for Disease Control and Prevention (CDC), co-authored a special report addressing the physician shortage, alongside Nicole C. McCann, BA, a PhD candidate in health services and policy research at Boston University School of Public Health.

In the report, published Wednesday in The New England Journal of Medicine, Walensky and McCann explain the reasons for the shortage and offer potential solutions, efforts which, as they note, “will only be successful if implemented within the wider context of health care reform…”

According to the report, the World Health Organization’s (WHO’s) definition of “adequate medical staff” requires at least 250 health professionals per 100,000 population. The U.S., on average, has 297 physicians per 100,000 population, but that ratio varies widely across the country, and comes in considerably lower in Health Professional Shortage Areas (HPSAs). The ratio in Mississippi, for example, is 204 physicians per 100,000 population. Currently, it’s estimated that 76 million and 123 million Americans live in regions identified as HPSAs for primary care and mental health, respectively. Despite several incentives offered by the Centers for Medicare and Medicaid Services (CMS) intended to increase the number of physicians practicing in HPSAs, there has been no significant effect on mortality rates or physician density in these areas.

By 2050, there will be an estimated 17.4 million Americans 85 years of age or older. By 2036, the National Center for Health Workforce Analysis projects a deficit of approximately 140,000 physicians. Additional projections include shortages of:

• 68,000 primary care providers, including:
  • 33,100 family medicine physicians
  • 30,100 internists
• 7,900 cardiologists
• 6,600 obstetrician-gynecologists

Contributing factors to the physician shortage

In the report, Walensky and McCann identified specific factors influencing the shortage of U.S. physicians, including:

• Medical school entry: Despite a modest increase in medical school enrollment over the past decade, significant disparities persist. Underrepresented racial and ethnic groups and rural students, especially those from minority backgrounds, remain critically underrepresented, a gap which, according to the report, is likely to widen following the 2023 Supreme Court ruling on affirmative action.
• Graduate medical education bottleneck: Graduate medical education (GME) remains a bottleneck, with federally funded residency slots failing to align with population health needs. Although 15,000 new slots were added in the past 20 years, rural areas received only 2% of Medicare-funded positions in 2020, exacerbating disparities in care distribution.
• Variation in physician location: As a result of the prevalence of medical schools and training positions in urban areas, many physicians tend to continue to practice in these areas, often drawn by higher per capita gross domestic product (GDP) and quality-of-life factors. Rural practice is strongly linked to having a rural origin, but attracting physicians to practice in these areas remains difficult. The 2022 Dobbs v. Jackson Women’s Health Organization decision has further influenced geographic preferences, with 82% of surveyed physicians favoring states that preserve abortion access and 76% responding that they would not move to states that have legal limitations on abortion and emergency contraceptives.
• Generational differences: Older physicians, nearing retirement, who trained for years in a fee-for-service era, produce twice as many relative value units (RVUs) annually as younger physicians, who prioritize patient-centered care. With nearly half of physicians over the age of 55, retirements outpace replacements, especially in rural areas, worsening shortages as RVU demands per patient continue to grow.
• Physician exodus: Physician burnout, worsened by the COVID-19 pandemic and affecting younger physicians at a higher rate, drives many to leave clinical practice, retire early or cut back on work hours, further straining the workforce.

Proposed solutions

Walensky and McCann offer a list of potential solutions to the worsening physician shortage. They note that, for any solutions to be effective, coordination and funding are required to enhance reliable monitoring to evaluate policy efficacy. Their potential solutions include:

• Supply and demand issue: Preventative efforts that target inequities and social determinants of health can reduce future demand, while diversifying the workforce with advance practice providers and team-based care models improves efficiency. However, increasing physician supply in high-need areas remains essential.
• Reducing the price of attendance/free medical school: In 2018, the New York University (NYU) Grossman School of Medicine was the first medical school in the U.S. to announce free tuition. Programs like this aim to reduce student debt and attract students from underrepresented backgrounds and rural areas. However, early results suggest limited success, as NYU saw a decline in Black student enrollment and only 14% of graduates entered primary care—well below the U.S. average of 30%.
• Other incentives: Programs including the National Health Service Corporation (NHSC) Scholarship Program offer scholarships and loan repayment up to $75,000 to attract primary care physicians to practice in underserved areas, proving more effective than broader initiatives like Public Service Loan Forgiveness.
• Diversity initiatives: Initiatives including prioritizing applicants from community colleges or those committed to serving underserved areas, can help address the physician shortage. Expanding mentorship programs, opening more medical schools in rural areas and integrating medical education into undergraduate programs, particularly at Historically Black Colleges and Universities (HBCUs), are key initiatives.
• Decreasing medical education production costs: With rising medical education costs, equally competent pathways to medical expertise is increasingly important. Competency-based education, focused on skill progression rather than time, along with a national credentialing process, could help reduce expenses. Although programs including free tuition and loan forgiveness reduce student debt, they don’t address system-level medical education costs and may even raise them.
• GME and international medical graduate reform: Efforts to expand GME positions are critical, but recent reforms have disproportionately benefited urban areas. Proposed bills to add rural-focused positions are stalled. Rural rotations have shown promising results in attracting physicians to underserved areas. International Medical Graduates (IMGs), although they modestly reduce the domestic physician shortage, match to residency at lower rates than U.S.-trained physicians and face visa restrictions.
• Addressing burnout: Efforts to combat physician burnout, funded by the American Rescue Plan Act, resulted in a decline in burnout rates below 50% in 2023, for the first time in four years. Possible solutions include reducing administrative tasks, promoting physician well-being and leveraging technological innovations which reduce administrative burdens, like digital scribes, automated billing and advanced data management.
• Compensation reform: In 2017, primary care providers earned significantly less than specialist care providers, with averages of $247,300 compared to $399,300. Despite some wage increases since the passage of the Affordable Care Act (ACA), the pay gap remains a key issue in addressing physician workforce challenges. Compensation reform, including changes to Medicare’s fee-for-service model and revisiting budget-neutral payment laws, is critical to balancing pay between specialties and improving primary care initiatives. However, these changes face resistance from specialty groups and Congress.

Walensky and McCann emphasized the urgency for policymakers and the health care industry to address the physician shortage, writing: “One thing is certain: the measures to date have not been applied at the intensity needed to avert the looming shortage crisis. This call to meaningfully address physician shortages is urgent.”