Amid mounting evidence that a nationwide healthcare workforce shortage is accelerating — with 20 states reporting scarcities of physicians and nurses — HRSA is convening a summit of 300 leading experts in Washington this spring.

“We gather here today with some urgency,” HRSA Administrator Elizabeth Duke told a planning team last month in Washington DC, where 30 agency analysts, bureau chiefs and national experts met to chalk out an agenda for the larger conference in June.

“This is a real challenge for us,” Duke told the group, “and we as a nation need to face the facts” that a shortage of at least 100,000 doctors and a million nurses is imminent.

Planning for the summit comes against a backdrop of calls for an overhaul of the national health care system and increased need as unemployment has caused thousands to lose insurance benefits in recent months.

“There are shortages in primary care, everywhere,” confirmed Associate Administrator Marcia Brand of the Bureau of Health Professions, “and they are growing. We think it’s not too late for primary care medicine, but there are a lot of folks out there who say it is...that we won’t be able to turn this around in time.”

“It’s the number one issue” for the 1,200 HRSA-supported health centers across the country and the 8,000 physicians who work in them, said Jim Macrae, associate administrator for the Bureau of Primary Health Care. “Especially if you’re the only provider in a remote community, or one of only two or three in a practice, you’re being asked to do it all. They’re getting more and more pressure...with no new staff.”

The nation’s largest provider

Bruce Behringer of East Tennessee State University, who moderated last month’s planning meeting, said the HRSA-funded health centers are a “unique microcosm” for studying the workforce crunch — and a linchpin in any move toward universal care.

With more than 7,000 clinical locations in every state and U.S. territory, the HRSA system is now “the largest primary care network in the country,” Behringer noted. Tending to a patient base of 16 million people, the health centers eclipse the largest private provider, California-based Kaiser Permanente, which serves 9 million clients.

In the past six years, HRSA health center grantees have added 3,200 physicians and more than 2,000 nurse-practitioners, physician assistants and nurse-midwives for a total of 13,000 frontline primary health professionals. At the same time, the health centers have generated an estimated $12.6 billion in local economic activity — and, when both direct and indirect effects are factored, 143,000 jobs.

But the centers are in the grip of an ongoing recruitment and retention crisis, as they operate in some of the most geographically isolated and economically distressed communities in the country. Four in 10 patients are uninsured. One third are children.

In the wake of a dramatic expansion and a 60 percent increase in their patient population, health centers have almost 6,000 clinical vacancies that have proven hard to fill. To reach the patient-to-clinician ratios currently in use by private HMOs, the HRSA grantees would need to hire five times that number, or 31,000 practitioners, according to a recent Bureau of Health Professions analysis.

Meanwhile, families in 1,700 rural counties and distressed inner-city communities nationwide confront a current shortage of almost 8,000 physicians, 7,000 dentists and 1,800 mental health professionals.

With the workforce shortages, Macrae said, starting salaries have climbed so high that some communities could find themselves “priced out” in the mounting competition to attract and keep clinicians.

“The salary demands are off the charts with historic norms,” he said, “and it’s changing those long-standing relationships between physicians and their communities,” as healthcare professionals entertain recruitment overtures and ever-rising salary offers.

Underlying causes

At HRSA’s Bureau of Clinician Recruitment and Service, Associate Administrator Rick Smith said the workforce numbers have steadily “tipped in the wrong direction” over the past 10 years — driven by demographic forces that challenge long-held academic assumptions about how many doctors, nurses and dentists the nation would need.

For decades, forecasts of the future healthcare workforce requirements of the country had been notoriously inconsistent, and often wrong, hampered by a variety of factors:

Poor data collection by state licensure and labor boards; long lag times between Census counts; and the general availability of foreign-trained healthcare workers eager to accept visas to fill localized shortages.

“Now, we’re talking about 47-49 million people in the categories of medically underserved, or unserved,” Smith said, “people who are almost completely without access to routine health care.

“Now, figure in the downstream consequences of the current economy: More people losing their jobs, losing their health care coverage, which means losing their access to preventative care. To that, add the thousands of returning veterans who are going to need unique health services, plus their families; and, of course, millions of aging Baby Boomers.

“Then, when you turn and look at the pipeline of students who are currently in medical schools, nursing programs, dental programs — and the ones who are in the waiting line behind them for admission — it’s nowhere near enough to meet current demand, much less the surge that’s coming.”

For Smith, and his counterparts in HRSA’s workforce-centered bureaus, the scenario represents a “perfect storm.”

Hit at both ends

“For all of the concern about physician shortages, and there is serious cause for concern there,” said Brand, “we are looking at a clear and present crisis in nursing. We have 98,000 people per year in this country dying because of medical errors, and the people we count on most to prevent those errors are the nurses on the ward with their hands on the patient charts.

“But a million-nurse shortage is not going to be made up in any kind of near-term timeframe,” she said.

“It’s not as simple as flipping a switch,” Smith added.

Here’s why:

Government-sponsored scholarship, student loan and academic debt repayment programs designed to encourage students to pursue careers in medicine and nursing have shrunk in recent decades.

Last year, 14,000 students applied to HRSA for financial assistance, for example, but the agency was only budgeted to grant one of every 7 requests. The shortfall was worst in nursing programs, where the agency received 9,000 applications for 600 available slots, a ratio of 15 to 1.

By the 1990s, what was originally forecasted to be a surplus of nurses turned into a rout, as thousands of women left the profession over pay equity, work schedule issues, and better opportunities in other industries — “particularly in IT, as the Tech Boom really took off,” Brand noted.

“There are 200 health disciplines in which we know we have shortages,” Brand said. “But we have not begun to quantify dozens of others in which women have traditionally been the backbone of the workforce — like dieticians, physical therapists, dental assistants, certain lab specialties. We’d be naive to think, given what we’ve seen in nursing, that the current generation of women isn’t feeling the same pressure to move on, or to avoid those occupations in the first place.”

With the conflicting workforce data on hand — or lack of data — through this period, funding for healthcare career development programs dwindled, leading colleges and universities to downsize (or close) their schools of medicine, dentistry and nursing. At the same time, shrunken faculties were rapidly aging.

“This problem goes back 15, 18 years ago, or more,” Smith said, “when all the projections by the medical associations and allied professional groups were that we would have plenty of healthcare workers for years to come. In fact, we were going to have too many nurses.

“By the time anyone realized we were headed for the rocks, there were fewer programs, smaller faculties and less overall capacity to produce (clinicians and nurses) in large numbers if we ever needed them.”

The result: an admissions log jam as students confront long waiting lists to get into medical, dental and nursing schools. In short, graduations are not keeping pace with retirements across many medical professions.

The average age of a practicing nurse, 46.8 years old, is now at its highest level since HRSA first began keeping data on the profession in 1980.

“Further, when you consider that upwards of a third of the workforce in many medical specialties is now over 50 years of age, you can see that time is not on our side,” said Duke in a speech last July in Phoenix to academic counselors, deans and professors. “Our workforce is getting hit at both ends.”

Tom Morris, associate administrator for the Office of Rural Health Policy, summed up the current dilemma this way: “We know there’s a large cohort of doctors and nurses who are headed for retirement — and that includes our university professors — and we know we don’t have the people in the pipeline to replace them. Any effort to reform health care can’t go forward without talking about this problem first.”

Said Smith: “We’re starting to see patient-to-staff ratios in some places that are almost frightening.”

A ruthless pecking order

Mary Wakefield, associate dean of the School of Medicine at the University of North Dakota — a state in which starting salary and benefits packages for graduating general physicians can exceed $150,000 — said the workforce shortages have accentuated a ruthless competitive pecking order in healthcare.

At the top, big city medical centers and private plan providers are able to offer the highest salaries and most attractive living arrangements for young doctors, dentists, nurses and their families.

In the middle of the marketplace, Wakefield said, a wide range of government- supported providers — federal and state prison systems, the Veterans’ Administration, the health centers — often have an edge in recruiting young professionals because of their relative proximity to attractive suburban communities, high-performing schools and the cultural amenities of downtown life.

At the bottom, however, are hundreds of rural enclaves, agricultural communities and Native American reservations that lack the population bases, local economies, or countervailing lifestyle benefits to attract and maintain their own healthcare providers.

Approximately 20 percent of the U.S. population lives in rural areas, spread out over 80 percent of the nation’s land mass, Morris reminded his counterparts at the planning conference in December.

“If urban areas are having their issues with workforce recruitment,” Wakefield warned, “that absolutely impacts the rural areas and patient care in those communities,” which already are at a competitive disadvantage.

Hilda Heady, an associate vice president for rural health at West Virginia University, added that there other unforeseen pitfalls working against rural communities as they struggle to hold onto primary care practitioners.

“One of the things that’s happening now is that we are finding that our health centers are losing primary care doctors and dentists to the federal prison system, which has been moving into rural areas, or to the VA, which is doing more rural outreach,” Heady said.

“These are federal dollars that are supporting the workforce for all of these agencies, but the pay scales are different and the benefits are different. So it’s out of balance. It turns into musical doctors. Just when you get one, they’re getting ready to go away” to work for another government entity or private plan provider offering better pay, more generous benefits and greater opportunities for professional advancement.

“We’re competing against ourselves, in more ways than one,” she said.