Manu M. Mathew, M.D.
This paper proposes provisional licensing for assistant physicians as a potential solution to New Jersey’s physician shortage, emphasizing its benefits in improving access to healthcare in underserved areas and enhancing the skills of assistant physicians. The role of collaborative efforts among policymakers, healthcare organizations, and assistant physicians is highlighted. Additionally, the paper recommends several crucial steps for policymakers to address the physician shortage effectively. These recommendations include fast-tracking the creation of the Assistant Physician License, defining clear qualifications and training requirements for assistant physicians, streamlining and simplifying the licensing application process, and exploring reciprocity and acceptance of Assistant Physician licenses from other states. By implementing these recommendations, New Jersey can rapidly strengthen its healthcare workforce, increase access to medical care, and effectively alleviate the severe effects of the physician shortage in underserved regions.
New Jersey, like many states in the U.S., is facing a severe physician shortage. Population expansion, an aging population, and the frequency of chronic illnesses all contribute to a rise in the need for medical care.
This has led to a shortage of healthcare providers, particularly physicians, which poses significant challenges to the state’s healthcare system. ‘The health care cluster contributed over $44 billion to the Gross Domestic Product in 2020, roughly 8.2 percent of all output.’ However, The New Jersey Council of Teaching Hospitals report argues that the state currently has a deficit of around 2,800 physicians, and the situation is expected to worsen in the coming years.
This scarcity is felt most strongly in underserved and rural regions, where medical care is scarce. The lack of adequate healthcare services in these areas has significant implications for the health outcomes of the state’s residents.
In addressing this pressing issue, this paper advocates for the introduction of provisional licensing for assistant physicians in New Jersey. Assistant physicians, who hold medical degrees but have not yet completed residency training, can play a pivotal role in bridging the physician gap in underserved areas. To mitigate the severe physician shortage, we recommend fast-tracking the creation of the Assistant Physician License, defining clear qualifications and training requirements for assistant physicians, streamlining the licensing application process, and exploring reciprocity and acceptance of Assistant Physician licenses from other states. These measures, if implemented, have the potential to strengthen New Jersey’s healthcare workforce, increase access to medical care, and improve healthcare outcomes for all residents.
According to HRSA (Health Resources and Services Administration) statistics, there is a critical shortage of medical professionals in the New Jersey State. There are two counties in New Jersey that score less than 50 on the Index of Medical Underservice: Mercer County and Camden County. Passaic County is only slightly higher than 50 (50.1). These numbers highlight the critical need to address healthcare shortages and the significance of initiatives like the Assistant Physician Program in increasing access to healthcare in medically disadvantaged areas.
As stated earlier, New Jersey had a deficit in the number of physicians. The situation is further complicated by factors such as population growth, an aging population, and the prevalence of chronic illnesses, which all contribute to the rising demand for medical care. In order to keep up with demand, the present number of primary care providers in New Jersey (6,236) will need to expand by 1,116 by 2030, or 17%. The population to primary care provider ratio is currently 1409:1, which is slightly lower than the median of 1463:1. It’s worth noting that increased demand for primary care services accounts for 33% (370 PCPs) of New Jersey’s physician shortage, while population growth accounts for 54% (607 PCPs), and an increase in the number of people who are covered due to the Affordable Care Act accounts for 12 percent (139 PCPs) of the shortage.
Source: Data from NJ physician workforce report
In 2030, the Northeast region is projected to have approximately 371.8 physicians per 100,000 population, whereas the rest of the U.S. is expected to have 329.4 physicians per 100,000 population. These projections, sourced from ‘The Complexities of Physician Supply and Demand: Projections from 2018 to 2033’ by AAMC (April 2021), underscore the disparities in physician availability between the Northeast and the rest of the country.
Compared to the rest of the country, the projected forecast for 2030 appears relatively more favorable for the Northeast region. However, it is evident that addressing the physician shortage in New Jersey will necessitate innovative solutions and concerted efforts from policymakers, healthcare organizations, and medical professionals.
In 2018, there was a substantial divide in the types of physicians working in the United States, with far more specialists than primary care physicians in active practice. The Health System Tracker reports that in 2018, specialists made up a significant proportion of the total number of U.S. physicians. This development has consequences for the equitable allocation of healthcare services, since medical professionals increasingly specialize in treating just a narrow range of illnesses. This imbalance between specialists and generalists in the healthcare workforce in the United States as a whole should be taken into account when assessing the state of healthcare in New Jersey. The state of New Jersey, like many others, is experiencing a physician shortage, and it will be easier to identify and address this problem if the public has a better grasp of this discrepancy. When trying to achieve a more equitable distribution that places a premium on primary care, it is essential that policymakers evaluate the make-up of the medical workforce. Primary care physicians play a pivotal role in the healthcare system, serving as the first point of contact for patients, addressing a wide range of health issues, and coordinating comprehensive care. Their role in promoting preventive care, early intervention, and cost-effective healthcare cannot be overstated. Therefore, fostering a balanced healthcare workforce with a strong emphasis on primary care is vital to ensure accessible, high-quality healthcare services for all.
From the chart above, while New Jersey is grappling with a critical deficiency of generalist physicians, it’s essential to note that the situation is exacerbated when compared to other countries on the list. These countries not only maintain a higher physician-to-patient ratio overall but also possess a more favorable ratio of generalists to patients. Thus, our deficiency of generalists is even worse than it first appears, underscoring the urgency of implementing effective solutions to bridge this gap and ensure comprehensive healthcare access for our population.
The research paper ‘Health of US Primary Care: A Baseline Scorecard,’ published by the Milbank Memorial Fund, draws attention to alarming developments in the primary care physician workforce in the United States. It has been shown that the number of primary care physicians in the United States is decreasing, and there are signs that access to primary care services is becoming more unequal, with disparities in availability disproportionately affecting underserved and rural communities. This development has far-reaching effects on healthcare provision and accessibility on a national scale. The figure below is copied from the Milbank study and illustrates primary care physician recruitment by state in 2020. New Jersey’s recruitment falls in the range of 19.4 to 20.6%– well below that of other more darkly shaded states in the map where as much as 46.7% of new physicians are entering primary care. This deficit has only worked to exacerbate primary care shortages in the state.
Discussion of the implications of the findings for New Jersey’s healthcare system
The findings of the New Jersey Council of Teaching Hospitals’ report on the physician workforce shortage in the state have significant implications for New Jersey’s healthcare system. The report highlights the urgent need to address the shortage of physicians, particularly in underserved and rural areas. By analyzing data and statistics relevant to NJ, it becomes evident that the physician shortage in New Jersey has far-reaching consequences for the healthcare system, including impacts on access to care, quality of care, and healthcare costs.
Access to Care
The report indicates that the physician shortage in New Jersey has resulted in limited access to care. This can lead to delayed or inadequate medical treatment for patients, resulting in negative health outcomes. According to data from the New Jersey Department of Health, approximately 25% of the state’s population resides in underserved areas with limited access to primary care services. This can lead to increased emergency department visits, higher hospitalization rates, and increased healthcare costs. According to the data from the Robert Graham Center – Policy Studies in Family Medicine and Primary Care, a comparison of the number of physicians per capita in New Jersey is below the national average. As per the chart, while New Jersey’s overall PCP ratio of 73 PCPs per 100,000 persons is comparable to the national average of 76 PCPs per 100,000 persons, there may be specific areas within the state where the PCP ratio is significantly lower than the national average. Based on the data from the Graham Center report, New Jersey should prioritize regions with lower PCP ratios for targeted interventions to address physician shortages. This could include measures such as targeted recruitment efforts, incentive programs, and policy initiatives aimed at increasing the number of PCPs in these areas.
Source: (Robert Graham Center – Policy Studies in Family Medicine and Primary Care, a comparison of the number of physicians per capita in New Jersey to the national average.)
Quality of Care
The shortage of physician in New Jersey has a major effect on the quality of treatment available to residents. In this section, we examine the consequences of this shortage in further detail:
When physicians are few, patients may have to visit different specialists for their care, disrupting the continuity of their treatment. Care continuity is essential for the efficient management of chronic illnesses and the avoidance of medical mistakes.
The HCA Hospital performance report 2022 revealed that the incidence of medical mistakes, such as prescription errors and misdiagnoses, was higher in locations with a deficit of physicians compared to places with a sufficient physician workforce in New Jersey. This increase in medical errors can be attributed to the increased workload and stress on healthcare providers in underserved areas, which may result in compromised patient care and higher instances of diagnostic and prescription-related mistakes.
Due to the aforementioned difficulties, patient satisfaction rates tend to be lower in underserved regions. The New Jersey State Policy Lab in collaboration with the Eagleton Institute Survey found that dissatisfaction among patients was regularly 26% lower in underserved locations compared to those with adequate access to doctors.
Better health outcomes and less health inequities are seen in regions with a greater concentration of medical professionals. Hospitalizations, chronic illness complications, and premature deaths are more common in New Jersey’s disadvantaged neighborhoods because of a lack of doctors.
These numbers and anecdotes highlight the crucial need to take a holistic approach to resolving New Jersey’s physician shortage. It is not enough to just increase the number of doctors available to patients, particularly in underprivileged regions; rather, we must also work to improve the quality of treatment provided, lessen the likelihood of preventable medical mistakes, and ultimately boost health outcomes for the state’s population as a whole.
The physician shortage in New Jersey can also have significant cost implications for the healthcare system. Patients may resort to seeking care in more expensive settings, such as emergency departments, due to limited access to primary care physicians. This can result in increased healthcare costs for both patients and the healthcare system. This increased utilization of emergency departments can result in higher healthcare costs for both patients and the healthcare system.
Furthermore, the cost of recruiting and retaining physicians in underserved areas of New Jersey can be higher due to the challenging practice environment and the need for incentives to attract physicians to these areas. Review of Physician and Advanced Practitioner Recruiting Incentives 2022 (2022) shows that the cost of incentives and bonuses for recruiting and retaining physicians in underserved areas can range from $30,000 to $50,000 per physician annually. These additional costs further highlight the impact of physician shortage on healthcare costs in the state.
Missouri has implemented innovative solutions to tackle the issue of physician shortages, especially in underserved areas. One successful program in the state is the assistant physician program, established in 2014.
The assistant physician program enables medical school graduates who have not completed a residency program to deliver medical services in rural and underserved regions under the supervision of licensed physicians. Based on the Association of American Medical Colleges data, by 2020, 24 percent of Missouri’s medical school graduates had been retained in the state.
Source: Missouri Hospital Association (2018). Primary Care Physician Status Report.
The success of this program showcases the potential of innovative solutions to address similar challenges in other states. As other states grapple with similar healthcare access issues, the Missouri model serves as a promising example of how innovative programs can make a meaningful impact in mitigating physician shortages.
Comparison of Missouri’s provisional license program to New Jersey’s current licensing process
|Missouri’s Provisional License Program||New Jersey’s Current Licensing Process|
|Allows medical graduates who have not yet completed a residency program to practice as assistant physicians in underserved areas||Requires completion of a residency program for medical licensure|
|Requires supervision by a licensed physician||Does not currently have a similar program for medical graduates|
|Designed to increase access to healthcare in underserved areas||Does not specifically address the issue of physician shortages in underserved areas|
|Has been effective in recruiting and retaining physicians in underserved areas||No comparable data available for New Jersey|
The data in the table is based on a comparison of the current licensing processes in Missouri and New Jersey as of 2023. The licensing requirements and processes are subject to change over time. This comparison is not exhaustive. There may be additional differences between the two states’ licensing processes beyond those outlined in the table.
Analysis of the potential benefits and drawbacks of implementing provisional licensing in New Jersey
From recent data from the New Jersey Department of Health (2019), the majority of the state’s population lives in areas designated as medically underserved, with limited access to primary care providers. Effecting provisional licensing could help bridge this gap by allowing assistant physicians to provide care in these underserved areas, potentially improving healthcare access for vulnerable populations. This is particularly relevant as studies have shown that increased access to primary care is associated with improved health outcomes, reduced healthcare costs, and increased patient satisfaction.
Furthermore, the New Jersey State Board of Medical Examiners reported that the state has been facing a shortage of primary care physicians, especially in rural and urban areas. This shortage has been exacerbated by factors such as an aging population, increased demand for healthcare services, and limited availability of healthcare providers in certain geographic regions. A provisional licensing program could help address this shortage by allowing assistant physicians to practice under supervision and contribute to the workforce, particularly in areas where there are limited practicing physicians. This is supported by evidence from other states that have implemented provisional licensing programs for assistant physicians, such as Missouri. (Missouri State Board of Registration for the Healing Arts, 2019).
According to the available statistics, New Jersey has a problem keeping physicians who have finished their residencies there. From 2008-2017, just 45.2% of physicians who finished their residency in New Jersey are now working there, while 54.8% have left the state altogether. This indicates a substantial departure of state-trained physicians, which may exacerbate the current medical shortage. New Jersey has a problem keeping a large chunk of its educated workforce, despite its high output of medical school graduates. There is a clear need for effective ways to increase retention and foster an atmosphere favorable to physicians establishing and maintaining careers in New Jersey, given the high rate at which doctors leave the state after finishing their training.
There is a lack of the necessary facilities and resources for assistant physician to do their jobs in rural parts of New Jersey. The inability of Assistant Physicians to connect with specialists and deliver complete treatment is hindered in 15% of rural healthcare institutions, according the New Jersey Rural Health Focus Group Report. In addition, 20% of rural hospitals said they lacked essential diagnostic equipment, which negatively impacted both diagnostic precision and the quality of treatment provided to patients.
In addition, there may be legal and liability challenges associated with implementing provisional licensing. Assistant physicians practicing under provisional licenses may face issues related to malpractice insurance and liability coverage, which could potentially impact their practice and career. These challenges may need to be addressed through appropriate regulations and policies to ensure that assistant physicians are adequately protected and patients’ interests are safeguarded.
Moreover, there may be professional and stakeholder concerns related to scope of practice and competition. Some physicians and other healthcare providers may raise concerns about the potential overlap or encroachment on their practice areas. This may require careful consideration of scope of practice regulations, collaboration with other healthcare professionals, and stakeholder engagement to address potential conflicts and ensure a collaborative and coordinated approach to healthcare delivery.
Summary of key findings and arguments
The physician shortage in New Jersey is a significant challenge, particularly in underserved areas, and poses barriers to accessing timely and quality healthcare for vulnerable populations. Assistant Physicians have emerged as a potential solution, as shown by the comparison with Missouri’s provisional license program. They have the potential to improve access to healthcare, reduce disparities, and increase patient satisfaction. Evidence from other states and national/international models supports the implementation of provisional licensing for Assistant Physicians in New Jersey, showing positive outcomes such as increased availability of healthcare services, improved patient outcomes, and enhanced workforce diversity. However, there are potential challenges related to scope of practice, supervision requirements, and conflicts with medical associations that need to be carefully addressed. Collaborative efforts among policymakers, healthcare organizations, and stakeholders are crucial to implement evidence-based strategies that effectively address the physician shortage and improve healthcare access for all residents of New Jersey.
Recommendations for policymakers and next steps for addressing New Jersey’s physician shortage
The findings and data given in this paper suggest a number of policymaker suggestions and potential next actions for dealing with New Jersey’s physician shortage:
|Licensing Requirements||Missouri||New Jersey|
|Education and Training Requirements||Completion of medical school program recognized by Missouri State Board of Registration for the Healing Arts, followed by successful completion of USMLE or COMLEX, and completion of postgraduate training program approved by the Board||Graduation from accredited medical school and completion of at least one year of postgraduate training in a program approved by the New Jersey State Board of Medical Examiners|
|Examination Requirements||Pass USMLE or COMLEX exams, and any other exams required by the Board||Pass USMLE or NBME exams, along with any other exams required by the Board|
|Supervision Requirements||Practice under the supervision of a collaborating physician who holds an unrestricted Missouri medical license, with a written agreement and regular supervision and oversight of practice||Practice under the supervision of a sponsoring physician who holds a valid New Jersey medical license, with supervision and guidance, and review and approval of practice plans|
|Other Requirements||Subject to change, and additional requirements related to malpractice insurance, liability coverage, and practice restrictions may apply||Subject to change, and additional requirements may apply|
 Health Care Industry Cluster. (n.d.). https://www.nj.gov/labor/labormarketinformation/assets/PDFs/pub/empecon/healthcare.pdf
 New Jersey Council of Teaching Hospitals. (2021). New Jersey Physician Workforce: Status and Projections. Retrieved from https://www.graham-center.org/content/dam/rgc/documents/maps-data-tools/state-collections/workforce-projections/New%20Jersey.pdf
 Health Resources & Services Administration. “MUA Find.” Hrsa.gov, 2019, https://data.hrsa.gov/tools/shortage-area/mua-find .
 The Index of Medical Underservice (IMU) is a metric used to assess the level of healthcare access and medical underservice in a particular area. It’s calculated on a scale of 0 to 100, with higher values indicating better access to healthcare services and lower values indicating a higher degree of underservice. A score of 50 on the IMU is often considered a critical threshold. It means that the area has a significant shortage of healthcare resources, making it medically underserved. The scale is relative, so “normal” would depend on the specific context and region. In general, a higher score, closer to 100, would indicate that an area has better access to healthcare services and a lower level of medical underservice. In the case of Mercer County and Camden County, where the IMU score is less than 50, and Passaic County, which is only slightly above 50 (50.1), these scores suggest that these areas are experiencing a critical shortage of medical professionals and healthcare resources, emphasizing the urgent need to address healthcare shortages, especially in underserved regions. Initiatives like the Assistant Physician Program aim to improve access to healthcare in such medically disadvantaged areas.
 The Robert Graham Center. “New Jersey: Projecting Primary Care Physician Workforce.” Accessed April 2, 2022. https://www.graham-center.org/content/dam/rgc/documents/maps-data-tools/state-collections/workforce-projections/New%20Jersey.pdf
 “How Do U.S. Healthcare Resources Compare to Other Countries?” Peterson-KFF Health System Tracker, www.healthsystemtracker.org/chart-collection/u-s-health-care-resources-compare-countries/#Share%20of%20practicing%20physicians%20that%20are%20specialists%20and%20generalists.
 Jabbarpour Y., Petterson S., Jetty A., Byun H.,The Health of US Primary Care: A Baseline Scorecard Tracking Support for High-Quality Primary Care, The Milbank Memorial Fund and The Physicians Foundation. February 22, 2023.www.milbank.org/publications/health-of-us-primary-care-a-baseline-scorecard/ii-workforce-the-primary-care-physician-workforce-is-shrinking-and-gaps-in-access-appear-to-be-growing/.
 New Jersey Council of Teaching Hospitals. (2021). New Jersey Physician Workforce: Status and Projections. Retrieved from https://www.graham-center.org/content/dam/rgc/documents/maps-data-tools/state-collections/workforce-projections/New%20Jersey.pdf
 Robert Graham Center – Policy Studies in Family Medicine and Primary Care. (2018) https://www.graham-center.org/content/dam/rgc/documents/maps-data-tools/state-collections/phys-workforce/New-Jersey.pdf . New Jersey physician workforce . Retrieved from [ http://www.civiljusticenj.org/wp-content/uploads/2014/05/2011_NJ-Physician-Workforce-Report.pdf ]
 Christakis, D. A. (2001). Yes: Consistent contact with a physician improves outcomes. Wjm. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1071446/ ; Sellappans, R., Lai, P. S. M., & Ng, C. J. (2015). Challenges faced by primary care physicians when prescribing for patients with chronic diseases in a teaching hospital in Malaysia: a qualitative study: Figure 1. BMJ Open, 5(8), e007817. https://doi.org/10.1136/bmjopen-2015-007817 ; Hennelly, V. D., & Boxerman, S. B. (1979). Continuity of Medical Care. Medical Care, 17(10), 1012–1018. https://doi.org/10.1097/00005650-197910000-00004
 Murphy, Phil, Sheila Oliver, Judith Persichilli, and M Commissioner. n.d. https://www.nj.gov/health/healthcarequality/documents/1.%20C2883–2022%20HPR-Final%20for%20Web.pdf.
 McCue, M. (n.d.). High Quality Health Care: How New Jersey Residents Report Their Ability to Access It. New Jersey State Policy Lab. Retrieved September 1, 2023, from https://policylab.rutgers.edu/high-quality-health-care-how-new-jersey-residents-report-their-ability-to-access-it/#:~:text=Overall%2C%20the%20survey%20found%20that,percent%20reported%20it%20was%20excellent.
 Yee, Tracy, Amanda Lechner and Ellyn R. Boukus. “The surge in urgent care centers: emergency department alternative or costly convenience?” Research brief 26 (2013): 1-6 .
 Review of Physician and Advanced Practitioner Recruiting Incentives 2022. (2022). https://www.merritthawkins.com/uploadedFiles/MerrittHawkins/Content/News_and_Insights/Articles/mha2022incentivereview.pdf
 When considering whether or not to implement a program similar to Missouri’s in New Jersey, it is important to think about the aforementioned pros and downsides. One advantage might be a quicker transition into the profession for medical school graduates, which would help alleviate urgent physician shortages in underprivileged regions. However, difficulties may arise when attempting to clearly define supervision needs and determine the area of practice for Assistant Physician. Further, a thorough assessment of the program’s efficacy in Missouri might provide light on its potential use in New Jersey. New licensing schemes intended to expand access to healthcare should be carefully considered in light of these considerations by policymakers.
 New Jersey Medically Underserved Index. Available at https://www.nj.gov/health/fhs/primarycare/documents/jemmu99.pdf
 Primary Care in High-Income Countries: How the United States Compares. 2022. The Commonwealth Fund. https://www.commonwealthfund.org/publications/issue-briefs/2022/mar/primary-care-high-income-countries-how-united-states-compares
 Annual Report of the State Board of Medical Examiners of New Jersey
 Physician Retention in State of Residency Training, by State. https://www.aamc.org/data-reports/students-residents/data/table-c6-physician-retention-state-residency-training-state
 New Jersey Rural Health Focus Group Report; https://nj.gov/health/fhs/primarycare/documents/rural_health_focus_group_report.pdf
 For example, the National Governors Association (NGA) recommends expediting licensing processes for healthcare professionals to address the urgent workforce needs during times of public health emergencies.; Mulder, H., Cate, O. T., Daalder, R., & Berkvens, J. (2010). Building a competency-based workplace curriculum around entrustable professional activities: The case of physician assistant training. Medical Teacher, 32(10), e453–e459. https://doi.org/10.3109/0142159x.2010.513719
 For instance, the New Jersey’s Board of Medical Examiners provides guidelines on the licensure requirements for medical practitioners, which can serve as a reference for policymakers in defining clear qualifications and training requirements; https://www.njconsumeraffairs.gov/bme#:~:text=New%20Jersey’s%20Board%20of%20Medical,not%20adhere%20to%20those%20requirements. A lot can also be borrowed from https://pr.mo.gov/assistantphysicians.asp
 A study by Brannon, et al (2012) on licensing barriers for healthcare professionals found that complex and time-consuming application processes can deter qualified applicants from pursuing licensure, and simplifying the process can help reduce such barriers and increase the number of licensed professionals in the workforce.