Changing Primary Care Contributions 1970 - 2015

Robert C. Bowman, M.D.

Summary

With departures of Nurse Practitioners (NPs), Physician Assistants (PAs), and internal medicine residency graduates (IM) from primary care over time, the changes are most obvious for primary care and more intense for rural and underserved locations. Family medicine will continue to graduate 1/3 the annual graduates, but will increase in share of primary care, rural, and underserved location to remain the dominant contributor in each with 40 - 60% of total primary care.

• Health policy tied to primary care should have a priority in the support of practitioners that remain in primary care and outside of major medical centers. Support for the practitioners that leave primary care and return to major medical centers over time should not be considered primary care support.

• Those hoping to wash their hands of primary care as a physician responsibility are mistaken in their assumptions. Current policies and major medical center decisions mean that physicians will retain 80% or more of contributions for decades. Policies favoring NP and PA providers are not likely to change their increasing preference of major medical center location.

• Careful consideration will support the assertions that major medical centers are the primary influences in all physician and practitioner distributions. Major medical centers will continue to shape workforce based on their own needs and health policy shaped by state, federal, and local government influences. There are numerous benefits gained from NPs and PAs working in major medical centers that are poorly understood and extremely important to understand regarding future workforce projections.

Introduction

The United States has attempted a number of different basic health access interventions is recent decades. These include the creation of Medicare and Medicaid, a revival of family medicine/general practice, the creation of nurse practitioners and physician assistants, and specific interventions directed to rural and underserved communities and those serving them. Notable policy impacts on primary care involve increases in choice of family medicine and primary care for the class years of 1965 – 1978, a doubling of medical student positions from 1970 – 1980 (resulting in quadrupling of primary care numbers), and various direct support interventions involving underserved and rural communities. 

 The following table represents estimates of the changing primary care contributions, based on current health policy, recent trends, and distributions of practitioners

Regarding primary care, rural, and underserved contributions.

1. The United States will depend more and more upon family medicine, not because of support or because of emphasis, but because family medicine remains while all others respond to serious problems related to health policy

2. Physician assistants and nurse practitioners will fail to gain in primary care share of health care delivery due to failures in design, implementation, health policy, and failure to recognize their value resulting in inactivity, major medical center careers, and corporate employment

3. Internal medicine levels will continue to decline, particularly in rural and underserved contributions

4. Pediatric contributions will not change

What this means

1. Those hoping to relegate primary care to non-physicians are mistaken in their assumptions.

2. Workforce planners greatly underestimate current secondary and tertiary capacity when they fail to include the massive shifting of NPs and PAs and other assistants in their calculations. They should be aware that NPs and PAs are increasing sources of major medical center care including the replacement of physicians, supplementation of physician services at much lower cost, and improvements in the revenue generation capacity of major medical center physicians.

3. The nation must do much more to understand the major determinant of physician, NP, and PA employment and training, major medical centers

4. Changes in health policy are unlikely any time soon and have taken years or decades to implement. Improvements in NP, PA, or IM primary care, rural, or underserved distributions are unlikely and should continue to decline slowly

5. NP and PA associations are likely to grow more divided and more distant from primary care, rural, and underserved orientation.

FPGP docs and IM docs were over 80% of the primary care workforce in 1970. The IM share will decline to 25% by 2015. FM started over 40% and decreased to 33%. Family medicine responded to national reinvestment in primary care and support of areas outside of major medical centers and the 1995 – 1997 group peaked FM production and the FM share of primary care. The result since this time has been steady primary care contributions of those remaining in family medicine plus declines in other types of primary care. These declines will result in family medicine moving back over 40% of primary care by 2015 and could be higher if departures from primary care accelerated above the current rate for IM, Med Peds, NP, and PA.

NP and PA shares of primary care will remain below 10% (less than 16% combined) as departures from primary care match primary care contributions from expanded annual graduations. Future changes will be determined by expansions of NP and PA programs and training positions. Although some project declines in NP and PA graduations, I think that we can expect PA program expansions to continue. This is likely as major medical centers have found new ways to benefit themselves and PAs with expansion. NP programs face the challenge of faculty for both nursing schools and nurse practitioner programs. The lack of faculty stolen away by increased clinical reimbursement is a rate limiting step for the growth of NP and nursing numbers. Significant declines are not likely either. Major lobbying efforts are expected to restore some faculty support, but are not expected to reverse losses of NP from primary care. More NPs and PAs that will not be found in primary care, rural, and underserved areas later is a huge problem.

Frankly health policy changes such as RBRVS changes or primary care improvements may not help NP and PA, as major medical centers have discovered their versatility and cost savings compared to more expensive physician types, their ability to expand specialty services, and their ability to generate more volume of services and productivity in conjunction with specialists.

One thought is that the impact of NP and PA on academic centers may be much like managed care impacts. With losses of referrals, the major academic centers faced cuts and tended to cut their generalist types of specialists. They had to keep their monopoly services and those with the highest reimbursements. Those cut happen to be the best teachers. Those replacing them will not be doing teaching. The teaching load will also not likely be shifted to the subspecialty folks either. Neglect or shifting to even more primary care responsibilities for medical education are likely.

The other result of NP and PA conversions is that the nation has new sources of specialists that enjoy the significantly enhanced reputation of primary care, rural, and underserved mission without delivering even a majority of graduates in to primary care, rural, or underserved care. Even government cuts based on such analysis will not matter as government supports of training are likely to be minimal compared to major medical centers. The physician workforce numbers will not consider this, although MedPac reports show strains in primary care access out of proportion to primary care.

Rural Changes - FM share is larger and will increase

PA share of rural primary care will grow to 8%, mainly with increased PA grads, but the levels are likely to fall over time as PAs return to major medical centers as do all other nonFP forms of primary care. NPs will remain about 5% of rural primary care workforce. IM will continue at 15% and peds will remain about 11%. Again the only way these are maintained are new graduates and those who have rural origins. In family medicine, the share of rural primary care will steadily increase back above 60% as others fall away from primary care and rural locations.

Underserved Changes – FM share will increase

Underserved zip codes have poverty at zip over 20% or federal designation of CHC, NHSC, whole county at zip. Underserved distributions over the next decades will remain much the same for most. This includes a 7% share for PA, a declining share for NP to 7 – 8%, 19% for IM, and 16% for peds. The family medicine share will climb over 50% of underserved primary care practitioners despite 1/3 the level of family physician grads compared to NP and PA. Staying in primary care and avoiding major medical centers over time are the two key factors for distribution of practitioners.

Major Medical Centers are medical school zip codes or have 75 or more total active physicians at a zip code (not exhaustive as incomplete and does not count PA or NP). Major medical centers are not considered underserved areas. MMCs have 75% of physicians, over 65% of NPs and PAs and other forms of primary care, and only 50% of FPs. MMCs hire the most family physicians, including the most during the 1995 – 1997 class years with maximal FP choice. It is likely that MMC attitudes and behaviors are the primary shaping force of all physician workforce and practitioner distributions, including family medicine. The medical students trained 100% in major medical centers are also in close contact with these attitudes and behaviors, a likely shaping force in career decisions, somewhat influenced by health policy. With improving primary care health policy, MMCs hire more in primary care, influence retention in primary care, and influence workforce for the nation. With poor support for medical education and primary care, MMCs minimize primary care investments, and use primary care sources outside of primary care.

Robert C. Bowman, M.D.

[email protected]

What Could Have Been Maximal Primary Care Training Capacity - designs could insure that 55% of IM are found in office based practice, that 18% of physicians are involved in family medicine, and that all NPs and PAs were delivering primary care. What does the lack of appropriate design cost us?

Head to Head: Physician Assistants in 2000 Compared to Family Physicians in State and National Location

Family Medicine Central: National Comparisons of Workforce

Physician Workforce Studies

www.ruralmedicaleducation.org