Primary Care Years: New Measures of Total Workforce Contribution
Primary Care Workforce Summary
Changes in Admissions Impacting Primary Care Choice and Distribution Beyond
Major Medical Centers - Students with the most connections to major medical
center areas of the nation before and during training are the most likely to
gain medical school admission and are the least likely to leave major medical
center training locations for practice. Well-connected higher status students
are increasing rapidly in admissions and are replacing lower and middle income
types of students that have long had greater levels of distribution and the
highest levels of choice of primary care and family medicine.
Changes in Admissions in Allopathic Medical
Schools
Declines in Family Medicine Greatly Diminish Physician Distribution and
Workforce Versatility - Family medicine, the only career choice that can convert
the non-distributional student types to meet the nations most pressing health
care needs has been cut in half in US MD Grads in the last decade. Only the
medical students taking osteopathic routes and those escaping to Caribbean
medical schools have managed to maintain the supply of the US born graduates
that distribute at the highest levels. All but a few allopathic private schools
are no longer a reliable source of family physicians and all but a few
allopathic public schools are declining. The nation has stable osteopathic
levels but osteopathic expansions may only yield the same relative number of
family physicians without health policy changes.
Collapsing Choice of General
Internal Medicine
Dependable Primary Care and Distribution - Family medicine levels of primary
care and distribution have remained constant despite adverse health policy that
has impacted all other forms of primary care. Family medicine graduates remain
in primary care at over 90% levels, maintain practice locations outside of major
medical centers with over 50% of graduates, and maintain sustained 20% or above
rural location for all class years and 10% or above underserved location. These
distributions are all twice the level of other primary care types.
Primary Care Retention
Family
Medicine Central: National Comparisons of Workforce
New Escape Mechanisms for Primary Care and Rural Workforce - Changes in Visa
regulations allow international graduates to bypass rural commitments and go
straight to major medical center locations. This means significant losses in a
major source of underserved rural primary care and mental health in addition to
losses of rural physicians in all specialties.
Changes in admissions and health policy mean great and growing difficulties for
primary care access, particularly in urban underserved and rural locations.
Family medicine retains a consistent contribution over the decades, resulting in
multiplier effects when compared to other types of primary care.
Facilitating Physician Distribution
For primary care contributions over a three decade span of workforce, the nation
would need to graduate at least 2.15 NPs, 2.36 PAs, 4.51 IM physicians, or 3.42
MPD physicians to obtain the same workforce effect as 1 family physician.
Dividing the total contribution of a theoretical 60,000 graduates over 30 years
yields 0.88 FTE of primary care per FM graduate, 0.41 FTE per NP, 0.374 per PA,
0.195 per internal medicine (IM) grad, and 0.257 per medicine pediatric (MPD)
graduate.
Overall each primary care graduate averages only 0.424 FTE of primary care as
compared to studies of the 1960 physician primary care graduates that managed
0.71 FTE per primary care graduate. The only primary care specialty to exceed
this is family medicine.
Current trends indicate that the nation will need 3 or 4 PAs or NPs for 1 FTE of
primary care or for the same contribution as a family physician within a few
years. The nation will need double this component to graduate rural
practitioners at the same rate as family physicians. Considerations of the
numbers needed to train to supply rural or underserved areas are important and
shift the balance toward family medicine, with fewer needed. This is a concept
regularly discussed by Howard Rabinowitz.
Although failures of health policy support for primary care and major medical
center hiring practices are the major reason for loss of primary care, the
direct indication is fewer NPs and PAs working with family physicians. Before
1984 over 55% of physician assistants worked with family physicians and rural
practice levels were well over 25%. Training up to this point prominently
involved rural family physicians. By 1996 only 40% of all PAs worked with FPGP
physicians and 25% of PAs were in rural locations. Now PAs are 17% rural and
family physician supervisors are 28.5%. Also 11.5 percentage points of PAs work
with FPs and have urgent care duties, a debatable form of primary care or
efficient primary care.
Head to Head comparisons of family physicians and physician assistants indicate
that both have similar total rural contributions, slight advantages for PAs for
isolated rural areas, and slight advantages for FPs in larger rural and small
rural areas. These studies involved PA levels for the year 2000, levels that
have declined by 1 percentage point a year while FP rural contributions have
remained a steady 24% for 30 years. It is not known which types of rural PAs
have declined in recent years.
Allowances for less hours, part time work, urgent care, paperwork,
administration, teaching, and losses to other careers mean even lower primary
care contributions. Some 65 – 75% of nurse practitioners and physician
assistants are currently in major medical centers or will be in the next few
years.
Unsustainable Growth Policies with Undependable Primary Care Result - The only
thing that has maintained rural and underserved levels of PAs and NPs is rapid
program growth, which is now slowing. Without plugging the leaks in all forms of
primary care created by health policy defects, the nation is wasting much of its
past, present, and future investment in this area. The driving forces are
clearly better salaries, hours, benefits, and opportunities in major medical
centers that have discovered new potentials for this versatile workforce. PAs
and NPs approached the cost to productivity ratios of the limited forms of
family medicine found in major medical centers. However PAs and NPs can generate
more reimbursement and greater efficiencies by working for those paid at much
higher rates beyond primary care. These include replacing significant numbers of
higher paid physicians, supplementing their efforts at greater reimbursement, or
improving their generation of revenues per unit of time. In addition, NPs and
PAs have lower benefit packages and are less able to negotiate for other
financial incentives compared to physicians.
Health Care Workforce Estimates
Education - Distributions of education set the stage for improvements in health care cost, quality, and access
Current Active Health Care Policy Issues
Top Workforce Outcomes Rankings
Changes in Specialty Choice 1987 - 1999
Changes in Admissions in Allopathic Medical Schools
Cost, Quality, Access, and Physician Workforce Expansion
Medical School Expansion 2004 - 2017
Distribution: The 70-30 Distributions That Complicate Physician Distribution
The One Per Cent Solutions that Resolve Distribution Problems
Flawed Physician Workforce Beliefs
Family Medicine Physician Distribution
Leveling Military and Rural Support Programs
Why Doctors Do Go To Small Towns
Shaping a Nation: Physicians Who Serve
Facilitating Rural Health with Rural Faculty
Academic Medicine's Season of Accountability and Social Responsibility
Research Related Regarding Workforce
Robert C. Bowman, M.D.