Atlas of Basic Health Access

Primary Care Decline: Declining Retention and Primary Care Failure Despite Expansions of Primary Care Graduates    The US design for primary care fails as 22,000 of 28,000 Annual Primary Care Graduates are Flexible and Leave Primary Care.

The Standard Primary Care Year Atlas        The Standard Primary Care Year  Primary Care in the United States must be understood in terms of actual delivery of primary care, not claims of primary care. Maximal primary care is 35 years of a career spent 90% in primary care with 90% active for a career with top volume. Minimal primary care is 27 years, 10 - 30% remaining in primary care, 60% active, and lowest volume of primary care.

Physician Distribution by Concentration Atlas   Physician Distribution by Concentration Coding Physicians concentrate in 4% of the land area in just 3400 zip codes in top concentrations. This is a workforce design that leaves 65% of the US population behind. Only the family practice MD, DO, NP, and PA forms are found 52 - 60% outside of concentrations and only the family physicians remain in family practice throughout their careers. Physicians with origins outside, physicians with training outside, physicians choosing family practice, and physicians older at graduation are lasting solutions for most needed health access. 

MCAT Central  The MCAT is not the reason for declining health access, but used inappropriately for admission, the applicants most likely to be found in most needed health access careers can be rejected for interview or for admission while those most exclusive in origins that are also most exclusive in scores become physicians. A balance of sufficient academics with final selection based on the characteristics most important for physicians is a design for health access, and for best physicians. A design of most exclusive admitted is a design for further concentration and decreasing health access. 

Health Access Recovery Atlas: Designs That Recover Primary Care and Health Access  Health access and primary care have been accomplished for many decades in many different ways. The only way to fail in health access is the prepare and admit the most exclusive, train most exclusively, graduate the fewest in the broad generalist family practice mode, and design policy that compromises primary care and health care for lower and middle income Americans in most need of health access.

Quality and Health Access Atlas      Quality Considerations in Health Care

Featured Graphics     Robert C. Bowman, M.D.

Producing Physicians and Non-Physicians is not enough for Health Access. Nurse practitioner and physician assistant graduates have followed US policy away from primary care just like physicians, and also leave at any time after graduation resulting in greater losses of primary care per graduate. ProduceNonPC.GIF   This loss of flexible primary care during training, at graduation, and each year after graduation must be understood to understand basic health access primary care. Nurse practitioners and physician assistants that have the free will to depart complex primary care careers, that are paid and supported at higher levels for departing primary care, and that generate more revenues and save personnel costs for their employers are not the solution for health access recovery. The result of the current design is that the US has produced higher and higher levels of physicians and non-physicians found in specialty care. Primary care production in the graphic remains flat and the family practice MD, DO, NP, and PA forms most associated with primary care and most needed health access remain flat. This is a problem because the US population has increased steadily. There is only the conclusion that the US neglects basic health access primary care. Only the family practice forms that remain in family practice distribute according to the population and not according to concentrations of physicians and health resources. Data from Colwill, COGME, AMA, the AMA Masterfile, AAPA, AANP, and Future Estimates by the author

PCDeclineDespite1990s.GIF  A primary care decline despite improvements in primary care reimbursement is most instructive at the current time. The high magnitude primary care reforms with increased reimbursement for primary are and decreasing specialist reimbursement resulted in only a minor slowing of the steady decline of primary care per graduate from 1970 to the current period and beyond. Flexible primary care training as found in IM, NP, PA just is not a good design. The inevitable conclusion is that changes in primary care reimbursement will have minimal impact on primary care delivery in the US. Permanent primary care is required for permanency in primary care. Of the 28,000 IM, NP, PA, PD, and FM graduates each year that could become primary care, only the 3000 annual family medicine graduates are clearly permanent primary care. More graduates in IM, NP, and PA with only 2 - 3 Standard Primary Care years will only result in further primary care declines per graduate. 

DecreaseNPPA88to08per.GIF Non-physicians are no longer sources of primary care that can aid in primary care recovery. In fact the annual numbers of graduates in primary care is declining despite increases in US populations and the increasing complexity of primary care delivery. The fall of primary care contributions and the dramatic increase in specialty care for non-physicians is noted in this graphic from 1988 to 2008 NP and PA graduates.

Primary Care and Health Access Policy Related Graphics

Primary care retention declines are illustrated for each of the five primary care sources. These are policy related declines as primary care support has decreased, especially relative to the attraction of specialty and hospital workforce in multiple dimensions.

The total primary care production for all 5 sources is totaled and divided by the number of IM, NP, PA, PD, and FM graduates for each class year.

pcpolicy - The effect of policy to reduce primary care retention is shown. Blue is the primary care remaining for each source of primary care. Red represents the primary care delivery that was formerly seen before graduates departed primary care at such high levels to reduce actual primary care delivery. Nurse practitioner contributions to primary care were never stellar due to inherent limitations in nurse practitioner workforce (lower activity, lower volume, fewer years). Foreign origin internal medicine internal medicine primary care is extremely limited with policy related retention declines

Changes in Specialty Choice 1987 - 1999 - A change toward primary care supportive policy and then away gives a chance to illustrate the impact of policy upon career choice.

Primary Care physicians and non-physicians have moved steadily away from primary care due to losses of primary care retention. What could be and what is reality is illustrated in the five primary care training forms. Very little primary care remains in the flexible forms destroyed as primary care by policy.  The ideal or what could be if these 5 forms were permanent and not impacted by poor primary care support is also shown in

Failure of US Flexible Primary Care Design: Permanent 25 SPC year production versus falling US primary care from 20 SPC years per graduate to 6

Failure of US Flexible Primary Care Design: Permanent Versus Flexible Demonstrating Failure of Design Plus Policy in addition to influences that increase or decrease Basic Health Access Above or Below the Limitation Set by Health Policy

Decreasing Primary Care Production in Non-Physicians Despite Expansion   with arrows and text

Decreasing Primary Care Production in Non-Physicians Despite Expansion simple graphic

The Pipeline to Primary Care Becomes More Efficient with Sufficient Primary Care Policy. More stay in primary care, more choose family medicine, more is produced, and more is retained. With insufficient policy, the flow decreases, the leaks intensify, and primary care capacity declines.

The Same Pipeline Concept Applies to other Systems such as education and health with teachers and nurses more likely to remain in the mill race to help deliver most needed education and health care. Poor policy support results in more leaks, lower production, and less capacity in education and health.

Nebraska Primary Care Changes, Metro and NonMetro, 1990 to 2000   State and Federal Policies Conspire to Erase Metro Primary Care while NonMetro Primary Care Based on the Permanent Primary Care Foundation of Family Medicine (and past planning) Remains (HPTC Tracking, Nebraska Office of Rural Health).

Collapse of Internal Medicine Primary Care - Decrease in Standard Primary Care Years of Primary Care Delivered Per Graduate By One Year Each Passing Class Year - Multiple Class Years Departing Primary Care in a Short Time

Physician Assistants in Family Practice Mode - Decline in FP 1988 to 1998 to 2008 to 2018 Results in Decline in Primary Care and Most Needed Health Access

Failure of Flexible Primary Care - The Standard Primary Care Year

Primary Care, Rural Primary Care, and Underserved Primary Care Contributions for 2008 Graduates of All Five Sources of Primary Care

Rural Primary Care Workforce and Underserved Primary Care Workforce for 2008 Primary Care Graduates in Standard Primary Care Years

Standard Primary Care Years and Policy Effect - Compare What Was with Nurse Practitioners and Physician Assistants with Top Levels in Family Practice Mode Compared to NP and PA with a much smaller FP fraction

The choice of family medicine is determined over the 1970 – 2005 class years (possible mainly because family physicians stay in family practice) for different birth origins from most rural to most urban or foreign born US graduates. Family medicine choice consistently layers out by birth origins from more normal with highest family medicine choice to most exclusive with least family medicine choice. Each birth origin layer is impacted by 5 policy periods from the earliest period before health access policy to build to a 1978 peak of family medicine with improvements in policy and slight declines with neutral 1980s policy then a peak family medicine choice during a return to primary care policy in the 1990s followed by the current destructive policy period with primary care being destroyed or prevented (destroyed for other forms, medical students prevented from a permanent primary care choice such as family medicine).

A curve is demonstrated that would have maintained sufficient primary care after the quadrupling of primary care from 1970 to 1980. An insufficient intervention with flexible primary care graduate expansion is shown. Even with 15,000 more primary care graduates, about 5000 each in internal medicine, nurse practitioner, and physician assistant annual graduates, insufficient primary care recovery is demonstrated. Even with the current and planned expansions, there will be no significant primary care capacity recovery as the US population increases and demands from more complex populations such as over age 65 and underserved populations increases. Also more complex demands upon primary care may limit primary care capacity and result in even more graduates needed.

Past, Present, and Future Family Medicine Choice by types of schools - These projections were used for determining workforce contributions for the future in basic health access and primary care. Even with lower percentages of family physicians, the contributions remain steady and family medicine maintains about 3000 annual graduates. Even with increases in annual graduates in other primary care forms, the primary care contributions decline as steadily lower percentages remain in primary care in the flexible primary care forms (IM, NP, PA).  Only specific efforts to admit, train, and graduate family physicians can improve family medicine graduate levels, and most needed health access in America.

Schools with Higher MCAT Scores Graduate the Fewest Family Physicians. Policy Also Shapes Major Declines in Family Medicine. The End Result is Loss of Major Sources of Most Needed Health Access in the United States

MCAT Scores - The Higher the Score, the Lower the Rural Workforce Production, especially for rural locations with less than 75 physicians at a practice zip code  This bivariate scatterplot compares MCAT to rural practice percentages, but logistic regressions note contributions regarding those admitted, training, family medicine choice, and older age at graduation. Higher MCAT scores reflect more exclusive students admitted, including those less likely to choose family medicine.  The combination reduces rural workforce. This is why a graduate from a school such as Duluth contributes 64 times the rural primary care compared to a top 20 MCAT school graduate. 


Specialization and Physician Workforce

Spec60to2050 - Physician workforce is tracked from 1960 to 2050 in total physicians, non-family physicians, non-primary care physicians, family physicians, primary care physicians

Spec98to08 - Physician workforce production has increased greatly for specialty care but has decreased for primary care, which is why expansions for primary care no longer work and result in more and more specialty care.

IMconcen - Internal medicine generalists are captured with increasing concentrations found in the counties with top population concentrations. All other physicians other than family physicians follow a similar pattern. Family physicians distribute equitably and remain relatively constant across locations with some tendency to avoid (or be excluded) from top concentration locations. Also family physicians are less than 5% of the physicians in the medical school zip codes and other top concentrations.

In the Following Sequence, the Birth Origins and Practice Locations of 1987 - 2000 medical school graduates are represented using county population density. In each column the value is the number of physicians born in the county type and practicing in the indicated county type divided by the total graduates. The diagonal tendency to be found practicing in a population density county similar to birth origin county is also demonstrated, especially for family physicians.

AlloPubSubsp - Allopathic Public Subspecialists coded for birth origin county and and practice location county by population per square mile. Allopathic private and international medical graduate subspecialists are the only ones that are packed into top concentrations at higher levels.

AlloPubHosp - Allopathic Public Hospital Support Specialists are matched to birth origin counties and practice location counties coded by PPSM. Concentrations in origins and in practice locations are shown.

Allopathic Public Office Internal Medicine physicians are matched to birth origin and practice location counties coded by PPSM Even Internal Medicine generalists have more concentrated birth origins and more concentrated practice locations 

Allopathic Public Family Physicians matched to birth origin and practice location counties, note maximal diagonal effect as generalist choice allows maximal return to origins similar to birth. Family medicine origins and practice locations are by far the most normal and the least exclusive. All other types of physicians have more exclusive origins and more exclusive practice locations.


Birth Origins Graphics

Physicians found in super centers with 200 or more physicians were traced to birth origins and were found to be more and more likely to arise from top concentrations. Higher probability of admission and higher probability of an exclusive medical school help shape exclusive concentrations in super center locations.

Physicians traced from underserved practice locations in 2005 are more likely to arise from populations with lower concentrations of people or income or both. Higher probability of underserved location are also associated with lower probability of medical school admission.

Physicians traced from underserved practice locations in 2005 are more likely to arise from populations with lower concentrations of people or income or both. Higher probability of underserved location are also associated with lower probability of medical school admission. This captures US medical school graduates and also estimates the foreign born component. This is a largely Asian component that resides in US counties but was not born in the US (90% of Asian populations are foreign born or have a parent who is according to the US census). The likely county of residence was estimated from the census and applied to this graphic. The “inconsistencies in some birth county categories appear to be filled in. Foreign born, Asian, and other highest income and most urban origin populations have consistently low rates of primary care, of family medicine, of rural, and of underserved career choices although some have urban underserved contributions. Concentrations in origins lead to concentrations in career and practice locations.

Physicians traced from rural practice locations in 2005 are more likely to arise from populations with lower concentrations of people or income or both. Higher probability of rural location are also associated with lower probability of medical school admission.

Family physicians were tracked to birth origin county coded by population density. There was a constant rate of 1 family physician admitted per 100,000 1970 birth county population per class year. The constant rate of family practice is contrasted with increasing admission probability of those with more urban (and higher income) birth county origins. Those most likely to gain admission with higher probability of admission were least likely to be found in family medicine. Those most likely to be found in family medicine arose from origins with lowest probability of medical school admission. Rural physicians, underserved physicians, and family physicians are the only types of physicians with a constant rate of origin across all populations

Choice of Family Medicine By Type of Medical School 1970 to 2040 - Actual and Projected

Who Fits the Pattern - DNA Pattern Matching Is Popular - Physicians were coded by birth origin county income level and school MCAT to illustrate the higher income origins of the graduates of the most exclusive medical schools and those who choose the exclusive careers.

Physician Older Age at Graduation and Increased Choice of Primary Care, Family Medicine, Psychiatry Careers, Rural Location, and Underserved Location  Older graduates represent less exclusive origin students. Older age, even controlling for origins and training, is associated with 30% or greater increases in most needed career choices.

Family Physicians - Origins and Practice Locations More Likely to be Outside of Top Concentrations - from the 65% left outside and serving the 65% outside with outcomes involving the Physician Distribution by Concentration Coding   see also video comparisons at Shorter presentation comparing 5 Specialty Types from origins to practice locations

Specialists of a more general nature such as general surgeons, urologists, and ob-gyn physicians are traced to their origins and linked to their PDC practice locations

Hospital support physicians are captured by birth origin county population density as well as practice locations. Super center location dominates with major center location prominent and few located outside of concentrations. More exclusive origins result in more exclusive career and location choices.

Internal Medicine and Pediatric physicians are captured by birth origin county population density as well as practice locations. As with subspecialists and hospital support physicians, super center location dominates with major center location prominent and few located outside of concentrations. More exclusive origins result in more exclusive career and location choices. Indeed IM and PD generalists are 70% found in top concentrations in 4% of the land area.

Subspecialists have the most exclusive origins, are more likely to arise from exclusive origins, and are most likely to be found in super center exclusive concentrations of physicians

The Standard Primary Care Year - A Required Measuring Tool for Reasonable Comparisons of Primary Care Forms

Table with Documentation of Specialization in Physicians, Nurse Practitioners, Physician Assistants

The Physician Distribution By Concentration Coding System Health Access has a new coding system based on zip code and adjacent zip code concentrations of physicians that are inside of concentrations as well as zip codes with 65% of the population that are outside of concentrations of physicians

Missing Persons: Eliminations of Primary Care in the 1980s and 2000s    Compare the graphics demonstrating production of primary care to identify the decades with decreased production and retention of primary care. Also remember the insufficient health access production extending for decades prior to the 1970s. Then consider the deficits being built now, for the next decade, and potentially beyond

Slide Show Brief Clip - Most Needed Health Access Careers By Birth Origins - Decreased Probability of Admission is Associated with Increased Probability of Most Needed Health Access 

The Health Access Medical School: The Only Solution for Health Access at the Current Time