Beyond Rhetoric to Reality in Health Access

Robert C. Bowman, M.D.     rcbowman@atsu.edu

Words such as primary care, health access, and continuity medical home are pleasing to the ears (especially when attracting grant funding), but actual primary care contributions are far more important than rhetoric.

The most important health care workforce needs for the next 50 years will involve primary care, rural health services, and services to underserved areas. Most needed workforce actually includes a larger population left behind. Those left behind are found in 30,000 zip codes that contain 65% of the United States population. These are zip codes outside of concentrations of physicians with only 20 - 30% of total physicians, physician assistants, and nurse practitioners sharing these zip codes.

Primary care needs alone will take 50 years of recovery. Declining primary care production and retention are such that even a doubling of graduates will not work. Even the 1990s major primary care reforms did not inhibit the steady losses in primary care delivery per primary care graduate.

Often most needed health access is considered in extreme terms when actually the needs involve most Americans. See The Illusion of Minority Status. What is missed by focusing on the extremes is that the health policy design concentrates 75% of physicians in 4% of the land area in just 3400 zip codes.

Medical schools have the ultimate physician concentrations and the most funding, but one of the reasons for top funding is that medical schools are always looking for more funds. Rhetoric arising from this 4% in top concentrations has steadily promised health care for the populations outside, but actual primary care production has utterly failed.

In particular the strategy of more graduates fails utterly. Producing more graduates is just fine for health professional schools and programs with 90% found in 4% of the land area, but it is difficult to pry graduates away from top concentrations after 30 years of life experiences in top concentrations. This is even more complicated when 85 - 90% of practitioner reimbursement goes to just 4% of the land area.

Any promises of most needed health access that do not address:

• More funding added to health care spending in the 29,000 zip codes left behind or funds shifted from the 3400 zip codes inside of concentrations to the 29,000 zip codes outside
• More of the family practice forms that remain permanently in family practice and primary care that are the only graduates that have higher probability of most needed health access (2 to 3 times)

Are basically proposals that will fund the grantee and not help the Americans left behind

Many hold on to the notion that nurse practitioners and physician assistants will be able to fill primary care gaps. This is not possible with steady NP and PA departures from primary care and from the broad generalist family practice mode. Less than 30% of nurse practitioners and physician assistants remain in the family practice mode and the declines have been steady for over a decade of annual surveys. Physician Assistant Changes in Family Practice

Non-physicians not in the broad generalist family practice mode follow the pattern of concentration of physicians not in family practice. All of the physician, nurse practitioner, and physician assistant graduates not practicing in family practice are concentrated at 65% or higher levels in 4% of the land area in top saturations of health workforce. Pediatric primary care and internal medicine primary care physicians have 70% found in 4% of the land area.

Only the MD, DO, NP, and PA forms who remain in the family practice mode reliably escape these most concentrated locations to most needed health access. But the nurse practitioner and physician assistant forms are departing family practice mode. With this departure, the losses include the rural, underserved, and primary care contributions formerly provided by non-physicians. The actual departure of nurse practitioners and physician assistants from primary care has averaged 2 to 3 percentage points per year since the creation of nurse practitioners and physician assistants. With widespread acceptance of nurse practitioners and physician assistants across a wide range of locations, populations, and specialties, departures from basic health access have continued. The departure may accelerate as aided by market forces. Market forces are set in motion by health policy. Nurse practitioners and physician assistants generate more revenue as specialists under the current reimbursement system. Also nurse practitioners and physician assistants cost far less than specialist physicians. Employers benefit, specialists benefit, and non-physicians obtain the highest salaries and benefits by specializing.

Most needed health access solutions require graduates to remain in primary care, to remain in rural or underserved areas, and to remain in zip codes with 65% of the US population and only 23% of physicians. This is most difficult at the present time when salaries for most needed health access are the lowest, when the nation sends only 10 – 15% of health resources to most needed health access locations, and when policy insures the fewest health care team members and the least support for basic health access care delivery.

A wait and see attitude has never served the nation’s health access needs. The most recent graduates must be studied to determine future primary care contributions. There is little doubt regarding the future for the sources of primary care. Family physicians remain in primary care although fewer medical students can trust this remaining permanent primary care source. Unlike innuendos from nurse practitioner organizations that only 1000 annual graduates are found in family medicine, the actual level is 3000 per year.

The internal medicine, nurse practitioner, and physician assistant primary care contributions are disappearing steadily over time. These flexible primary care forms are impacted most by policy. Nurse practitioners, physician assistants, internal medicine graduates, and foreign origin international medical graduate (FIMG) internal medicine graduates depart primary care during training, at graduation, and each year after graduation. In the flexible primary care forms, departures are inevitable as employer and employee both benefit with increased salaries and increased revenue generation by moving to specialty careers.

Future Health Access Contributions for 2008 Graduates¹

The FP Mode is the broad generalist office based mode in practice, not the form of training such as Family Nurse Practitioner. The FIMG IM is the foreign origin international medical graduate internal medicine physician.

It is just not possible to claim primary care contributions when graduates of flexible primary care sources have the fewest remaining in primary care (IM, NP, PA), the fewest years in a career (NP, IM), the fewest active (NP, IM, PA), and the lowest volume of primary care delivered (NP, PA, IM. The most important rural and underserved primary care contributions are made consistently by the family practice MD, DO, NP, and PA forms. Departures from this mode result in departures from most needed health access and from primary care itself.

·         Family medicine residency graduates deliver multiple times more primary care, rural primary care, and underserved primary care compared to all other forms.

·         Nurse practitioner primary care is inherently lowest volume, lowest activity, and fewest years. Even with 100% remaining in primary care or three times the current level, the maximal primary care is 9 Standard Primary Care Years. The current trade off is a loss of 27 years of nursing to become a nurse practitioner to deliver 3 – 4 Standard Primary Care Years. This is a poor choice given the 1 million nursing shortage expected by 2020. Nurse practitioner increases have depleted nursing and nursing faculty. Nurse practitioners make significant specialty contributions in volume limited specialties and cost less than specialist physicians. The lower SPC years per graduate with declines continuing negates primary care contributions.

·         Without being forced to remain in the family practice mode, physician assistant primary care and health access contributions are also not reliable. Physician assistants in specialties such as emergency medicine, orthopedics, and surgical subspecialties have ridden highest salary offerings to 35% of graduates or a greater percentage than primary care physician assistants at 33%. Physician assistants also have the advantage of lower cost compared to specialty physicians. The lower SPC years per graduate with steady declines continuing negates any primary care advantage.

·         Internal medicine health access contributions have vanished with lowest primary care retention and rural distribution as well as underserved distribution only average for physicians. Internal medicine remains 70% inside of concentrations at about the same level as all physicians. Internal medicine increases the most in counties with top concentrations of people, leaving lower and middle population density counties behind. The rapid rise of hospitalism together with the move to urgent, hospital, and emergent care insures the end of significant internal medicine primary care contributions in the future. With increases of tens of thousands of hospitalists a year, 75% have been internists. The new hospitalist positions have crowded even more physicians in zip codes with over 75 physicians in 3400 zip codes in 4% of the land area.

·         Pediatric contributions are important in locations with urban concentrations of physicians. Pediatricians are found 70% in zip codes with 75 or more physicians just as in internal medicine primary care. Pediatric graduates have moved away from rural and underserved locations and steadily toward physician concentrations over past decades of class years. There are also fewer children in the United States. The needs in the United States are practices away from concentrations and services to older and oldest, not youngest patients.

The futility of expansion as a means to improving health access is evident from the changes. Departures from primary care, rural, and underserved locations are a constant under current health policy. Only expansions of family physicians can address needed health access because only family physicians stay in the family practice mode, stay in primary care, and stay in the rural and underserved locations in most need of health access. Family physicians remain a permanent form, but medical students cannot trust a permanent choice of primary care under current policy. This is a contrast between family medicine and all other forms. Other forms are flexible and depart primary care with poorly supportive policy. Family medicine is impacted at the only decision point possible, the single decision to become a family physician during medical school. When medical students pass up the choice of family medicine, they pass up decades of primary care contributions.

Additional investments in flexible forms (IM, NP, PA) are of little value to health access without lasting primary care and distribution. With departures from generalist and family practice modes, the rural and underserved contributions are lost. Expansion in a time period of worsening health access policy and declining primary care retention simply fails to address health access using non-physicians.

The effect of United States policy can be seen in individual medical schools. Few understand the variation in health access production. Duluth has led the nation for decades in primary care production as a premier health access medical school. Duluth admits and trains for rural locations and family practice careers. About half of Duluth graduates do a 9 month longitudinal preceptorship working with rural family physicians. This Rural Physician Associate Program is the most comprehensive health access training available for future rural physicians. From creation in the 1970s to 2008 Duluth has managed to graduate 45 – 50% into family medicine each class year. By 2009 the optimal health access admission and training efforts at Duluth were finally impacted with family medicine choice declining to 36% for a decline from 16 SPC years to 13 SPC years per graduate.

Primary Care and Rural Primary Care Estimates

Calculations for the medical school primary care contributions are seen below in osteopathic findings.

Medical schools that depart the family practice focus with fewer family physician graduates have markedly decreased primary care and rural primary care production. The internal medicine and pediatric contributions are not reliable in current policy and are not able to address the needs of the 65% left behind.

Duluth has had some decline in family practice despite the same optimal admission and training focus. The effect is best understood as a federal health policy impact. This has been seen in all other schools but Duluth managed to hold off adverse policies the longest. Health access schools tend to be policy resistant, but are not immune to significantly adverse policy.

Top 20 MCAT medical schools admit the types of medical students that have the lowest probability of primary care, rural or underserved careers; the most exclusive schools train specifically for hospital, specialty, and research careers; and the most exclusive schools train medical students in the most exclusive environments with the least primary care and family practice physicians. The end result is that the most exclusive schools graduate the fewest family physicians, produce the least primary care, contribute the least rural care, and contribute the least underserved care. Graduates of the top ranking MCAT schools are found with 80% inside of top concentrations of physicians in 3400 zip codes in 4% of the land area. These are most often medical school zip codes and other zip codes with the very top concentrations of physicians. Graduates of top 20 MCAT schools make many important contributions, but not in health access.

It has become politically correct to do all possible to have the appearance of primary care contribution. Poor understanding of primary care by the people of the United States allows this to continue. The reporting of primary care has become deceptive. The current internal medicine graduates have 90% choice outside of primary care. Medical schools should no longer count senior medical students matching to internal medicine programs as primary care. Pediatric primary care retention is 50 – 60%. Some schools and programs can claim higher, but a claim of only 50% of match graduates in pediatrics should be the maximum allowed. Medicine pediatrics rapidly moves to hospital and specialty careers.

Family medicine remains the only reliable primary care contributor using the first career choice results found in the annual senior medical student match. Internal medicine is entirely unreliable in primary care contributions. Pediatric programs vary from zero remaining in primary care to the traditional 70% levels found commonly a decade ago, but the declines continue. Nurse practitioner and physician assistant primary care contributions are also not reliable.

The standard measurements of primary care must remain family medicine, internal medicine, and pediatrics without including women’s health, emergency medicine, or psychiatry. A best estimate for primary care is found by counting 90% of medical students choosing family medicine, 50% of medical students choosing pediatrics, and 10% of medical students choosing internal medicine as future primary care physicians. Top ranking schools should be cautious regarding pediatric primary care contributions as specialization rates are higher.

Mercer was a 1970s medical school creation like Duluth and other schools. All had much higher primary care, rural, and underserved production led by their family practice graduates. Until recently Mercer graduated 30% more into family medicine. Mercer’s decline in family medicine to less than 8% is one of the largest and has resulted in significant rural, underserved, and primary care losses.

Another way to categorize most needed contributions is a consideration of practice locations by county population density. There are major differences in health access contributions.

·         Lowest rural distribution - International graduates and United States allopathic private medical school graduates that were born in other countries have the lowest rural contributions.  They were born, raised, and trained in the top concentrations of people, physicians, and income in the world. Probability of rural location is consistently lowest for physicians with origins most closely associated with concentrations or combinations of concentrations.

·         Next worst rural distribution is found in US origin international medical graduates and allopathic private graduates.

·         The allopathic public and osteopathic schools are most likely to serve in needed health access careers.

·         Top rural contributions are found in dedicated health access schools.

Allopathic private medical schools send few to counties with lowest population density and higher ratios of graduates to the most densely populated counties. Osteopathic and allopathic public graduates have better rural location rates than allopathic private and international medical school graduates and are less likely to concentrate in counties with top concentrations of population.

The ultimate health access contribution is found for the health access schools that work with their state to coordinate birth to admission, admission, training, career choice, and policy.

Physician distribution can also be compared by specialty. Internal medicine graduates follow the pattern of greatest concentration in counties with top population density.

Family physicians follow a completely different pattern in distribution. Rather than concentrating in concentrations of people, income, and physicians, family physicians remain distributed at about 1 per 100,000 per class year. This is illustrated in the recent graduates as well as national distributions of 30 – 40 per 100,000 in all class years of graduates across population distributions, income levels, and populations in need of health access.²

The Futility of Expansion In Adverse Health Access Policy Periods

The doubling of medical school graduates from 1970 to 1980 was optimal for health access due to the optimal primary care policies of the time period. The percentages of primary care graduates doubled, resulting in a quadrupling of physician primary care numbers in a decade led by family medicine. The new nurse practitioner and physician assistant contributions were small in number but were relatively pure primary care forms at this time.

The 1970s expansion was entirely different than the current expansions occurring at the worse possible time in recent workforce policy history.

Doubling of Graduates does not improve health access in adverse policy periods. In fact a doubling of graduates is often required just to produce the same primary care as noted in physician assistants.

Physician Assistant and Osteopathic Doublings

Physician assistants doubled in annual graduates but primary care contributions did not increase. The osteopathic graduates have also more than doubled but the family medicine graduate levels are likely to remain steady in the 500 – 600 range. It may be possible to reach 700 osteopathic family physicians a year but this requires more than a doubling of graduates for much the same result. As with allopathic medical schools, osteopathic schools are admitting more of the types of physicians with lowest family medicine choice (fewer lower and middle income, lower and middle population density origin students) and training is more likely to involve associations with concentrations.

The really bad news is that all of United States primary care production has diminished. Unlike specialty care that can be created from residency training or existing primary care practitioners, primary care can only arise from a dedicated primary care effort. Losses from primary care tend to be one way over time.

US total primary care production peaked at about 260,000 to 280,000 SPC years per class year in the optimal primary care policy in the 1990s class years for all five sources. Primary care was extremely important to capture market share and teaching volume under managed care influences.

The current health policy has rebounded in the opposite direction and the primary care production is opposite. Primary care production has declined to about 180,000 SPC years per class year where it is likely to remain. US primary care production needs to rise to about 350,000 to 400,000 SPC years per class year by the class of 2020. This is a requirement as 65% of the population remains behind in health access, as the elderly double in the next 20 years, and as primary care becomes more complex.

Once again the calculations reveal that only family medicine can fill the gap between needed primary care and current production. About 5000 more family physician graduates a year is 125,000 more SPC years per class year. The same primary care production from flexible forms requires 40,000 to 60,000 more annual graduates for a combination of IM, PA, and NP graduates. Even then the contributions are not dependable in primary care, rural, or underserved dimensions.

Value of Family Medicine

• Remains in primary care at 2 to 9 times the level of other sources
• Remains in family practice broad generalist mode at 3 – 5 times other sources
• Goes to and stays in rural and underserved locations at the highest percentages or about 2 – 4 times other physicians and greater than NP and PA distributions other than the fewer NPs and PAs remaining in family practice mode. Medical School Type and Career Choice and Most Needed Health Access
• Most numerous at Community Health Centers and especially in rural CHCs³
• Essential component of rural health clinics, Critical Access Hospitals, whole county primary care shortage areas
• Top rates of ambulatory services to the elderly, adults, women’s health
• Takes over child care from pediatrics increasingly in the years after age 4 and in the locations beyond concentrations of physicians where pediatricians are less likely to be found.
• Most consistent in all class years regarding health access contributions, not deteriorating with each class year or each year after graduation
• Least likely to be found in top concentrations of physicians that have sufficient or excess primary care
• Most likely to be older at medical school admission with more life and health experiences
• Most likely to share origins or background with patients – the least exclusive origin physicians
• Highest volume of primary care per graduate in a career or per unit of time
• Highest productivity in primary care
• Lowest cost compared to productivity
• Most years in a career
• Easiest to arrange shared call for smaller group or practice settings
• Best overall distribution to all populations in need
• No age limitations regarding patients that can be seen
• Able to adapt and deliver a wider range of services including procedures, endoscopy, minor surgery, mental health, inpatient, emergency care, deliveries, geriatric, sports medicine

But health access requires careful coordination to prepare (birth to admission) and admit those most likely to choose family medicine (and go where most needed in rural and underserved dimensions), to admit those with reasonable life and health experience prior to admission, to train for health access in most needed locations, to train with family physicians in optimal primary care environments, to coordinate the orderly progression to a decision for a family medicine residency training program, and to coordinate the orderly progression to meet the needs of states regarding health access.

The current situation involves admission of the least likely health access candidates, training in the least likely environments, policy that does not allow medical students to trust a permanent health access career choice such as family medicine, and policy that sends only 10% of health resources to zip codes with 65% of the population.

It does not take sophisticated research to understand these problems in health access. It requires common sense. The solutions are easy. All that is required is not to do what the United States is doing in every important component related to health access.

There are many ways to graduate and maintain needed health access. There is only one way to produce too little and destroy it.

• The United States prepares and admits the students least likely to choose health access careers.
• The United States forces medical students and medical schools through a narrow biomedical focus to pass board examinations to become a physician.
• The United States supports the most exclusive training in locations with the most exclusive physicians in the most exclusive concentrations of health resources.
• The United States supports the most exclusive career choices and drives students and graduates away from primary care choices.
• The United States supports policy that concentrates physicians and health resources in just 4% of the land area.

Major sources include the 2005 American Medical Association Masterfile as well as nurse practitioner and physician assistant data.^4-6

References

1.            Bowman RC. Measuring Primary Care: The Standard Primary Care Year. Rural Remote Health. Jul-Sep 2008;8(3).

2.            Ferrer RL. Pursuing equity: contact with primary care and specialist clinicians by demographics, insurance, and health status. Ann Fam Med. Nov-Dec 2007;5(6):492-502.

3.            Rosenblatt RA, Andrilla CH, Curtin T, Hart LG. Shortages of medical personnel at community health centers: implications for planned expansion. Jama. Mar 1 2006;295(9):1042-1049.

4.            Birth Origins Database Compiled from 2005 Masterfile Physician Database Medical Marketing Service; 2005. Updated Last Updated Date.

5.            Goolsby MJ. 2004 AANP National Nurse Practitioner Sample Survey, part I: an overview. J Am Acad Nurse Pract. Sep 2005;17(9):337-341.

6.            American Academy of Physician Assistants. Data and Statistics.  http://www.aapa.org/research/index.html, 2009.