Ducking Health Access: the National Studies

If it looks like a duck, swims like a duck and quacks like a duck, then it probably is a duck.

But logical arguments are not always completely logical, practical, or relevant.

There are five primary care training forms that look like primary care, take care of patients like primary care, go to various government entities to get funding support, and get paid the same lowest rates for those remaining in primary care.

But studies including entire national populations reveal the inconsistencies. The newest family practice residency graduates will deliver 25 Standard Primary Care years per graduate. This is a level that is at least 6 to 10 times the primary care per graduate of the 2008 internal medicine, nurse practitioner, and physician assistant graduates. These flexible primary care forms that depart primary care with each passing month deliver only 2 – 4 Standard Primary Care Years per graduate and the actual value has declined with each passing year.

The most simple explanation is possible. Family physicians continue to look like primary care, stay in primary care, stay where they are most needed, and remain in place despite the worst health access policy in decades. The flexible primary care forms (IM, NP, and PA) leave primary care during training, at graduation, and each year after graduation.

While other nations can count primary care doctors and count on their primary care doctors delivering primary care, this is not possible in the United States. Each form of primary care is different in the number of years in a career, the volume of primary care, the % remaining active in practice over a career, and the % actually remaining in primary care over a career. Studies by Bowman capture these 4 factors in a Standard Primary Care Measuring tool assessing actual delivery.

Estimates for the number of years in a career, the percentage remaining in primary care over a career, the percentage remaining active in health care, and the percentage of volume of primary care delivered (compared to the top volume standard set by family physicians) are compared for each specialty and are also unique to the class year of graduation. 

Primary care delivery can be calculated for one form of primary, all forms, all forms for a class year, certain types of schools, individual schools or programs, or contributions past, present, and future.

No studies can capture actual primary care graduates in the United States because the graduates vary so much in actual delivery of primary care. This is not true in other nations with permanent primary care in design and in workforce. This was not always the case in the US. Primary care graduates have decreased from 20 Standard Primary Care years to 6 SPC years per graduate. As seen in the graphic, a permanent primary care form would have continued to deliver 25 SPC Years per graduate. The US design for primary care tolerates a steady destruction of primary care to 6 Standard Primary Care years per graduate with expected decline to only 4 SPC years per graduate.

Primary care delivery requires the actual delivery of primary care. Graduates with delays in entry of 8 years or more (nurse practitioners, foreign born international medical graduates), with the most graduates inactive or outside of the United States or part time (NP, FIMG), with the lowest primary care retention (IM, PA, NP), and with the lowest volume of primary care delivered (NP) are greatly limited as training sources of primary care. Other national studies reveal that those in most need of efficient and effective primary care have chosen the permanent primary care form delivering the most primary care.

National studies by Rosenblatt in JAMA reveal that family physicians are found in Community Health Centers at 50% greater numbers compared to nurse practitioners2 even though family practice graduates are outnumbered almost 2 to 1 by the 160,000 graduates of nurse practitioner programs. Even after a 10 year period of graduating twice as many nurse practitioners per year compared to family physicians, nurse practitioners still remain behind.  What few understand that as nurse practitioners depart primary care and the broad generalist family practice mode, they also depart basic health access.

This CHC location pattern represents a natural experiment that is most instructive. The centers that represent the nation’s choice for care of the underserved have chosen family physicians over all other physician and non-physician primary care forms. As indicated by the study, those most sought by CHCs at the current time are family physicians and basic health access registered nurses. Both will be in major shortage long past 2020. The nation has finally decided to add financial support for CHCs comes at a time when the nation’s workforce is galloping away from care of those left behind.

Another consideration in health access involves location, location, location. Expansions of pediatricians cannot help primary care. The most basic fact is that there are fewer American children. In addition the Committee on Pediatric Workforce has noted that pediatricians are limited in rural and in underserved locations, preferring to remain in practice locations with higher concentrations of people and physicians.3 Outside of 4% of the land area in top concentrations and beyond 4 years of age, it is the family practice forms that take over basic health access roles for children. More pediatricians cannot address rural pediatric needs with decades of decreasing rural choice.4

Studies by Bowman using the 2005 Masterfile revealed that primary care is actually saturated in 3386 zip codes with top concentrations of physicians and health resources, commonly around medical school locations. The locations with concentrations of physicians represent zip codes with 75 or more physicians. These zip codes represent 4% of the land area and 35% of the population. Not only are physicians concentrated together at highest levels, the zip codes with concentrations of physicians are also clustered tightly together (Manhattan, Boston, Texas Medical Center, many others). This translates to even more concentration than a simple representation of just 4% of the land area. Populations at these 3386 zip codes enjoy ready access to 75% of the nation’s physicians and a much higher ratio of physicians to population.

Outside of locations with concentrations, the ratios are much different. The 65% of the United States population outside of top concentrations has only 20 - 25% of physicians. This is a one to three ratio of physicians to population. There is only one type of primary care that avoids the inequities of this United States health policy design – the broad generalist family practice mode.

For those left behind including 70% of the elderly and 60 – 65% of children, only family practice MD, DO, NP, and PA forms match up with 50 – 60% of the various family practice types found in zip codes outside of concentrations.

This contrast is important to understand.

·         Family practice MD, DO, NP, PA – distribution according to population

·         All others not family practice including nurse practitioners and physician assistants not practicing in the broad generalist FP mode – concentrate in locations with concentrations of physicians, health resources, and people

The contributions of the various forms of primary care can be considered using ambulatory care studies such as the Medical Expenditure Panel Study (MEPS). Four different age groups were studied by Ferrer using 2004 MEPS data. In this study, family physicians were found equitably distributed across all types of United States populations by geography, by poverty level, or by various origins.5 The age group breakdowns also reveal the advantages of a primary care form that stays primary care, stays active, and delivers the top volume of primary care.

Adult

Senior

Women's

Pediatric

Any ambulatory visit

69.6%

92.2%

71.5%

70.4%

Family physician/GP

43.4%

62.7%

39.0%

20.2%

Surgical specialty

23.7%

49.3%

14.0%

12.3%

Medical specialty

20.6%

44.7%

11.2%

6.3%

General internist

13.5%

28.9%

6.7%

Nurse-practitioner

10.8%

18.5%

12.7%

7.5%

Other specialty

8.7%

16.7%

6.2%

2.9%

Psychiatrist

2.9%

1.7%

3.0%

Physician’s assistant

2.8%

3.2%

3.5%

1.5%

Obstetrician/gynecologist

31.0%

Pediatrician

45.3%

From 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.

First of all it is important to have a baseline. About 70% of Americans in 2004 had ambulatory visits except for those over age 65 where over 90% had ambulatory visits. Family physicians led in all ambulatory categories except in pediatrics. However ambulatory visits are stacked to the extremes of the very young and very old. Pediatricians see the very youngest less than age 4. The family physicians take over care increasingly after age 4 and for populations outside of the current concentrations of pediatricians.

Surgical and medical specialty physicians are the next group, then general internists. It is of note that substantial losses of internal medicine physicians, current and future, to hospital and specialty careers, will result in massive gaps in ambulatory care.

Nurse practitioners follow, but this is an appropriate term as nurse practitioners, except for those remaining in the family practice mode, are following internal medicine pathways to cardiology (already 6%), oncology, and other hospital and specialty careers.

Physician assistants have the lowest contributions despite rapidly increasing graduate numbers. This is primarily due to increasing emergency, orthopedic, and subspecialty percentages that now claim over one-third of existing physician assistants. The losses in all physician assistants have been primarily from the family practice mode over the last 12 years and primary care percentages have declined by 1 – 2 percentage points a year during this time period.

Ob-Gyn physicians are second to family physicians for women’s health, remain hospital focused, and are limited in the health care needs by age and location.  Actually ob-gyn physicians have the edge when adjusted for fewer numbers of ob-gyn physicians. But the family medicine contribution is remarkable given the scope of ambulatory care covered.

Again beyond the concentrations of physicians in 3386 zip codes with 75% of physicians, the family practice modes dominate. This is because family practice modes remained balanced at 50% inside and 50% outside of concentrations while all other specialties in MD, DO, NP, and PA remain inside of concentrations in 4% of the land area.

Family practice forms of DO, MD, NP, and PA are the most important health access solutions for the United States at the current time just as in decades past and in decades to come. The family physician forms remain relatively resistant to the current health policy design that has melted other forms of primary care.

Unfortunately primary care training does not always mean primary care practice. The nurse practitioner and physician assistant graduates are less and less likely to choose primary care each passing year. Also graduates of all previous class years fall away from primary care. This includes those who were formerly in the family practice mode of care. Following current health policy and market forces to salaries $10,000 more or greater per year, they are departing primary care for hospital and specialty careers. The flexible primary care nurse practitioner, physician assistant, and internal medicine sources are melting away, leaving the family medicine and pediatric primary care forms as the permanent solutions.

Only family physicians remain steady in family practice, in primary care, in rural, and in underserved contributions. The United States enjoys 30 – 40 family physicians per 100,000 people across all types of practice locations. Family physicians are the major source of ambulatory health care for most Americans and will remain so.

This family physician characteristic is both bad and good. It is good to see family physicians as more and more dominant in basic health access. It is bad to see primary care graduates in any form driven away from health access. It is very bad to see the consequences of the current design where future family physicians are driven away from medical school, where medical students receive little or no encouragement toward family medicine careers, and where health policy involving health access is so poor that medical students cannot trust the government design enough to choose family medicine.

The United States has entered a fifth policy era, arguably the worst health access policy design of all.

·         No Health Access Policy – Prior to 1965 large segments of the United States population was left behind, particularly children and the elderly and lower and middle income America.

·         Reconstruction - It took 13 years from 1965 to 1978 to rebuild enough health access infrastructure to regain medical student trust in health access careers. The United States quadrupled primary care numbers from 1970 to 1980 with optimal recovery. The return of family medicine was the major improvement, emphasized by state and federal policy and backed by support for family medicine and primary care in medical education.

·         Neutral Policy – The levels of health access were sustained, but not advanced during the 1980s.

·         Return to Health Access – The 1990s reforms were necessary as health access funding was no longer sufficient to support primary care. The threat of managed care resulted in a massive shift of graduate medical education choices away from hospital based careers to primary care careers, especially family medicine. Family medicine levels peaked at 4000 graduates a year. Even medical schools and top concentrations of physicians were forced to hire as much primary care as possible to preserve market share and teaching volume.

·         Desertion of Health Access – The 1998 production of future primary care for all five forms was nearly 280,000 Standard Primary Care years per graduate or about 12 SPC years per graduate. In 2008 the nation actually have 2000 more “primary care” graduates, but the primary care delivery per graduate decreased to 7. This is due to internal medicine declines from over half of graduates to 10% remaining in primary care, declines of physician assistants from 54% primary care to half of this level, and similar declines of nurse practitioners. Because declines in primary care percentage involve all graduates at 1 – 2 percentage points a year, expansions of graduates can no longer increased primary care delivery. Expansions can only result in more hospital, hospitalist, urgent, emergent, and specialty care. Family practice residents can still be counted on for 3 decades of primary care per graduate, but there are only 3000 as compared to the 4000 of a decade ago. The end result is less than 200,000 Standard Primary Care years of graduates produced at a time when the national demand for primary care production should be nearing 400,000.

Deficits will continue to accumulate for the next decade since no changes in policy or design have been implemented. The investment of 18 billion in health information systems and the doubling of Community Health Centers and the National Health Service Corps cannot help.

Actual health access improvements are limited to just one choice now – more family practice residency graduates, specifically an increase to about 8,000 a year to put a dent in health access needs and to make sure the health access needs matches up to the populations in need of health access.

The other choices for health access would have to address an annual deficit of 200,000 SPC years accumulating with each new class year. The 200,000 would have to be divided by the 2 – 4 SPC years per graduate for the flexible primary care forms. In other words even with a mix of expansions, the 200,000 annual deficit in primary care production each year would require 50,000 to 75,000 additional internal medicine, nurse practitioner, and physician assistant graduates given their current career choices as shaped by health policy and market forces.

And each year of delay only makes matters worse as desperate people seek any available form of health care, including the forms that deliver the least health care and the lowest quality health care at the highest cost. And the source of workforce for these needs is existing primary care.

It seems like discussions of the Continuity Medical Home and other elite discussions and debates should wait until we actually find a way to keep continuity with primary care graduates keeping in primary care. Current decisions to expand physicians without a direct reliable expansion of graduates that will stay in primary care and nursing leadership decisions to take 2 more years away from workforce to train nurse practitioners as a nurse doctors (plus more faculty needed, plus more specialized focus, plus greater age before delivering care) just do not make sense.

Meanwhile family physicians remain steady in primary care. There are losses of family physicians out of primary care, but these are not the substantial losses found in other forms. But more family physicians could be lost in future years, if the national design continues to fail in basic health access.

The United States must move beyond “stealth capability’ in primary care. It must move beyond flexible forms of primary care that are produced and that exist, but they cannot be seen. Smoke and mirrors fail when the real health needs of most Americans are involved. Promises have failed, are failing, and will fail. The common sense, the science, and the practicality all demand primary care that remains in primary care. The nation needs about 12,000 graduates a year who actually remain for 35 years at 90% in primary care, 90% active, and 90% of the volume of a family physician.

This cannot be done by primary care graduates that only contribute 2 – 4 Standard Primary care years per graduate requiring 60,000 to 100,000 graduates a year.

What the nation must realize is that the definitions of primary care matter far less than primary care practitioners that actually see patients.

The Standard Primary Care Year considers (see Basic Concepts)

·         35 years in a health care career from age 30 to age 65 as compared to 27 years for nurse practitioners or international medical graduates due to delays in entry

·         the volume of primary care delivered rated from 100% or the actual volume of a family physician to nurse practitioners with 60% of the volume of a family physician

·         activity in practice (not part time or inactive) from 88% for physicians to 60% for nurses and nurse practitioners or 60% for international medical graduates with over 20% leaving the United States and 8% chronically unemployed

·         retention estimates for primary care ranging from 95% for family medicine residency graduates to 33% for nurse practitioners to 25% for physician assistants to 10% for internal medicine residency graduates.

The product of these four factors represents the Standard Primary Care years delivered. Family physicians deliver 25 SPC years in a career, pediatric residency graduates deliver 20, and the flexible primary care forms deliver less than 4 years of primary care per internal medicine, nurse practitioner, or physician assistant graduate.

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

2.            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.

3.            Committee on Pediatric Workforce. Pediatrician workforce statement. Pediatrics. Jul 2005;116(1):263-269.

4.            Randolph GD, Pathman DE. Trends in the rural-urban distribution of general pediatricians. Pediatrics. Feb 2001;107(2):E18.

5.            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.

 

Health Care: Dividing the Nation

Basic Health Access: Bringing a Divided Nation Back Together

www.basichealthaccess.org

www.physicianworkforcestudies.org

www.ruralmedicaleducation.org