Past, Present, and Future Primary Care in the United States
Health Access Recovery That Fails Versus True Recovery
Robert C. Bowman, M.D.
The United States has managed to design a health access plan that fails for a majority of Americans. The demand is particularly severe for about 20% in rural locations and for a slightlty different 20% in underserved locations. All told there are 65% of Americans found in zip codes with only 20 - 25% of physicians. This is because the health care design crowds 75% of physicians in 4% of the land area in 3400 zip codes.
There is really only one source of primary care that remains in primary care and remains serving the populations in most need. Family medicine physicians are 30 – 100% of the local health care available for most Americans, particularly the elderly. This is possible because family physicians are a small percentage of the physicians where saturations of physicians and primary care exist. What changes is not family physicians who remain 30 - 40 per 100,000 across nearly all populations. What changes is that other types of physicians as well as the non-family practice nurse practitioners and physician assistants melt away as concentrations of physicians, income, and people diminish.
The Family Physician, the sole remaining permanent source of primary care that goes and stays where needed is essential to health access recovery that works for most Americans. Family practice physicians have double, triple, or quadruple the rate of location of all other specialties even when controlling for origins, training, and age at graduation. Reference with table using logistic regression on complete populations of physicians
Production of primary care graduates is not the problem. The United States will likely increase so-called primary care graduates from all five sources (IM, NP, PA, PD, FM) to 45,000 by 2042 even without intervention.
Primary Care Graduation Numbers By Class Year Graphic
The steady increase to about 45,000 graduates by 2040 should be sufficient for primary care delivery in the United States. The problem is the peculiar design of American primary care that relies upon flexible forms that can go either way, to primary care or to specialty care. Even taken to extremes of graduates, flexible primary care fails in the basic delivery of primary care.
The reason is primary care retention problems for all forms of primary care. See Graphic.
Once again the problems are not primary care production, at least not numbers of primary care. The problem is retention and emphasis on primary care that stays primary care. Since the creation of nurse practitioners and physician assistants these non-physicians have found more and more useful purposes beyond most needed health access resulting in 2 to 3 percentage point declines in primary care on average for each year of their existence. From over 65% to half of this level and lower for the most recent graduates who have declines to come, as in the past decade.
The declines are shaped by current health policy as employers, specialists, nurse practitioners, and physician assistants all benefit from specialization. The process works for more money for all with more Americans left behind by lack of basic health access as precious and scarce primary care is converted to specialty care. This also results in the inevitable movement toward top concentrations of physicians and health resources that is resisted only by the family practice broad generalist forms that remain in family practice and in primary care. Those that remain are limited to family physicians alone.
When combining the annual production of primary care for all sources and dividing by the number of annual graduates, a Standard Primary Care year per graduate figure can be generated for each class year of graduates. The following graphic captures the steady decline in primary care. Once again the decline is not in numbers of graduates, which have increased. In fact physician assistants have doubled in the past decade with no additional primary care delivery added and with more primary care needed than ever before.
Primary Care Delivery - Decline in SPC Years per Primary Care Graduate 1970 to 2042
In the 1960 class year of medical students, the primary care retention was tracked by the American Medical Association and just over 50% remained in primary care at the close of their career. (Erdmann JB, Jones RA, Tonesk X, Dudley ME. AAMC longitudinal study of medical school graduates of 1960. Hyattsville, MD: U.S. Department of Health, Education, and Welfare, Public Health Service, Office of Health Research, Statistics and Technology, National Center for Health Services Research; 1979.
This 50% end point translates to about 70% primary care retention for an average 1960 primary care graduate over a 35 year career. Only family medicine graduates exceed this 70% retention figure with 90% or above for past class years. Pediatrics is falling below 50%. Nurse practitioners can claim only one-third primary care (with many missing graduates likely not to be in primary care not counted). Physician assistants began in 2008 with 28% primary care and will fall below 25% as predicted by 11 straight years of decline in annual surveys. Internal medicine has actually ceased as a source of primary care graduates as less than 10% remainfor future primary care over the next decades for the 2008 class years and beyond.
Past, Present, and Future Primary Care production can be tracked by class years of graduates.
Despite increasing graduates, the United States production of primary care (with primary care retention considered in the SPC year) is flat at a time when the US will double the elderly, will become more diverse, will require more complicated steps for basic health access practitioners, and will increasingly fail to have enough colleagues and support personnel (especially basic health access nursing).
There is one way to recover health access and one way to delay health access recovery.
Primary Care recovery can begin (still will take 50 years to resolve) with a steady increase to 5000 more family medicine graduates a year with an increase of 125,000 SPC years per graduating class by 2020 It is worth noting that primary care production would have been sufficient if permanent primary care had been implemented rather than flexible primary care which failed in the 1980s as well as since 2000.
Primary Care recovery is delayed or prevented by approaches such as the combination of 5000 more internal medicine graduates plus 5000 more nurse practitioner graduates plus 5000 more physician assistant graduates. A 50% increase in total graduates does not dent primary care production, just as a doubling of physician assistants failed to improve primary care delivery from the 1998 to the 2008 class years. Even with 15000 more annual graduates a year, it is not possible to turn 2 to 4 Standard Primary Care years per graduate into sufficient primary care workforce.
The good news (for some) that family medicine will increase in share of total primary care is really bad news for most of the nation. This is due to the fact that the US only graduates 3000 of the most efficient, effective, and lasting primary care graduates. The reason for family medicine share of total primary care increasing is because the other 4 primary care forms are moving away from primary care. This is the really bad news for most Americans.
With the intervention of 5000 more family medicine graduates by 2020 (up to 8000), the family medicine share increases, but the good news is that rural, underserved, Community Health Center, and elderly populations as well as those left behind have someone that will care for them. There is a choice of
Physician assistants in family practice could make a dent in needed health access, but they would have to sign contracts at admission to PA school to serve 20 or more years in most needed health access as a family practice physician assistant. Only those that stay, matter to most Americans.
Frankly anyone claiming primary care, including family physicians, should have to sign commitments to primary care at admission to a health professional school. It is the only way that deception can be reversed so that the nation can rely upon true primary care. The problem for flexible forms such as NP, PA, and IM is that they can do so much better by not signing a contract. Also health professional schools do better if they can claim primary care and get credit for primary care and yet not deliver primary care in graduates. Such is US health policy.
For government, the failures of the last two generations of leadership in politics and health care is a nightmare. With only days in office each new President and each new Congress for the next 20 or more years will be blamed for the past failures of the past two generations. This is because Americans fail to understand that basic infrastructures such as family structure, nurturing, child development, early education, basic access to higher education, and basic access to health all depend upon the last two or more generations to build, rebuild, and support the infrastructure for future generations.
5000 more family medicine residency graduates makes sense even when current definitions of primary care do not.
Health Care: Dividing the Nation Basic Health Access: Bringing a Divided Nation Back Together
www.physicianworkforcestudies.org
