Instate Office Primary Care Contributions

 

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

 

Most states are in big trouble regarding basic health access primary care workforce. The United States does not even understand what true primary care workforce is. Not only that, but all states are producing insufficient primary care that remains primary care. Finally the physician and non-physician workforce produced by many if not most states, will be leaving for other states. In each case the gradient is provided by US health policy that moves primary care away from primary care (destructive policy); by US health policy that moves physicians and non-physicians to other states that have greater concentrations of physicians, health funding, economics, and people; and by US health policy that fails to support health care for the populations that most depend upon primary care.

This study includes tables for the individual medical schools divided into four medical school quartiles regarding instate primary care contributions. It is even more tragic to deliver the really bad news. This is older data based on 2005 practice locations that reflect 2003 and 2004 locations. In the past 5 years, serious changes have resulted in far less primary care. All of the medical schools listed make lower contributions to primary care as health policy changes have decreased primary care capacity greatly. The last medical school to fall prey to policy was the school that focused most on permanent primary care and rural workforce contributions. Up until 2008, Duluth managed to maintain 46% family practice choice. Family practice is the most important instate primary care component. Duluth has not changed admission and training, but Duluth appears to have succumbed to US health policy with a decline to 36% family medicine for 2009 graduates.

 

The greatest declines have involved schools declining the most in family medicine graduates. The values were calculated using 30 years of primary care for family practice residency graduates and for residency graduates expected to remain in office based general internal medicine and office based general pediatrics. Since these figures were compiled, internal medicine retention in primary care has declined even further. Only 10% of recent graduates are expected to remain in primary care. Pediatric primary care retention is heading for 50%. Levels would be even lower without 15% of white females consistently choosing pediatric primary care.

 

Instate primary care is about graduating physicians that remain in primary care that also remain instate for practice. A number of factors determine instate primary care such as medical school admission and training, state health policy regarding primary care, graduate medical education training, economic considerations, and geographic considerations (large state, island, peninsula, coastal, few competitive neighbor states and the fewest tough competitors such as high growth or high recruitment states).

 

Top Quartile Above 6.28 Instate Primary Care Years Per Graduate

		Total	Instate Office Primary Care %	Instate Primary Care Years Per Grad	Office Primary Care %	Office Primary Care Years	Ratio Instate to Total
Duluth	MN	235	39.6%	11.87	60.4%	18.13	65.5%
Mercer	GA	427	37.7%	11.31	51.8%	15.53	72.9%
UC Irvine	CA	1061	32.4%	9.73	38.5%	11.54	84.3%
UC Davis	CA	1055	31.4%	9.41	42.7%	12.82	73.4%
Western Osteopathic	CA	1422	30.0%	9.01	54.8%	16.43	54.8%
Wright State	OH	1028	27.5%	8.26	47.9%	14.36	57.5%
U North Texas Osteopathic	TX	1103	26.8%	8.05	41.2%	12.35	65.2%
Michigan St Osteopathic	MI	1398	26.5%	7.94	38.0%	11.39	69.7%
Ohio U Osteopathic	OH	1088	25.9%	7.78	38.6%	11.58	67.1%
U of Minnesota	MN	2568	25.9%	7.76	38.9%	11.68	66.4%
U of Massachusetts	MA	1165	25.8%	7.75	41.7%	12.52	61.9%
UC San Diego	CA	1401	25.5%	7.64	35.6%	10.69	71.5%
Brody East Carolina	NC	807	25.4%	7.62	37.5%	11.26	67.7%
Arkansas	AR	1519	25.3%	7.60	39.6%	11.87	64.1%
UCLA	CA	2077	25.3%	7.58	33.1%	9.94	76.3%
Morehouse	GA	352	25.0%	7.50	47.4%	14.23	52.7%
Hawaii	HI	656	25.0%	7.50	38.9%	11.66	64.3%
East Tennessee State	TN	662	24.2%	7.25	36.4%	10.92	66.4%
NY Osteopathic	NY	1804	23.8%	7.15	40.6%	12.19	58.7%
U of Southern Cal	CA	1753	23.8%	7.14	30.5%	9.16	77.9%
Nova SE Osteopathic	FL	1254	23.8%	7.13	41.7%	12.51	57.0%
U of Texas Houston	TX	2207	23.7%	7.10	34.9%	10.47	67.8%
Michigan St Allopathic	MI	1224	23.0%	6.91	42.5%	12.75	54.2%
UT San Antonio	TX	2309	23.0%	6.90	33.7%	10.12	68.2%
U of Tennessee	TN	1803	23.0%	6.89	36.2%	10.85	63.5%
U of Arizona	AZ	1047	22.9%	6.88	38.4%	11.52	59.7%
Southern Illinois	IL	806	22.8%	6.85	43.2%	12.95	52.9%
U of Washington	WA	1899	22.8%	6.84	40.6%	12.18	56.2%
UC San Francisco	CA	1745	22.1%	6.62	34.3%	10.30	64.3%
Texas Tech	TX	1156	22.0%	6.59	32.2%	9.65	68.3%
South Alabama	AL	733	21.4%	6.43	38.9%	11.66	55.1%
Texas A & M	TX	547	21.2%	6.36	30.9%	9.27	68.6%
Oregon	OR	1050	21.0%	6.31	35.9%	10.77	58.6%
U of Louisville	KY	1471	21.0%	6.30	34.0%	10.20	61.8%
U of South Dakota	SD	572	21.0%	6.29	43.4%	13.01	48.4%
Oklahoma St Osteopathic	OK	836	20.9%	6.28	38.9%	11.66	53.8%

 

Consistent levels of family practice choice above 35% was the defining characteristic of medical schools contributing the most to instate primary care and all location primary care. In these top distributional medical schools the internal medicine and pediatric residency graduates arising from these medical schools also had top levels of office primary care retention.

 

It is impossible to separate admission and training of the types of medical students associated with primary care capacity from family medicine, from retention of office based primary care, from more average MCAT scores, from a wider range of medical student parents, from older medical students, from a wider range of origins in a number of dimensions such as geographic, socioeconomic, culture, language. In each case the changes are generally in the direction of lower and middle income origins and matching to the United States population best instead of shifted 3 or 4 standard deviations to highest concentrations in origins, training, career choice, and health policy concentrations.

 

Osteopathic schools and the newer allopathic medical schools contributed the most.  Without the 1970s health policies that created new public medical schools that lead in all primary care categories and all six of the osteopathic public schools, the nation would have a much more serious primary care problem. The losses of 1970s family physicians and primary care physicians (primary care numbers quadrupled in the 1970s expansion) to inactivity and retirement are now a part of the current problems in primary care capacity and distribution.

 

The lack of state and federal support to shape medical education is one of the primary difficulties of the current era. Poor primary care reimbursement deflects medical students from the remaining permanent primary care choice of family practice, incents residents to leave generalist primary care careers to do fellowships, and destroys primary care capacity in nurse practitioners and physician assistants.

 

 

Background

 

Across the United States there is great uncertainty in primary care. Most have a sense that primary care capacity is decreasing, but the nation has no actual measure of primary care capacity. The nurse practitioner, physician assistant, and internal medicine forms that are thought to represent primary care are 70 – 90% specialty care. The so-called collapse of primary care is only a part of the larger collapse of all of health care into fewer locations. Super Center and Major Center locations have 75 or more physicians at a zip code and contain 50% of family physicians, 70% of internal medicine or pediatric generalists, 75% of physicians and 80 – 92% of most specialists, GME positions, and research positions. They continue to grow while urban and rural locations outside of super centers and major centers continue to shrink. Movements to major medical center careers and locations involve higher levels of transition out of state. Generalist physicians have the best opportunity to stay instate but again this depends upon state conditions relative to nearby states, powerful states, and the policies of the United States involving primary care support. Weaker states, powerful states who fail to invest their fair share in children, education, opportunity, higher education, and medical school positions, and policies that fail to support primary care all favor concentrations in major medical centers in fewer states and locations. Better investments in birth to admission, broader opportunity, and supportive national health policies involving primary care enhance primary care capacity in all states.

 

The author created a standard primary care workforce year using the results of the physicians most likely to remain in primary care and distribute to the most needed rural and underserved locations. Family physicians with rural origins that attended medical schools with the most focus on family practice, primary care, rural, and underserved locations were used to set the standard. In these schools the family physicians remained 96% in family medicine, 96% active, had the top primary care volume delivered 100%, and had an estimated career length of 35 years. This results in 32 years of primary care. More typical family physicians have 90% retention in primary care, 90% activity, and slightly lower volume of primary care for 29 years of primary care. When measured at the training program level, pediatric residents deliver about 16 years of primary care while flexible primary care training forms (IM, NP, PA) deliver 2 – 4 Standard Primary Care Years per graduate.

 

The rapid collapse of internal medicine has been unanticipated, but fits with internal medicine graduates receiving by far the greatest benefit from specialization. Using 1987 – 2000 graduates, the internal medicine graduates remaining in generalist office based internal medicine as well as the office based pediatricians were counted as 30 years of primary care. This is a known overestimate as the US has lost 30,000 internal medicine generalists to hospitalist careers in the past 6 years alone.

 

The primary care workforce year estimates are a way to attribute all of the future primary care years to a single class year. This can include all graduates in a school or a program or a physician origin. Class year contributions also reveal much about health policy with 1990s class years maximal in primary care capacity. Medicaid doubled from 1990 to 1995, managed care pushed graduates into family medicine choice and internal medicine residents into primary care careers, and the nation sequentially shifted more reimbursement to primary care and away from specialty and hospital care. Since this period of time complete reversals of policy combined with rapidly rising costs of delivering care have destroyed primary care numbers, choices, retention, and durations. Good primary care policy years greatly expand the potential for primary care capacity through a number of mechanisms. Poor policy years distract, divide, and fragment primary care capacity and kill off primary care practitioners directly and indirectly.

 

Different types of medical schools make different contributions to the nation’s primary care capacity. The schools that exclude the students most likely to choose primary care by selecting those with the highest scores, by training environments involving the lowest exposures to primary care, and by training students away from primary care in mission and curriculum graduate the fewest family physicians. Their graduates are also least likely to remain in generalist internal medicine and pediatric careers. Distributional medical schools admit the broadest range of medical students in scores, origins, ages, and socioeconomic levels; focus more specifically on family practice in mission, admission, training, and training environment, graduate more family physicians, retain more in office based generalist primary care, deliver more primary care volume per graduate, deliver more primary care in underserved locations, deliver more primary care outside of major medical center concentrations where primary care levels are most often adequate, deliver more geriatric care, deliver more economics of health care to areas in need of economics, and deliver more care to less educated populations, populations with less health care coverage, populations with lower income and lower social organization, populations with higher need, and populations with the lowest physician concentrations.

 

This article is written from the perspective of instate contributions. In the first table different types of medical schools are listed by their office primary care graduates for the class years of 1987 – 1998, the percentage of Office Primary Care Physicians in Instate Practice, and the Instate Office Primary Care Years or the number of office primary care physicians multiplied by 30 years per graduate divided by the total medical school graduates.  The West Coast Distributional schools include UCLA, the University of California Irvine, the University of California Davis, and the University of Washington. These are schools that have admitted a broader range of students, focused on primary care, and graduated higher levels of family physicians, at least for this time period. About 1633 of the 6092 graduates of the 1987 – 1998 class years remained in office primary care and instate for practice resulting in 8.04 instate office primary care years. States such as California that are large and have fewer neighbors and fewer competitive border areas retain larger shares of graduates. States with stronger economics, more physicians, and different geography (island, peninsula, and coastal geography) have fewer physician losses. Other states have multiple neighbors who are often economically stronger presenting difficulties with instate retention. Some states manage to retain more even with multiple competing neighbors. This takes a very coordinated statewide effort involving birth to admissions, training, and policy. Some states have no true medical school or few instate medical school positions. This creates a number of problems such as poor selections of the students who will return to serve a state (choice of those who specialize and leave rather than those who return and serve primary care needs), less training experiences instate, fewer graduate medical education positions instate (hurts all access to all 3 physician sources allopathic, osteopathic, and international), and neglected instate health policy development.

 

 

Types of Medical Schools, Primary Care, and Instate Primary Care

	FPGP	Off PC	Total PC Years Per Grad	Instate PC Years Per Grad	% PC Remaining Instate
Allopathic Private
Historically Black	19.0%	38.3%	11.48	2.37	20.6%
MCAT 10.5-12	5.0%	21.5%	6.45	2.13	33.0%
MCAT 10-10.5	8.6%	26.3%	7.90	2.43	30.8%
MCAT 9.5-10	11.0%	29.0%	8.69	2.91	33.5%
MCAT 9.25-9.5	13.2%	29.8%	8.93	2.49	27.8%
MCAT 8.5-9.25	29.1%	48.8%	14.65	8.56	58.5%
Allopathic Public
UMKC NEOUCOM	13.3%	28.9%	8.66	4.52	52.2%
West Coast Distributional	20.2%	38.0%	11.41	8.04	70.4%
MCAT 10.5-12	10.5%	27.9%	8.36	4.48	53.7%
MCAT 10-10.5	17.0%	33.6%	10.07	5.30	52.7%
MCAT 9.5-10	14.2%	31.5%	9.46	4.84	51.1%
MCAT 9.25-9.5	17.5%	33.9%	10.17	6.03	59.3%
MCAT 8.5-9.25	19.7%	36.3%	10.90	6.13	56.2%
Osteopathic Private	35.2%	43.8%	13.14	4.91	37.4%
Osteopathic Public	36.2%	39.7%	11.90	7.10	59.7%
US Graduates Not Military or Puerto Rico	15.6%	31.6%	9.49	4.47	47.1%

Primary care physicians associated with military medical school or family practice residency are most commonly listed as hospital based. Graduates past the 1998 class year or before 1987 have higher levels of primary practice activity listed as residency, not classified, inactive, researchers, or administrators.

 

 

 

	Office Primary Care in Instate Practice	Total Graduates 1987 – 1998	% Office Primary Care in Instate Practice	Instate Office Primary Care Years
West Coast Distributional	1633	6092	26.8%	8.04
Osteopathic Public	1369	5781	23.7%	7.10
MCAT 8.5 – 9.25	3740	18079	20.7%	6.21
Allopathic Public	21040	118287	17.8%	5.34
MCAT 9.25 - 9.5	4365	24878	17.5%	5.26
Osteopathic Private	2391	14597	16.4%	4.91
U MO KC, NEOUCOM Early Admit	331	2197	15.1%	4.52
MCAT 9.5 – 10	7817	54626	14.3%	4.29
MCAT 10 - 10.5	5057	39045	13.0%	3.89
Puerto Rican	358	3126	11.5%	3.44
MCAT 10.5 – 12	3375	35558	9.5%	2.85
Allopathic Private	5837	69420	8.4%	2.52

 

 

 

One point must be clarified. In the past decade primary care contributions from each of these medical schools have decreased substantially with family practice choice cut in half and with declines from 50% to 25% for internal medicine residents remaining in office based primary care.

 

Top Quartile Above 6.28 Instate Primary Care Years Per Graduate

		Total	Instate Office Primary Care %	Instate Primary Care Years Per Graduate	Office Primary Care %	Office Primary Care Years	Ratio Instate to Total
Duluth	MN	235	39.6%	11.87	60.4%	18.13	65.5%
Mercer	GA	427	37.7%	11.31	51.8%	15.53	72.9%
UC Irvine	CA	1061	32.4%	9.73	38.5%	11.54	84.3%
UC Davis	CA	1055	31.4%	9.41	42.7%	12.82	73.4%
Western Osteopathic	CA	1422	30.0%	9.01	54.8%	16.43	54.8%
Wright State	OH	1028	27.5%	8.26	47.9%	14.36	57.5%
North Texas Osteopathic	TX	1103	26.8%	8.05	41.2%	12.35	65.2%
Michigan St Osteopathic	MI	1398	26.5%	7.94	38.0%	11.39	69.7%
Ohio U Osteopathic	OH	1088	25.9%	7.78	38.6%	11.58	67.1%
U of Minnesota	MN	2568	25.9%	7.76	38.9%	11.68	66.4%
U of Massachusetts	MA	1165	25.8%	7.75	41.7%	12.52	61.9%
UC San Diego	CA	1401	25.5%	7.64	35.6%	10.69	71.5%
Brody East Carolina	NC	807	25.4%	7.62	37.5%	11.26	67.7%
Arkansas	AR	1519	25.3%	7.60	39.6%	11.87	64.1%
UCLA	CA	2077	25.3%	7.58	33.1%	9.94	76.3%
Morehouse	GA	352	25.0%	7.50	47.4%	14.23	52.7%
Hawaii	HI	656	25.0%	7.50	38.9%	11.66	64.3%
East Tennessee State	TN	662	24.2%	7.25	36.4%	10.92	66.4%
NY Osteopathic	NY	1804	23.8%	7.15	40.6%	12.19	58.7%
U of Southern Cal	CA	1753	23.8%	7.14	30.5%	9.16	77.9%
Nova SE Osteopathic	FL	1254	23.8%	7.13	41.7%	12.51	57.0%
U of Texas Houston	TX	2207	23.7%	7.10	34.9%	10.47	67.8%
Michigan St Allopathic	MI	1224	23.0%	6.91	42.5%	12.75	54.2%
UT San Antonio	TX	2309	23.0%	6.90	33.7%	10.12	68.2%
U of Tennessee	TN	1803	23.0%	6.89	36.2%	10.85	63.5%
U of Arizona	AZ	1047	22.9%	6.88	38.4%	11.52	59.7%
Southern Illinois	IL	806	22.8%	6.85	43.2%	12.95	52.9%
U of Washington	WA	1899	22.8%	6.84	40.6%	12.18	56.2%
UC San Francisco	CA	1745	22.1%	6.62	34.3%	10.30	64.3%
Texas Tech	TX	1156	22.0%	6.59	32.2%	9.65	68.3%
South Alabama	AL	733	21.4%	6.43	38.9%	11.66	55.1%
Texas A & M	TX	547	21.2%	6.36	30.9%	9.27	68.6%
Oregon	OR	1050	21.0%	6.31	35.9%	10.77	58.6%
U of Louisville	KY	1471	21.0%	6.30	34.0%	10.20	61.8%
U of South Dakota	SD	572	21.0%	6.29	43.4%	13.01	48.4%
Oklahoma St Osteopathic	OK	836	20.9%	6.28	38.9%	11.66	53.8%

 

Consistent levels of family practice choice above 35% are the primary characteristic of all of the medical schools contributing the most to instate primary care and all location primary care. In these top distributional medical schools the internal medicine and pediatric residency graduates from these medical schools also have top levels of office primary care retention. It is impossible to separate admissions of the types of medical students associated with primary care capacity from primary care emphasis in training from family medicine and from office based primary care retention.

 

Osteopathic schools and the newer allopathic medical schools make top contributions. The osteopathic public schools as a group have consistently excellent contributions across family practice, primary care, rural, and underserved careers. Without the 1970s health policies that created new medical schools, the nation would have a much more serious primary care problem. The lack of state and federal support to shape medical education is one of the primary difficulties of the current era. Poor primary care reimbursement deflects medical students from the remaining permanent primary care choice of family practice, incents residents to leave generalist primary care careers to do fellowships, and destroys primary care capacity in nurse practitioners and physician assistants.

 

 

Second Quartile of Instate Primary Care Contributions at 4.58 to 6.27 Years

		Total	Instate Office Primary Care %	Instate Primary Care Years Per Graduate	Office Primary Care %	Office Primary Care Years	Ratio Instate to Total
U of Colorado	CO	1498	20.9%	6.27	35.4%	10.61	59.1%
UMDNJ Osteopathic	NJ	661	20.9%	6.26	41.0%	12.30	50.9%
U of Indiana	IN	3054	20.8%	6.24	32.5%	9.76	63.9%
U of South Carolina	SC	733	20.7%	6.22	35.9%	10.76	57.8%
U of Mississippi	MS	1159	20.5%	6.16	33.5%	10.04	61.3%
Philadelphia Osteopathic	PA	2473	20.5%	6.14	38.5%	11.56	53.1%
U of Missouri Columbia	MO	1226	20.4%	6.12	36.9%	11.08	55.2%
U of Kentucky	KY	1034	20.0%	6.01	36.2%	10.85	55.3%
LSU Shreveport	LA	1117	19.9%	5.96	31.7%	9.51	62.7%
Med Col Georgia	GA	2066	19.5%	5.84	33.5%	10.05	58.1%
LSU New Orleans	LA	1991	19.2%	5.77	29.8%	8.94	64.6%
U of Nebraska	NE	1431	19.1%	5.74	35.2%	10.55	54.5%
U of South Florida	FL