Resolving Primary Care and Basic Health Access Shortages
Robert C. Bowman, M.D.
The United States has a design that is quite unique for primary care. Most graduates trained in primary care training programs fail to be found in primary care during their careers. The amount of primary care delivered per graduate continues to fall with each passing year and with each passing class year. This design is certainly not the permanent primary care design of other nations with a dependable primary care contribution based on simply the number of graduates. The influences upon primary care capacity are readily seen as policy resulting in production and retention of primary care (or lack thereof) as well as influences regarding admission and training.
A reality check is involved. One way to face reality is to understand how many graduates would be required just to result in the same primary care as peak primary care levels in the 1990s. During the 1998 class year the United States produced about 300,000 Standard Primary Care Years of primary care from the five sources – internal medicine, pediatric, family medicine, nurse practitioner, and physician assistant training programs.
In the United States the primary care per graduate has continued to decline each year. Only during the 1990s with multiple simultaneous policy changes favorable to primary care as well as decreasing reimbursement for specialty care were able to hold primary care per graduate steady (but overall still not an improvement). It is safe to say that primary care per graduate will continue to decline for all types of graduates even with the minimal changes in reimbursement proposed.
So how much primary care can we expect from the 5 different primary care forms and how many graduates would it take to produce the primary care of the 1998 class year?
Graduates Required to Return to 1998 Class Year Production and Retention of Primary Care
|
|
Primary Care Retention Percentage Average for a Career |
Active Percentage Through an Average Career |
Years in a Primary Care Career |
Volume Average Compared to Top Primary Care Volume |
SPC Years per Graduate for a Career |
Annual Graduates Required For 1998 Primary Care Production |
|
Internal Medicine |
10% |
75% due to FIMG |
31 due to FIMG |
83% |
2 |
150,000 |
|
Pediatrics |
50 – 60% |
84% |
35 |
95% |
14 – 16 |
20,000 but wrong ages and locations |
|
Nurse Practitioners |
30 – 40% |
60% |
27 |
60 – 70% |
3 – 4 |
75,000 - 100,000 |
|
Physician Assistants |
25% |
70% |
35 |
70% |
3 – 3.5 |
85,000 to 100,000 |
|
Family Physicians |
85 – 90% |
85% |
35 |
100% |
25 |
12,000 |
No other existing source of primary care other than family medicine or family medicine plus pediatric primary care can address past needs or move toward future needs with 350,000 or 400,000 Standard Primary Care Years required of the 2020 class year. The levels shown above only begin to address the gap in primary care and basic health access.
To return to 1998 levels of primary care production would require graduates that have the most years in a primary care career, the most retained in primary care, the most remaining active in health care, and the top volume of primary care per graduate. In addition this graduate would need to have a track record of distribution to rural populations and to underserved populations at greater than average levels. Flexible primary care forms of internal medicine, nurse practitioners, and physician assistants have become sources of hospital and specialty workforce where most graduates are found. Expansions in IM, NP, and PA make sense only for specialty workforce. Generic expansions of physicians and non-physicians do not result in improvements in primary care workforce. For the last 30 years the increases in physicians and non-physicians have favored specialty care rather than primary care and basic health access and this will continue throughout the current expansions in this decade and next.
Physician Production of Specialty Versus Primary Care 1998 to 2008 Substantial increases in specialist workforce now enter the US workforce from all sources of physicians. While current specialist levels may be a concern, more than enough positions have been converted to specialty workforce production. But of course this has come at a cost of primary care production. In addition, massive new specialty workforce arises from existing primary care internal medicine, nurse practitioners, and physician assistants.
Non-Physician Production of Specialty Versus Primary Care 1988 to 2018 - Specialty care has consistently been produced at higher levels with greater reductions of primary care contributions in the past decade and the decade to come at current rates of departure from primary care steady for over a decade.
Only family medicine residency graduates remain in primary care, remain active, deliver the top volume, and remain distributed to the populations in most need of health access. Other forms of primary care fail to remain in primary care or in the broad generalist family practice mode that does distribute where needed. Family medicine is documented with multiple times the ambulatory care delivered to the elderly and to adults compared to primary care forms with more graduates. Family medicine delivers multiple times more care for Community Health Centers, rural locations, underserved locations, poor, near poor, patients with lower education levels, and all of the most complex populations.1-4 Physicians born in predominantly African American rural counties are found returned to such counties at 25% and family medicine choice doubles the rate of return to 50%. Family medicine, except where excluded by practice locations with top concentrations of physicians, remains instate at the highest levels resulting in a much better return on investment for states that have invested in instate students during education and higher education and medical education. Family physicians are resistant to health policy that drives practitioners away from primary care. The same health policy design also drives physicians out of state to locations with top concentrations of physicians. States without medical schools and graduate medical education concentrations are being left in the dust. Even states with medical schools face the prospect of only 30% instate retention instead of 50 - 60% levels, grossly insufficient when these schools are responsible for half of the state's physicians.
The only problem with family medicine is failures in the United States regarding those most likely to become family physicians. The United States has a massive failure in child development, early education, and higher education for lower and middle income children that are most likely to become family physicians. United States medical schools are less and less likely to admit the lower and middle income children most likely to become family physicians. Also US medical education fails to include specific primary care and health access training that results in 100% primary care graduates that remain in primary care.
The one size design that is supposed to fit all in American education, American higher education, American medical education, and American health policy results in most Americans not having basic health access. The majority of Americans left behind in education, economics, and other distributions are also left behind in basic access to health care in workforce and resources and the economics related to health care. By the way, the lower and middle income children are essential sources of teachers, nurses, public servants, and other basic serving human infrastructure, so more than just basic health access infrastructure is involved.
Most importantly for health care, a better child is a better student, is a better employee more likely to have health care coverage, and makes better decisions regarding when to access health care and what to do about health care not related to physicians, which is actually most of health care decision making.
The Standard Primary Care Year
The Health Access Medical School: The Only Health Access Recovery Solution
1. 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.
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. Mold JW, Fryer GE, Phillips RL, Jr., Dovey SM, Green LA. Family physicians are the main source of primary health care for the Medicare population. Am Fam Physician. Dec 1 2002;66(11):2032.
4. Bowman RC. Measuring Primary Care: The Standard Primary Care Year. Rural Remote Health. Jul-Sep 2008;8(3).
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