Steps To Health Access

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

1. A national design must include an entire nation, not just a minority of the population with health care delivered in a small percentage of the land area with top concentrations

2. A basic primary care health access foundation must be laid – otherwise the most challenging and temporary reform periods are required to address basic care that continues to be steadily left behind

3. Nations must produce primary care that remains in primary care

4. Overproduction of basic health access primary care means workforce versatility and preparedness

5. Underproduction of basic health access means decades required to recover health access and reform a dysfunctional health system

6. Priority must be placed on the versatile broad generalist family practice mode of primary care

7. The general and generalist specialties most depend upon health access policy

8. Health access focus typically involves a majority left behind, not just the extremes of low concentration in income or people

9. The health professionals that serve the 65% left behind are more likely to arise from the 65% left behind

10. Permanent primary care training should be emphasized and should replace any flexible primary care training that can yield low or declining levels of primary care

11. Primary care training that fails to yield a majority of graduates remaining in primary care for an entire career should be changed in terminology to specialty training

12. Movements of primary care graduates toward hospital and specialty careers and away from family practice careers results in departures from health access

13. Best health access is the result of retention in a primary care specialty, retention in primary care, retention in a particular continuity location

14. Health access recovery requires a priority on increased years in a career, increased primary care retention, increased percentages of graduates remaining active, and increased volume of primary care delivered rather than fewer years, more inactive or part time, lower volume, and lower percentages remaining in primary care.

15. Grant programs are to be avoided as they are abused by the socially or politically organized. Those left behind by education, economic, health, public security, and other systems are also inevitably left behind by grant programs as compared to infrastructure type programs with reliable funding and long term planning capability

16. Health access is about working now for decades of basic health access to meet the top priority needs for the next generations rather than a focus on immediate health services often of questionable need

 

Unlike the carefully ordered steps to becoming a doctor, the steps to health access must all be addressed simultaneously. The effort must be maintained year after year for decades. Health access requires decades of planning. In a nation that has not set health access as a top priority separate from specialty care, health access graduates must be protected from abuses and misuses. This is all too obvious as tens of thousands of primary care internal medicine, nurse practitioner, and physician assistant graduates have been converted from primary care to specialty care in the past few years.

In the most recent years primary care policy has moved from optimal policy building up primary care to the worst possible policy – policy that results in destruction of primary care with the rapid conversion of existing primary care practitioners from primary care to specialty care.

·         The most recent devastation trades a small gain for hospitals and no gain overall for health care for a major loss of primary care internal medicine physicians. As hospitals shave fractions of a day of costs to improve profit margins the responsibilities for care are transferred to patients, to families, and to outpatient care. Since such patients are less and less likely to have continuity primary care sources under the current design and care is being transferred to physicians that exist on paper only. As primary care is more difficult to find, rural hospitals and Critical Access hospitals turn to hospitalists and emergency care. Of course they also hire locums physicians, hospitalists, emergent care physicians and physician assistants who previously made their health care contributions as rural primary care practitioners.

·         Locums brokers profit by converting continuity primary care to temporary primary care at higher cost resulting in more profits going to those not delivering any care. The process results in higher pay for temporary non-primary care that attracts more primary care away from primary care.

·         Urgent care and emergent care is no real substitute as care involves much higher costs. In turn patients with difficulty finding continuity primary care turn to emergent and urgent care and the downward spiral of cost, quality, and basic health access continues.

Discontinuity forms also result in less efficient use of lab, tests, referrals, and imaging made worse by lack of continuity with the patient. Training complicates matters. The focus of training is not missing a diagnosis rather than efficient and effective care. Since many health conditions do not have a diagnosis or a cure, cost and quality problems are magnified as each new encounter runs through the same futile options. Also since people in the United States have not experienced true continuity primary care, continuity primary care is poorly understood. Few understand that those who gain medical school and medical leadership positions were raised in families that went directly to any care that they desired. This is one reason why continuity primary care homes can cause a stir in medical leadership and in foundations since this centuries old concept of continuity seems so novel.

National studies of workforce distribution are helpful in illustrating the principles of health access. Even a simple division into practice locations associated with physician concentrations and practice locations outside of physician concentrations can be revealing. Locations with 75 or more physicians can be coded as locations with physician concentrations. About 3380 zip codes have top concentrations with 75% of physicians, 35% of the population, and 4% of the land area. This leaves just 23% of physicians to serve 30,000 zip codes with 65% of the population (2% for military and international). Also this 23% of physicians must serve 70% of the elderly, those in highest poverty, and others with the most complicated health care needs. They must also operate with the fewest health resources, the least updated facilities and materials, and the fewest colleagues.

Once again the United States divides health care into ultimate concentrations and the remaining populations left behind. Physician leaders concentrated over 90% in 4% of the land area fail to understand what is going on in health care for 96% of the land area and 65% of the population. Over 92% of physician researchers and 90% of graduate medical education positions are listed in 3400 zip codes with much higher concentrations in the few medical school zip codes where 90% of all medical education occurs. Medical education concepts are formed in locations that have top resources, the most lines of revenue, and the highest reimbursement in each line of revenue. They also have the fewest family physicians (4 – 5%, often less than 3% in top concentrations) and primary care physicians (16 – 20%) in the nation. Care is dominated by vertical segmented specialty care. Since health resources are also distributed according to the most specialized physicians with resource intensive hospital services, about 85 – 90% of health resources are distributed to these 3400 zip codes.

Understanding how divided health care has become and how it may work to divide the nation is an important concept. Also the types of medical students, training programs, and careers that can help reduce divisions are important.

A return to basics is indicated for all who lead the nation. Physicians have had the least primary care experience from birth to admission, during training, and after training. Nursing leaders appear to have forgotten about the most important aspects of nursing - enough nursing and basic health access nursing. Leaders in medicine have forgotten about having enough physicians in the basic health access careers. While there are a few that benefit from elite nursing or elite medicine or elite distributions of resources, these are not the bread and butter basics needed by most Americans. These are also not the choices that will help bring a divided nation together with better distributions of health, better distributions of health resources, and better distributions of the leadership represented by physicians.

Also the specialized medicine and specialized nursing leaders have the advantage of funding and time to further their agendas while the basic health access nurses and practitioners would rather just serve their patients.

Divisions 90% vs 10%, 80% to 20%, or 70% to 30% are a consequence of the United States design for health care again and again - too many physicians for some and too few for many, too much expenditure for some and too little expenditure for many, too much economics for health care distributed to some and too little health care resources distributed to far too many. These are basic understandings that must be illustrated before moving on with improvements in health care, health care access, and physician distribution.

The cornerstone of health access is enough health access nursing and nursing trained specifically in health access. This needs to be integrated with basic health access involving physicians and facilities. Basic health access nurses and physicians are also optimal for public health, disaster response, health care during pandemics, lower cost of health care, increase in quality, and access for an entire population instead of massive limitations. The current design completely ignores these priorities. The one thing that cannot be addressed in a pandemic or disaster is a shortage of 1 million nurses or a totally ineffective health care system as panic or damage wipes out most of the health care delivery in a state.

The health access priority in design has more than just single limited advantages. Perhaps the greatest advantage is resilience.

1.         A national design must include an entire nation, not just a minority of the population with health care delivered in a small percentage of the land area with top concentrations

This would seem to be common sense, but the current design fails for most Americans in one or more financial, facility, personnel, or proximity dimensions. An even more basic step is required. Health care leaders must understand the top priority of health access. Health care leaders have expressed that primary care is not marketable to American consumers as documented by Ferrer.1, 2, 5 In an era dominated entirely by market forces with health care designed to favor hospital and specialty careers, this is not a surprise.

New leaders are needed that understand that the top priority in health care design is basic access to health. The maximal benefit in health care cost, quality, and access is provided with a boost from no access to some access.

While it is possible to see that primary care faces great challenges in the usual locations frequented by health care leaders during the current destructive primary care policy era designed by these same health care leaders, the same health care leaders have lost awareness of 65% of the nation that depends upon primary care for 40 – 100% of physicians. Basic primary care is essential for most of the nation and the demand for primary care quadruples for Americans moving from age 50 to 75. This demand is increasing in the areas where only family practice forms of MD, DO, NP, and PA are found in greater concentrations.

2.         Nations Must Produce Primary Care That Remains Primary Care

The major error in studies of primary care is to study only the graduates who are currently in primary care. Any level of academic rigor requires missing graduates to be considered such as those who trained in primary care but are not in primary care (most primary care graduates), those who are primary care graduates but are inactive or part time (nurse practitioners, international graduates), and those who are primary care graduates but have left the United States (international graduates, 30% deliver no health care in the US). Those familiar with the proposed solutions for primary care deficits will find that the solutions also have deficits in remaining active in primary care and in the United States.

Those that hope to convince governments of their health access contributions must demonstrate efficient and effective primary care. These studies demand consideration of all graduates, not limited sampling.

When the major problem is failure to retain graduates in primary care, studies of only those found practicing in primary care fail utterly. Studies appropriate for an entire nation must include all graduates. Also when the major reason for poor primary care retention is bankrupt US policy regarding primary care, a failure to consider those leaving primary care misses the most important point that policy is destroying primary care.

When all graduates are considered with adjustments for retention, activity, volume, and years in a career in the United States workforce, the actual delivery of primary care can be considered. Primary care capacity does not involve a definition of primary care or even graduates who are practicing primary care. Primary care capacity is about more primary care delivered per graduate during an entire career.

Appropriate studies suitable for consideration of primary care capacity indicate major advantages for one particular form of primary care. Family practice forms are separated from all others in terms of optimal capacity. These studies result in greater than 25 years worth of primary care for a family medicine residency graduate and less than 4 years per graduate for nurse practitioner, physician assistant, and internal medicine graduates.  International medical graduates born in other nations that complete internal medicine residencies have the lowest primary care contribution of all at 1.2 standard primary care years.

If health care workforce studies reflected the reality of primary care capacity, major journals would not support the forms of primary care delivering the least primary care per graduate, but they do so regularly. Generic internal medicine, nurse practitioner, and physician assistant contributions are regularly noted.

Studies are needed that separate the family practice forms that are the most concentrated sources of basic health access, rural health care, underserved health care, women’s health care, care of the elderly, and care of the 65% of the nation that shares zip codes with only 23% of physicians.

Nurse practitioner, physician assistant, and physician leaders would no longer be able to promote generic expansions as solutions that are not really solutions for most of the nation. Nurse practitioners and physician assistants were solutions in the initial design with most beginning and staying in the family practice mode, but these years are long past.

Permanent Primary Care Forms

Family physicians remain in the broad generalist family practice mode that is most responsible for rural and underserved contributions at 95%. Family physicians remain 90% in primary care throughout their careers. Family physicians have the top activity shared by all physician forms at 86 %, family physicians have top primary care volume, and family physicians have the maximal 35 years (or more) for a career. In many ways the nation has shaped family physicians into optimal health access by excluding family physicians from areas with top concentrations and by paying less for primary care requiring more volume and activity and years. When pay is higher as in specialists, they work week is shorter, the vacations are longer, and the retirements and outside activities are greater.

The advantage of family physicians is actually the most important consideration for primary care. Family physicians remain in family practice, remain in primary care, and remain distributed in a pattern closest to the distribution of the United States population. When medical students pass up the choice of family medicine to become pediatricians they lose a decade of primary care and when they pass up family medicine for internal medicine, they lose two and a half decades of primary care. This is because internal medicine graduates remain only 10% in primary care and this is 2 Standard Primary Care years per graduate compared to 25 SPC years for a family physician.

Pediatric workforce considerations are entirely different. Expansions of pediatric residents utterly fail to help primary care where it needs help. These expansions involve the wrong ages and wrong locations and the wrong children in most need of care in the United States. This is due to limitations set by selection and training requirements that limit rural and underserved contributions.

Pediatric workforce crowds into saturations with 70% located in 4% of the land area in top concentrations of physicians.6  Fewer pediatricians (25%) choose to locate practices in the 30,000 zip codes where 65% of US children are found.

Pediatric residency graduates did have 80% primary care retention in the 1970s with slow declines to 70% that remained in the primary care supportive 1990s. After this period, the pediatric primary care retention levels have declined more rapidly with only 50 – 60% remaining in primary care and further declines expected each class year and each year after graduation. One of the factors responsible for slower decline is that pediatric specialists have not increased in salary as fast as internal medicine specialists.

Overall the pediatric residency graduate on average can be expected to contribute 15 years of primary care. There appears to be some retention after the first years of transitions although policy is so poorly supportive this is difficult to predict. Some retention appears to be determined even before medical school admission. About 15% of white female medical students choose pediatrics. They are more commonly higher income and urban in origin. Gender, pediatric choice, and concentrations in practice locations are consistent.

There are consequences of pediatric choices to concentrate. Concentrations of primary care lead to lowest salaries and these also are translated to the rest of the nation since the locations with concentrations set the policies for the rest of the nation. Primary care all appears to be alike in concentrations with low pay and support, but is very different for the remaining 96% of the land area outside of concentrations. Of course few physician leaders, students, residents, and national leaders grasp this difference.

Flexible Forms of Primary Care

Other forms of primary care (IM, NP, PA) are best described as flexible. This is not about lack of commitment. It is about health policy influences. Internal medicine, physician assistant, and nurse practitioner graduates melt away from primary care during training, at graduation, and each year after graduation. Coupled with activity, volume, and career length considerations, this results in 4 or fewer Standard Primary Care years of primary care per graduate. Less than a majority begin in careers with active delivery of primary care. Even for those beginning in primary care, departures are expected throughout careers for internal medicine, nurse practitioner, and physician assistant graduates. Market forces, health policy, higher salaries, hospitalist opportunities, urgent care, and lower personnel costs to health system employers will drive more from primary care with each passing year beyond graduation.

When considering geriatric (4%) and women’s health (11%) contributions, nurse practitioners can claim 56% in primary care or 22,000 assembled full time equivalents from 39,000 returned surveys. But physician and physician assistant measurements more commonly include internal medicine, pediatric, and family practice and do not include geriatrics or women’s health. A compatible nurse practitioner level was 41% in 2004. Since that time 5 more years of primary care declines of 1 to 2 percentage points a year have reduced this to a lower level. Given future declines likely to occur for years in 2008 graduates, a conservative primary care retention percentage would be 33%. Government reports may give geriatrics as primary care but still about one-third are in primary care. It is important to remember that geriatric and other specialty nurse practitioners are tied to facilities and concentrations of specialists while the family nurse practitioners that remain in the broad generalist family practice mode (20 – 25% at most) deliver the rural, underserved, and most needed health access. Moving away from family practice moves graduates away from most needed health access and toward hospital and specialty concentrations of physicians.

Nurse practitioner workforce is difficult to understand without some basic logic and common sense. When considering only those actively delivering primary care, the numbers look good. But when considering inactive, part time, and missing graduates as well as graduates that never use the nurse practitioner degree except to increase income in a current hospital job, the nurse practitioner contributions look quite different. While studies of active graduates favor nurse practice, studies of all graduates suitable for national workforce decisions reveal a different story. Nurses now graduate from nursing school at age 31 (and aging). Nurse practitioners averaged 10 years of RN experience with a decline to 8 year of experience more recently. While this is important for shaping nurse practitioners in many ways, this is already 20 – 25% of workforce lost for nurse practitioners in a career. Then nursing derived workforce (RN, NP, midwife) averages 60% active compared to 85% for physician primary care. It takes 5 nurse practitioners to deliver 3 full time equivalents due to inactive and part time graduates. Also nurse practitioners have 15% found in administrative careers or about 4 times the level of other primary care sources. This was before the nurse doctor training spread to 200 programs with a massive increase in administrative duties and movement away from primary care delivery. Nurse practitioners also deliver the lowest primary care volume of any primary care training form. Again this appears to be nurse training derived from hospital focus and one on one patient care responsibilities.

The nurse practitioner departures from primary care can be tracked two ways but a warning is required. Nurse practitioner studies often track the specialty of training but this does not reflect the current duties of a nurse practitioner that can be a wide variety of practice modes. One way to track nurse practitioners uses the FTE method as noted above. The other way is to track the rise of nurse practitioners in areas such as cardiology and other specialties. About 6% are now found in cardiology careers and movements to other internal medicine subspecialties continue at a rapid pace.7, 8

Less than 30% of 2008 physician assistant graduates began in primary care and only about 20% began work with family practice physicians. Physician assistants that remain in the family practice mode contribute over 60% of the primary care. In annual surveys of physician assistants, family practice physician assistants are 2 times more likely to be found in rural locations, are 30 times more likely to be found in a Federally Qualified Rural Health Clinic, and are 6 times more likely to be found in a Community Health Center. The fraction of 2008 graduates starting in family practice has declined to just 20% and appears to be the segment most likely to be part time.9 Higher paying emergency, orthopedic, and surgical subspecialty careers attract more new physician assistants and also move primary care physician assistants to the most concentrated physician locations and away from primary care.

The greatest differentials in primary care compared to specialty care salaries are found in internal medicine. In addition the hospital based training and orientation is strongest in internal medicine. It is not a surprise that internal medicine departures from primary care have been the most rapid and the most complete. Internal medicine surveys of medical students indicate further declines to only 10% of new internal medicine graduates remaining in primary care.10 Even then the primary care supply is not safe as hospitalist careers have increased by tens of thousands a year and 75% have been internists with great losses in internal medicine primary care after graduation.11

Family physicians are making greater relative contributions mainly due to slowest departures from primary care while all other primary care sources lose graduates during training, at graduation, and each year after graduation. While this may eventually help the nation to value family physicians appropriately, the overall changes are devastating for most Americans.

3.         Overproduction of Basic Health Access Primary Care Means Workforce Versatility and Preparedness

This is once again common sense. Specialty workforce has been able to arise from nearby specialties and from primary care within a few years.

Primary care production takes more time. Even with too much primary care produced, there is the optimal potential for public health, health access, and more general careers to be addressed.

Duluth focuses on rural practice and family practice outcomes. Duluth admits rural origin, lower and middle income origin, family practice interested, rural practice interested students with service orientation. Duluth trains graduates in health access and half of Duluth graduates spend 9 months with rural family physicians in a rural community. Duluth does graduate 50% in family medicine and 40% of primary care into rural locations, but also contributes to women’s health, rural specialties, general surgery, neonatology, geriatric care, and other primary care specialties. When “overproducing” the Duluth model actually addresses the major workforce needs. In contrast the allopathic private schools can address mainly the needs of 4% of the land area as few distribute outside of this locations, few choose general careers, and few choose generalist careers.

Focus on health access results in versatile workforce. Duluth graduates can do anything. Focus on narrow concentrations results in brittle workforce that is unable to adapt to US health needs.

4.         Priority Must Be Placed on the Versatile Broad Generalist Family Practice Mode of Primary Care

It is not difficult to demonstrate that family physicians and the nurse practitioners and physician assistants most closely associated with the family practice mode provide health access for the populations in most need of health care. The advantages of a broad scope generalist are numerous.

·         Maximal distribution patterns - matching up best to the United States population with 50 – 60% found serving the 65% of the population left behind in 30,000 zip codes.

·         Workforce versatility at the macro level – The United States has always demonstrated the ability to move from more generalized to more specialized, usually within a few years.

·         Workforce versatility at the micro level - Family physicians have demonstrated the ability to adapt toward local needs such as women’s health, procedural care, inpatient care, emergency care, mental health, public health, and many areas in rural or inner city locations. When the nation had enough medical students entering family practice in the 1990s, family practice even specialized into these various need areas. This provided specific training for specific needed workforce areas. The current version of family practice is increasingly generic, but is still very different compared to other physicians that specialize (organ, procedure, technology) away from the health care needs of 65 – 90% of the population.

·         Exclusion factor – a sad fact is the family practice modes are excluded from top concentrations. This is an important factor in distribution and most needed health access. Only 4% of physicians in medical schools are family physicians, about one-third of the level nationwide. In the east coast ultimate concentrations, only 2% are family physicians. Where family physicians are excluded, primary care physicians, nurse practitioners, and physician assistants are also at lowest levels using state correlations. When nurse practitioners and physician assistants leave the family practice mode, they are more accepted and also leave most needed health access.

5.         Underproduction of basic health access means decades required to recover health access and reform a dysfunctional health system

Primary care has taken decades to build. The start is usually awareness of serious health access problems, then social organization, then finally some reforms that are helpful but fall short of establishing health access infrastructure, then the reforms steadily fail over time as the nation is less aware.

Health access primary care requires birth to admissions preparation, admission of physicians that represent the 65% of Americans left behind, focus on health access in training, graduation of family physicians, and policy to support each of these steps and the practitioners permanently remaining in primary care and the lower and middle income populations most likely to be seen by health access professionals. Needless to say, the United States is doing everything wrong at the current time.

The result is a brittle workforce, primary care that actually is not primary care in most cases, destruction of primary care to become specialty care, a dysfunctional primary care situation at best, an even more dysfunctional health system, massive cost overruns and inequities, and decades needed for any recovery of health access.

There are consequences of inadequate primary care and health access that must be considered. The consequences are so severe that even proponents of universal access need to slow down. A rapid adoption of universal access without the modifying influence of primary care would be a sure way to result in a short, brief universal access period. Astronomical increases in cost would be released by pent up demand without primary care to address the most basic health care needs efficiently and effectively.

History is a great teacher in this area. The institution of Medicare and Medicaid and the managed care period resulted in the same releases of pent up demand. With a rapid movement to universal health care, the same scenario may play out as in managed care. Just as primary care improves, the reforms (managed care, universal access) are defeated. It is of note that the 1970s changes were more palatable to medical education when the package came with some medical education support. The 1965 – 1978 period lasted far longer than the mid 1990s reforms.

6.         Priority must be placed on the versatile broad generalist family practice mode of primary care

All three forms of family practice (physician, physician assistant, and nurse practitioner) are most vulnerable at the current time.

·         Admission - With selective admission policies that admit fewer of the lower and middle income students with higher probability of family medicine choice, admission policies result in fewer family physicians. The probability of a choice of family medicine increase linearly from 25% for the medical students born in the most rural and lowest income counties to 15% for average county concentrations of people and income to 5% for physicians born in the highest income and most urban counties. The difference is that those with origins in top concentrations manage a rate of admission of 14 – 20 admitted per 100,000 birth population per class year. The one admitted that becomes a family physician in this group is 5%. In the most rural and lowest income counties, there is still only 1 admitted per 100,000 that becomes a family physician but this is 1 in 4 or 25%. Schools such as Duluth manage 50% family practice choice with a combination of optimal admission and optimal training.

·         Training – Schools training medical students in rural or more normal locations have top levels of family practice and distribution. But this is the exception, not the rule. Training is most commonly found in the most extreme locations with the most physicians and the most specialty physicians, the most extreme health conditions, the most health resources, the lowest percentages of family physicians and primary care physicians, and dysfunctional primary care.3 It is easy to see how training drives off family medicine choice. Training changes are also seen in nurse practitioners and physician assistants. New hospital and specialty tracks divert trainees during training. Graduate degrees require more time and most commonly result in more specialization with movements away from primary care, rural, and underserved careers. As graduate outcomes change in a program, expectations change, the types of graduates that are admitted change, and further changes are seen in training and outcomes.

·         Health policy – Policy impacts are grossly underestimated as powerful influences on family medicine choice as well as primary care retention. The same policies that make it difficult to choose a permanent form of primary care such as family medicine also drive flexible forms such as internal medicine, nurse practitioners, and physician assistants away from primary care. Those hung up on antiquated concepts of all primary care as alike need to understand new terminology and concepts that reflect actual delivery of primary care.

Once medical students pass up the chance to become a family physician, the nation loses decades of health access services per graduate. The flexible primary care forms can contribute greatly in the broad generalist mode, but these are careers with the lowest salaries, the lowest support levels, and the most complex patients. Steady departures from the family practice mode can be seen for nurse practitioners and physician assistants over the class years and the years after graduation. A foundation for health access must be built on a dependable primary care form that stays in primary care and stays where most needed.

7.         The general and generalist specialties most depend upon health access policy

Movements of medical students away from family practice and of all other sources of primary care away from primary care during training, at graduation, and each year after graduation confirm the destructive impact of current US health policy upon primary care and most needed health access.

Five Periods of Health Policy

8.         Health access focus typically involves a majority left behind, not just the extremes of low concentration in income or people

Much ado is made about rural health, minority health, women’s health, care for age 65 and above, disparities in health, and underserved populations by various definitions. A common method to gather attention is to dramatize changes such as rapid increases in minority populations or older Americans. When considering the broader dimension of day to day life in America, the current construct allows each of the above minorities in need of care to compete against one another and against one another in areas such as education and public security.  A less cohesive nation also tolerates those who promote divisions.

The resolution of the problem must involve one realization – more than a majority of Americans are left behind by the current maldistributions. The real pathway to health access recovery must involve the 65% of the American people left behind by the current design.12

The real issue is not the extremes left behind. The real issue is how to pry resources and physicians away from those with extremes that are doing very well in the current design and have the greatest influences on the design itself – birth to admission, selection of health professionals, training design, and policy. This will be difficult since 75% of physicians, and 90% or more of medical schools, researchers, residency programs, medical associations, and those in close association are doing very well.

Those who must be convinced control the databases and the flow of information regarding editors, journals, and the types of studies supported. Those in charge also shape those who gain admission to medical school, how they are trained, and who becomes leaders in health care. The history of needed reforms is clear. Changes in 1965 and the 1990s had to overcome the resistance of those in charge of medicine. Continued resistance remains even with gathering awareness of flaws in the design.

A basic principle of medicine is involved. First do no harm. With individual patients the design of health care that causes harm is more easily understood. Even when the design involves an entire society and when changes in the design would impact 75% of physicians, there is no less need to abandon the primary charge of medicine. Currently most physicians could afford to do a little less well to allow basic health access physicians to do a little better. Politicians have not helped much and if an across the board 20% cut occurs in all physicians, only those with special funding mechanisms will be able to remain in primary care.

9.         The health professionals that serve the 65% left behind are more likely to arise from the 65% left behind

Evidence based studies gain much attention, but their limitations are still significant. Few realize that studies that capture all or 95% of subjects are far better than evidence based. Logistic regression studies on entire populations of physicians are possible. These can indicate the solutions for health access and physician distribution.

Four factors are associated with improved distribution of physicians outside of current concentrations. As it turns out these are also supported by common sense. Physicians found in practice locations outside of concentrations

were born outside of concentrations (1.5 to 3 times odds ratios)

are family physicians (2 times urban needed, 3 times rural needed locations

are older at medical school graduation 1.3 times odds ratios

are normal in training (allopathic public, osteopathic)   1.3 – 1.6 odds ratios

are trained outside of concentrations  (1.5 – 2 times odds ratios) in a wide range of United States medical schools from the most average to the least exclusive (not allopathic public, not high ranking in MCAT, not international schools).

Translations would be

1.      normal and less exclusive origins,

2.      normal and less exclusive careers,

3.      mature, life and health experienced graduates who are more service oriented and less likely to be children of professionals, and

4.      normal training on normal health care needs of entire nations in more normal locations and situations.

Are associated with distributions of physicians where they are needed.13

Health policies are also top priority for physician distribution. Policies continue to shape career and location choice in physicians, physician assistants, and nurse practitioners. Health policies that encourage practice locations beyond current concentrations are

1.      Policies that encourage or require choices of family medicine, generalist, and primary care careers

2.      Policies that establish family medicine, generalist, or primary care medical schools or training programs

3.      Policies that distribute health resources, health care coverage, facilities, health care team members, and physicians to the 65% of the United States population outside of current concentrations

The United States is basically doing none of the above.

·         Origins – all most likely to distribute are being replaced by those least likely to be found outside of concentrations

·         Career Choice - Most believe that physicians are free to choose careers and locations but this is a myth as career and location choices are limited for those who are more normal and those are trained in more normal settings. Expansions of family medicine and primary care oriented schools in the 1970s accompanied by a doubling of medical school positions resulted in a quadrupling of primary care production in a decade.

·         Older graduates – Older graduates were only 7% of United States medical school graduates in the 1960s but increased to 17% during the 1970s. The level has stabilized at about 23 – 24%. One interpretation of the increase was greater appreciation for older age medical students, even with lower scores, different parents, and different colleges.

·         Training – United States training grows ever more focused on science, disease, and exclusive health care. Medical students are not selected, trained, or tested on health access concepts. The curriculum includes a wide range of disjointed specialized areas rather than a cohesive focus on an organized patient-centered focus. Too few faculty (too costly), faculty that are too specialized as required by accreditation, faculty that are distracted by numerous other duties, extreme low levels of family practice (4%) and primary care (16%), and dysfunctional primary care examples are only a few problems.3, 14, 15

Origins Outside of Concentrations – Physician origins are important determinants of career choice and practice locations. Birth origins can be tracked for 96% of allopathic United States medical school graduates (US MD Grads). These can be matched to concentrations of people, income, or physicians regarding the origins of physicians. Origins can also be tracked by parent income level and other measures such as professional or physician parents. Physicians from the top 20 – 30% in origins involving concentrations of income, concentrations of population, and concentrations of physicians dominate admission with 60 – 70 of graduates, but have the lowest family practice, primary care, rural, and underserved contributions.  Physicians arising from the 70% of the United States population left behind in admission have 2 – 3 times greater distribution to the 65% of the United States population that is located outside of concentrations. Physicians with origins beyond concentrations also have 2 – 3 times greater choice of family practice. Origins, training, older age graduates, and family practice all make separate and substantial contributions to the 65% outside of current physician concentrations as demonstrated by logistic regression. 13

The relationships follow linear associations as the physicians associated with top concentrations in birth have half of the probability of distribution outside of concentrations and have the lowest levels of rural, underserved, primary care, and family practice choice. From the role modeling perspective and lifestyle career choice perspectives, they also have the least exposures to rural peoples, underserved populations, primary care, generalist ways of life and health, and family practice.

Family Practice Graduates - The pathway to health access recovery appears to be complicated, but studies demonstrate consistently that the family practice mode of care matches up best to the 65% left behind in any one of a number of measures. About 53% of family physicians are found in zip codes of less than 75 physicians with 65% of the population and 23% of total physicians. These are also 38,000 zip codes with over 70% of the elderly. Those in most need of care now and in the future clearly are in need of the family practice mode. What is required is equity in distribution, a characteristic only associated with family physicians.5 Studies of family physicians confirm consistent distributions of 30 – 40 family physicians per 100,000 across a wide range of practice locations.

Nurse practitioners and physician assistants with greater retention of graduates in the family practice mode have actually exceeded family physician distributions, but this period from 1970 – 2000 appears to have come to a close. As accepted health professionals across hospital care and specialty care, nurse practitioners and physician assistants are moving away from health access. Now with fewer family physician graduates and with fewer nurse practitioners and physician assistants remaining in the family practice mode, the nation’s health professional training programs are moving away from health access for most Americans.

One important point needs to be made. Family practice residency graduate levels have decreased, but are far above the 1000 annual graduates reported by 35 nursing associations, United Health Care, and the American Public Health Association in their zeal to support the Title VIII nursing grant application.16 Even the 25% of foreign origin family physicians from international schools contribute nearly 4 times the level of primary care as the average physician assistant or nurse practitioner and the United States origin physicians deliver over 7 times more primary care.17

Also the 3000 family nurse practitioner graduates a year that are reported actually only contribute1800 full time equivalents of family nurse practitioner work since nurse practitioner inactive and part time levels require 5 graduates to contribute 3 full time equivalents.18 Also the active nurse practitioners deliver the lowest volume of primary care per graduate. Nurse practitioners lose the first ten years to delays in entry to nursing school, nursing school (average graduation 33 years now), an average 8 years of nursing, and then 15 – 24 months of nurse practitioner training. Advanced nurse training, part time, inactive, and nurse doctor training take even more primary care delivery away. Most of these are set in stone due to nurse derived workforce, but one factor is changing steadily and progressively. Nurse practitioners have reached acceptance across hospital and specialty careers, resulting in steady declines in primary care retention each class year and each year after graduation. These annual losses in nurse practitioner and physician assistant primary care can be tracked and anticipated given the current health policy construct. Even more devastating is losses from the family practice mode that also follow the policy construct. In physicians the policy impact limits numbers of medical students that can trust a permanent primary care form; however, once chosen the nation can depend upon 25 or more years of primary care per family physician. In nurse practitioners and physician assistants, each passing year results in departures of all class years from family practice, primary care, and the locations in most need of health care.7, 17-19

When making workforce recommendations to an entire nation, reports must be avoid distortions and must have details such as inactive and part time graduates, fewer years, lower volume, and departures from primary care.

Family physicians are not at the peak levels of 3500 - 3900 annual graduates found during optimal primary care policy in the 1994 – 1998 class years, but they have remained at the 2600 – 3000 level. What is more important is that these few primary care graduates, the lowest number of graduates for all five forms, will contribute the most primary care for the United States. The family practice contribution for the 5 primary care training forms will remain the highest at around 35 – 40%. Internal medicine with over 7000 graduates a year will decline to less than 15% of the nation’s primary care contributions with lowest primary care retention and the least primary care years per graduate. Nurse practitioner and physician assistant contributions will remain less than 15% each. Increases in graduates coupled with declines in primary care percentage equal no net gain. Pediatric contributions will remain 20 – 25%.

What is important to note about primary care is that it will be missing as the nation continues to grow and to grow more complex while primary care production will remain much the same for the next 2 decades. More primary care graduates with lower primary care years per graduate equals no net gain with relative losses due to increasing primary care demand.

More physician, nurse practitioner, and physician assistant graduates will no longer work in the current policy environments since graduates begin in primary care at such low levels and since primary care departures continue throughout internal medicine, physician assistants, and nurse practitioners. Pediatric primary care is a different consideration in that pediatric care is saturated in the locations served by pediatricians.6 From the primary care perspective, the nation needs the same or fewer pediatric residency graduates.

The decision for family practice remains the most important decision in health access as it was decades ago and one hundred years ago. When physicians pass up the decision for the permanent primary care choice of family medicine, the nation loses one or two decades of primary care compared to other forms. This appears to be a one stage decision, a permanent decision. Pediatric primary care is a two stage decision. Other forms of primary care are more flexible. Their decision to remain in family practice or primary care must be year after year. When nurse practitioners and physician assistants opt for non-primary care tracks during training, depart primary care during practice, or leave family practice associations any year after graduation, they are departing health access and the most needed practice locations. They will not be returning.

As Madison noted in his article about service orientation, “The careers of twentieth century US physicians show a general tendency to drift from the broad toward the narrow and never, so far, in the opposite direction.”20 This has been the case with physicians, physician assistants, and nurse practitioners and the pattern has continued or even accelerated into the 21st century.

The United States has managed two natural experiments demonstrating the ability to hold steady in this area during the 1970s and the 1990s, but the past decade has indicated an even more rapid movement to more exclusive physicians in admissions, in training, and in career choice with policy leading the way.

10.       Permanent primary care training should be emphasized and should replace any flexible primary care training that can yield low or declining levels of primary care.

It is hard to appreciate the concept of long term retention without some historical background. Medicine, health access, primary care, and generalists have been closely associated up until recent times. Specialization in physicians has followed specialization in other societal areas and has been associated with concentrations of people, income, and health resources. Movements to graduate medical education training tended to leave generalists behind with many having one or two years of training after medical school.

More detailed studies begin with the graduates of the class of 1960. These graduates were tracked and just over 50% remained in primary care over a lifetime.21 Using survival curve deteriorations of primary care over an entire career, an estimated 71% of the career of a primary care graduate of the class of 1960 was spent in primary care. Pediatric residency graduates have maintained about 80% in primary care up until the past 15 years. Internal medicine graduates have had greater variations in primary care retention. Departures from primary care after graduation make estimates difficult using recent databases, but over 60% were found in office primary care until the 1980s declines. In the 1970s new formal primary care training programs were created in the form of family medicine, nurse practitioner, and physician assistant training programs.

The nation has now had the chance to evaluate these five forms of primary care training since 1970. Family practice residency graduates appear to be on course for a steady 90% remaining in primary care with potentially some deterioration to 85%. There is an increase to 95% as seen in areas that have better support for primary care (less fee for service, lower costs of delivering health care, better salaries, lower costs of living).

Nurse practitioner primary care has steadily declined with rates of 41% remaining in primary care in 2004 using family practice, internal medicine, and pediatric primary care contributions (not including geriatrics and women’s health).7, 8 These studies did not adjust for missing graduates. Steady deteriorations have followed the last decade of policy changes and are likely to continue.

Few realize that nurse practitioner primary care remains inherently limited. Late entry is the rule. Nurses now average age 32 – 33 at nursing school graduation. Nurse practitioners average 8 years of experience as a registered nurse and train for 2 years. Advanced training and nurse doctor training also take away from potential primary care. Nurse practitioners at 15% in administration have 3 – 4 times the administrative activities that limit care delivery compared to other primary care sources. In addition it takes 5 graduates to provide 3 full time equivalents (FTE) due to part time and inactive nurse practitioner graduates. Some of these factors that limit contributions are inherent in nurse practitioners while other aspects are a complement to the efforts of nurse practitioners.7, 17, 19

Nurse practitioner and physician assistant contributions are valued by employers in a wide range of health care areas. Initially challenged to maintain a rural and underserved profile, practitioners are widely sought as colleagues, replacements, and supplementation. A low cost hospital and specialty care source results in lower costs of salary, benefits, Social Security, support staff, insurance, and other areas.

From a primary care and health access perspective; however, this is not good news. Compared to family physicians, nurse practitioners and physician assistants did not quite reach cost to productivity maximum contributions. The equations change in specialty care where salaries are lower and revenue generation is much higher. The productivity to cost advantages of nurse practitioners and physician assistants in specialty care are likely to remain. Even improving primary care policy support would not restore primary care retention. The advantages include capturing market share in locations with shortages of specialists, funneling patients in to additional specialists, increased utilization of costly equipment, and allowing physician specialists to concentrate on billing codes that capture even higher levels of revenue. The push of salary advantages and the pull of market forces set by current health policy will continue to deplete flexible forms of primary care.

Physician assistants have decreased to 33% of all graduates in primary care. Using 2008 survey data an estimated 27% - 31% of 2008 graduates began careers in primary care and decreases continue at 1 – 2 percentage points a year as in the last 12 annual surveys.9 Even during maximal health policy support across the 1990s, 30% of primary care physician assistants departed primary care.22 These were physician assistants trained in primary care, experienced in primary care, and rewarded for primary care.

The situation is very different now with physician assistant careers marketed as the best regarding hours, duties, and pay. Fewer interested in primary care are attracted to physician assistant training. Fewer are trained in primary care. Fewer have years of primary care experience. There are penalties for primary care choice and there is active recruitment away from primary care by those who control health care expenditures in the nation.

Even without any interventions in policy and without long term incentives to remain in family practice, the nation can continue to expect over 80% primary care yield from a family practice residency graduate and more likely over 85%. Pediatric graduates will yield about 50% while internal medicine primary care levels continue to decline in ways that make predictions inaccurate only months later. Less than 35% of the career of a nurse practitioner will involve primary care and less than 30% for a physician assistant career.

Only the intervention of family medicine training represents an improvement over the 1960 levels of 71% of a primary care career associated with the delivery of primary care.

11.       Primary care training that fails to yield a majority of graduates remaining in primary care for an entire career should be changed in terminology to specialty training

The proof is in the ultimate outcome. When 90% of internal medicine graduates are not found in primary care, the internal medicine training should not be called primary care training.

When two-thirds of nurse practitioners are found in hospital and specialty careers, nurse practitioner training should not be called primary care training.

When 70% of physician assistant graduates fail to enter primary care, physician assistant training should not be considered primary care training.

When those admitted to a program sign contracts to provide a decade or more of primary care, the nation will have some assurances of actual primary care. Under current policy that destroys primary care by converting it to hospital and specialty care, this is the only recourse.

12.       Movements of primary care graduates toward hospital and specialty careers and away from family practice careers results in departures from health access

The studies of departures of physician assistants from family practice to specialty care are revealing. The loss involves not only departure from primary care, but also departure from rural and from underserved locations. Nurse practitioners departing family practice and primary care follow the same pattern.

Few appear to understand the consequences of steady movements to hospital and specialty care in all health professionals. Few understand that expansions of graduates in physicians, nurse practitioners, and physician assistants can no longer graduate enough to keep up with steady small percentage annual departures from primary care from the huge pools of graduates in the current workforce. With so many departing primary care, the consequences are enormous regarding enough care, enough experienced primary care, available primary care, primary care in the rural and underserved locations, primary care for the 65% of the population outside of concentrations, and the consequences of lack of primary care in cost and quality of health care.

13.       Best health access is the result of retention in a primary care specialty, retention in primary care, retention in a particular continuity location

Activity levels are an important consideration for actual workforce delivery. Nurse practitioners have 62% activity levels when comparing the graduates needed to equal 40 hours of full time equivalent, physician assistants have 74% active, and physician activity levels range from 85 – 90%.8, 18 With nurse doctor training and with graduate degree focus and longer training for nurse practitioners and physician assistants, changes are likely. At 60% activity it will take 5 NP graduates to equal 3 FTE of NP contributions. At 70% activity it will take 3 PA graduates to equal 2.1 FTE of PA contributions. Greater activity levels result in greater primary care delivery. Of course primary care studies most commonly include those active in primary care. Since these studies do not consider inactive, missing, or part time graduates they fail to illustrate the limitations of graduates that complete training and contribute much less to workforce.

14.       Health access recovery requires a priority on increased years in a career, increased primary care retention, increased percentages of graduates remaining active, and increased volume of primary care delivered rather than fewer years, more inactive or part time, lower volume, and lower percentages remaining in primary care.

The United States has a design for health access that is unique in that most graduates do not enter health access careers. If each of the five forms of primary care training resulted in a broad scope generalist that remained in permanent primary care, there would not be a need for comparison studies. Because the primary care forms do vary in years in a career, activity, volume delivered, and primary care retention, a standard primary care measuring tool was developed. Almost immediately this tool had to be revised due to further departures from primary care contributions and additional considerations of international graduates who also lose career contributions with fewer years of a career.

The future primary care estimates for an average 2008 graduate for each of the five training forms are listed with revisions. A career length of 35 years is possible for physicians and physician assistants. The Standard Primary Care (SPC) Year is the product of career years, percent activity, percent volume compared to family physicians, and percent remaining in primary care. A newer modification considers the SPC years for each year of age of the various graduates as activity, volume, and primary care retention change over time.

·         Family practice - 25.2 compared to the original 29.3 years (adjustments down due to 25% of graduates that are international graduates of international origin)

·         Physician assistant graduates – 3.3 SPC Years compared to the original 6 years (adjustments due to fewer beginning in primary care in 2008 studies)

·         Nurse practitioner graduates – 3.3 SPC Years compared to the original 2.9 years (new method using year to year contributions plus some increase in the estimate of the volume of primary care delivered)

·         Pediatric graduates – 18.7 SPC years and steady (new method)

·         Internal medicine – 2.3 SPC years compared to 5 years (adjustments for foreign born international graduates at 45% as well as primary care retention cut in half to 10% for all graduates).

Internal medicine appears to be on course for less than 10% retained in primary care for an entire career with few beginning at graduation and losses likely to continue after graduation to hospital, specialty, and hospitalist careers.10, 11, 23, 24

Retention is also important to consider regarding practice location patterns. Family practice residency graduates initially approached 30% found in rural locations in the 1970s. This level was boosted by shortages and steadily increasing 1970s support levels. Since that time family physicians have settled into a steady 20% in rural locations for the last 30 class years of graduates. This is about two to three times the rural rate of other physicians. Decreases in rural rates also reflect changes in the family practice residency graduates to higher income and more urban origins as found in all entering the United States workforce.

·         About 25% from international medical schools with international origins have a reduced level of 12% rural location.

·         The highest income and most urban origin family physicians with United States origins also have similar rates of 12 – 14% found in rural locations.

·         The changes in the last 20 years in admission also include major increases in Asian (3% to 23%) and foreign born (3% to 16%) United States medical students.

Family practice still triples rural location rates across the range of physician origins and across medical school types and individual medical schools, but the baseline of rural distribution begins low when the physicians have the most concentrated origins in at least three dimensions (income, people, physicians) if not more (scores, professional or physician parents, close proximity to medical schools). Regarding rural distribution, the changes result in even greater dependence upon the choice of family medicine to result in any distribution. This is also seen in the Jefferson Physician Shortage Area Program studies where a wider gap in rural location rate is found each year between PSAP graduates and other Jefferson students with few PSAP graduates required to equal the same rural workforce contribution as more Jefferson graduates. A specialty that remains in primary care and in rural locations has serious advantages for those in most need of care.25

Family physicians also maintain a steady rate of 15% found in underserved locations across the class years of graduates. This compares to 7% of all physicians, 6% of all US MD Grads, and 21% of the United States population found in underserved locations using the Physician Distribution by Concentration coding.

Nurse practitioners and physician assistants have enjoyed superior rural and underserved primary care contributions. In the early years these were likely to be levels 50% higher than family physicians, but this was when nurse practitioners and physician assistants were much more likely to train with family physicians. They also more commonly established careers in the family practice mode. Departures from the family practice mode have resulted in substantial decreases in primary care, rural, and underserved contributions.

One family practice residency graduate provides the same rural primary care or underserved primary care contributions as 6 – 10 times as many graduates from physician assistant or nurse practitioner programs.8 The physician assistant working with family physicians has 6 times the Community Health Center location rate of other physician assistants, 2 to 4 times the rural location rate, and 30 times the federally qualified rural health clinic rate.9

Top levels remaining active in practice, top volume of primary care delivered, top years in a career possible at 35 years, top retention in primary care, top retention in the family practice mode, top levels of rural primary care, top levels of underserved primary care, and top levels of care of the elderly appear to meet all of the requirements for health access improvement or recovery. 

15.       Grant programs are to be avoided as they are abused by the socially or politically organized. Those left behind by education, economic, health, public security, and other systems are also inevitably left behind by grant programs as compared to infrastructure type programs with reliable funding and long term planning capability

Grant programs appear to be made to be abused. Those that justify the abuse are typically the most socially organized. Certain states, medical schools, institutions, and organizations expend enormous resources capturing as many lines of federal and state and foundation revenues as possible. Other states, cities, and populations are left behind without the ability to muster a grant effort.

One of the ultimate indicators of problems from grants was demonstratd by frontier applicants. These applicants without much in the way of health resources were turned down for their application to gain resources because they did not have enough resources.

In a political process it is difficult to avoid two areas. One area is those socially organized voting the US Treasury to their own pockets. This was a major concern of those who founded the United States and their concerns were justified in recent decades and especially in a rapid spending spree such as a bailout. The second concern is that programs are designed that are subverted to other uses not the best for the program design. This is a more subtle problem since the funds are generally used for the purpose of the program, but the grant may not send funding to the originally intended populations who may not even know that the program exists and is not already organized to take advantage of the program.

A common device for insuring that favored applicants win out is a grant program with short time lines, irregular grant notices, and irregular and less dependable grant funding availability.

Shortage designations, Community Health Center, Federally Qualified Health Center, Rural Health Clinic, and Poverty Access Programs will continue to be abused, requiring revisions, then more complicated regulations, then requiring consultants, etc. Eventually again only the most organized need apply.

16.       Health access is about working now for decades of basic health access to meet the top priority needs for the next generations rather than a focus on immediate health services often of questionable need

Principles of Health Access Summary Points

Steps to Health Access

Basic Health Access Concepts To Review

The Basic Table - Taxonomy, Themes, and Theories Related to Experiential Place and the Principles of Health Access

Experiential Place and Health Access Considerations

The Counterproductive and Untrue Perspective of the Impossibility of Health Access

Nebraska: A Practical Application of Experiential Place and Workforce

Why Physician Workforce Needs New Tools (and a health access perspective)

Basic Health Access Index

Physician Workforce Studies

www.ruralmedicaleducation.org