Summary Document - Why an Expansion of 5000 More Family Medicine Graduates Is the Only Current Workforce Solution That Makes Sense

Summary by Robert C. Bowman, M.D.

Details on the Basic Barrier of Primary Care Retention (Also Past, Present, Future Graphics) - It is just not possible to recovery primary care without graduates that remain 80% or more in primary care for a career.

The greatest challenge for those most desiring to learn is the basic requirement of unlearning much of what has been programmed, taught, or absorbed over previous years or decades of life. While it may seem that the information age has provided new sources of learning, it has been clear since Edward R. Murrow's 1950s statements that agendas such as advertising distort the information that is presented to us. In areas such as physician workforce, even the top journals and media sources make errors based on programming, assumption, or bias.

Relevant Approaches To Basic Health Access Workforce

An increase of 5000 more annual family medicine graduates steadily by 2020 is the remaining health access recovery vehicle at the current time. The United States should increase toward a goal of 8000 family medicine residency graduates selected and trained for health access, training in areas in need of health access, and trained by those delivering health access in continuity teams, should be the primary workforce goal of the United States for the next decade.

Few understand that changes in health workforce take 35 or more years to accomplish. This is the duration of a career for most existing health workforce forms. Nurses, physicians, and physician assistants all have careers that begin about age 30 and extend to age 65.

Mistakes made in the past two generations result in consequences for subsequent generations in workforce and in national populations in need of health care. The most obvious consequences of poor planning, poor tools, and poor long term focus are periods of too few and too many physicians in physician numbers and types.

While top workforce experts assert that the United States is short of physicians, the focus has been on specialty physicians. This is a short term focus rather than the long term focus on health access for the next two generations that is a requirement for health access workforce.

The changes already implemented in the past decade will already be more than enough to resolve shortages of specialists. The changes include a 50% or greater increase in allopathic US medical schools production of specialists, a 50% increase in osteopathic specialist graduates, a 50% or greater increase in international graduates specializing, conversion of internal medicine graduates from 50% to 90% specialty care, conversion of pediatric graduates from 25% to 50% specialty care, conversion of nurse practitioners from 30% to over 60% specialty care, and conversions of physician assistants from 40% to 72% in specialty care. Non-physicians are not the answer as conversions from primary care to specialty care continue along with new graduates more likely to avoid primary care. In each case the United States has converted primary care production to specialty care production resulting in massive losses in primary care production that actually results in primary care while increasing hospital and specialty workforce. In addition the changes move physicians and non-physicians away from most needed health access to locations that already have top concentrations of physicians, non-physicians, and health resources.

The primary care losses have been the most devastating in the past decade with primary care contributions by class year decreasing from 300,000 to 200,000 Standard Primary Care years. Longer term the average primary care graduate contribution was 20 SPC years per graduate in 1970 and has declined to less than 6 Standard Primary Care years with further declines to 4 SPC years likely. Unlike the slower physician changes based on new class years, the non-physicians make rapid shifts not only at graduation but each year after graduation. Also primary care has always been a primary source of new specialists. The most recent examples include emergency physicians and also hospitalists arising from primary care. Tens of thousands of primary care internal medicine physicians have shifted away from primary care in the past 3 years. Flexible primary care sources (IM, NP, PA) are just not reliable as a foundation of health care in the United States.

New concepts are required to understand the peculiar American treatment of primary care and basic health access. Other nations have a basic health access infrastructure with separate training, accreditation, and support. These do not exist in the United States and increases in specialty and hospital demand end up compromising basic health access.

In order to capture the primary care effects, new tools were needed. Claiming primary care no longer works. It is the actual delivery of primary care that matters, particularly with regard to most needed health access or the move from no health access to some degree of health access. Those at the front lines in most needed health access are the family practice broad generalist forms (MD, DO, NP, and PA). If NP and PA family practice forms had stayed in family practice for their decades long careers, some reductions in deficits would have been possible. But once again the peculiar US design and the flexible primary care training solution has been revealed as no solution at all.

The Standard Primary Care year measuring tool uses the most current data to estimate the next 35 years of primary care contributions for each source of primary care for each class year of graduates.

One of the advantages of assigning future contributions to the class year is the ability to measure the impact of health policy upon primary care production. For a specialty such as family medicine where permanent career choices are the rule, family medicine choice can be used to illustrate the impact of policy on career choice. (Five Periods of Policy and Family Medicine Choice) While other factors such as type of training, origins of the graduates, age at graduation, and career choice make a difference, it is health policy that is the real gatekeeper. Current US policy has opened the floodgates to specialization while reducing the flow of primary care to a trickle. In addition the pool of primary care also is being tapped to supply other health care needs, eroding primary care capacity further. National studies are required that capture the changes in this primary care pool. Retention in this pool is the most important measure. Policy can fill the pool and policy can retain primary care in primary care, but once again current US health policy is destructive to primary care - preventing filling and causing hemorrhage. More transfusions without stopping the hemorrhage, or better yet, injecting a workforce form such as family medicine that is resistant to hemorrhage, is the answer for basic health access recovery.

United States health policy has been variable over five periods in the past fifty years from lack of health access policy, to building policy 1965 – 1978 (financial access building health access for lower and middle income and rural populations, quadrupling primary care graduates 1970 to 1980), to neutral, to rebuilding in the 1990 – 1995 policy (doubling of Medicaid focused on more populations covered, temporary primary care payment reforms, forced choice of primary care), to destructive in the current policy era from 2000 to the present and continuing for future years. The destructive policy era is defined by massive conversion of primary care graduates away from primary care.

Optimal growth in primary care production was found for the 1970s due to the quadrupling of primary care numbers as well as new sources that were predominantly in primary care. Another peak period of growth was found in the 1990s class years of graduates once again with massive increases in the family practice graduates as well as an increase in primary care retention for IM, NP, and PA graduates. The peak primary care production was around the 1998 class year with over 300,000 Standard Primary Care years from all five sources adjusting for primary care retention, activity, volume, and years of a career as well as different origins such as US or foreign origin international medical graduates for each source.

The current destructive policies have resulted in a decline in primary care production to about 200,000 Standard Primary Care years. This is a 50% decline in production at a time when primary care demand is increasing for a number of reasons.

The United States increased production of all five sources of primary care graduates from 24,000 to over 28,000 from 1998 to 2008 mainly with a doubling of physician assistant graduates (3100 to 6500), but the actual primary care production decreased from 300,000 Standard Primary Care (SPC) years for the five primary care sources for the 1998 class year to less than 200,000 Standard Primary Care Years for the 2008 class year production. Actual primary care production has declined from 12 Standard Primary Care years to 7.2 SPC years per graduate. Again US health policy has shaped grossly inefficient primary care production with record low levels of primary care retention resulting in less primary care years per graduate record low levels set each class year and each year after graduation.

More graduates that fail to remain in primary care fail to resolve basic health access problems or the health needs of most Americans, particularly the elderly who are found in different locations compared to current concentrations of physicians.

Many speak the language of continuity and promote the value of continuity, but those in the field that have delivered continuity know the true story. The folly of continuity involves failure of continuity in workforce. Places do not serve people. People serve people. Shortages of basic nursing and basic health access practitioners undermine basic health care delivery, undermine the economy that depends upon efficient health care, undermine the confidence of the public in government, and undermine the ability of the government to function (costs, trust, efficiency). When people claim continuity or primary care or health access advantages, be sure that the graduates of such schools or programs sign a contract to actually provide most needed health workforce for a decade or more (15 years is better). It is the only way to insure that the promised primary care or health access will actually be realized.  Without continuity as basic as staying in primary care, there will not be primary care.

Primary care and nursing shortages have existed for some decades. Shortages in nursing and in primary care will worsen under current policy that dictates shortages in basic nursing and basic primary care. Nursing shortages are best expressed by HRSA as 1 million nurses short by 2020. Losses of entry nursing positions, losses of nursing faculty to clinician careers, and direct losses of nurses to become clinicians will increase the shortage potentially beyond 1 million. This is likely to require a new form of basic health access team member to replace the basic nursing deficit. New professionals will likely be needed for basic oral health and basic mental health as the failures in basic human health care infrastructure are allowed to continue.

Nursing must have nursing champions for basic nursing recovering coupled with better pay and support. If nursing hopes to have a role in primary care, nursing must find champions that will challenge the current leadership and create nurse practitioner programs with graduates that sign contracts to remain in family practice mode for 27 years with 80% active, 80% of the volume of a family physician, and 80% remaining in primary care. this results in 14 Standard Primary Care years - worth an investment. The current 60% active, 60% of the volume of a family physician, and 33% remaining in primary care (FM, IM, PD) results in only 3 - 4 SPC years, not worth the investment and the losses of basic nursing and basic nursing faculty. Of course this would require a separate training, accreditation, and contracting compared to existing nurse practitioner efforts. But of course the same is needed for primary care physician assistants and primary care physicians for any hope of health access recovery and a true foundation for health care in the United States somewhat resistant to short term consumptive patterns.

Basic health access generalists also will need better pay and support for any hope of health access recovery.

Primary care production requirements for a minimally sufficient primary care recovery will be nearly 400,000 SPC years per class year by 2020 or about double current production.

The futility of generic expansion as a vehicle to basic health access is illustrated by the requirements of numbers of flexible primary care forms required to fill the gap in primary care production. A combined expansion of 70,000 more internal medicine, physician assistant, and nurse practitioner graduates a year would address this gap by an additional 200,000 SPC years of production but would be impractical, would be incredibly costly, and would deplete basic nursing workforce. Nor could this expansion be expected to remain in primary care as current flexible primary care IM, NP, and PA graduates only supply 2 – 4 Standard Primary Care years per graduate due to 10 – 33% primary care retention.

The United States has produced half of the needed annual primary care since the beginning of the new century and will continue to produce half of the needed annual primary care production until the nation returns past 300,000 SPC years per class year and moves toward a more reasonable level to meet population growth, the doubling of the over 50 and over 65 and over 75 populations, and the complex care needs of lower and middle income Americans left behind by location, by the types of practitioners needed, and by financial access to health care.

The United States can increase from 3000 graduates a year or 75,000 SPC years from family medicine to 8000 per year at 25 Standard Primary Care Years per graduate or 200,000 total SPC years. This is the quickest, most efficient, most effective, and lasting way insure sufficient primary care production and retention. 

Specialist workforce has been more than sufficiently expanded due to three major sources – steady United States medical school expansions each class year with much higher percentages of specialty graduates, international medical graduate sources that remain highly focused on hospital and specialty care, and massive conversions of existing primary care to specialty care from the large existing pool of multiple recent class years of physicians and non-physicians.

Pediatric expansions will not work for the ages, locations, and populations that are in need of primary care. Fewer American children, declining contributions in older children, limited pediatric rural and underserved contributions, and departures from primary care are an increasing problem for pediatric workforce solutions. For urban children, pediatric primary care is essential. Beyond concentrations of physicians and health resources, pediatric primary care is a lower probability solution.

Family medicine at over 90% remaining in primary care is the most reliable source of primary care with other forms resulting in only 10 – 30% found in primary care. The actual FTE of primary care for nurse practitioner and physician assistant solutions is even lower due to increased part time and inactive graduates as well as lower volume of primary care delivered compared to family physicians.

Family medicine at 25 Standard Primary Care years per graduate in an average 35 year career is the most lasting source compared to other sources delivering 6 – 12 times less primary care or 2 – 4 SPC years for NP, PA, or IM program graduates.   Graphic SPC years   See tables in Basic Health Access Concepts document

Family medicine is the family practice source that best meets the ages, populations, and locations in need. Nurse practitioners and physician assistants that remain in the broad generalist family practice mode can also meet these needs as 50 – 60% are found in locations with 65% of the United States population and only 23% of physicians, but NPs and PAs depart this FP mode steadily to hospital and specialty careers. This moves NPs and PAs steadily away from primary care, rural, and underserved locations with each passing class year and each passing year after graduation.

Optimal solutions at the current time involve retention in a career for 35 years, retention in primary care at over 90%, retention in the family practice mode at over 90%, optimal retention as active in a health care career, care for lower and middle income populations, care of older populations, and retention in rural and underserved locations. Only family medicine meets these criteria.

Internal medicine at 10% of graduates remaining in primary care is no longer a source of primary care and average rural and underserved contributions fail the nation’s populations in greatest need.

Nurse practitioners and physician assistants fail to remain in primary care with losses during training, at graduation, and each year after graduation as United States policy dictates the conversion of these flexible primary care sources to optimal revenue sources as hospital and specialty care.

Specialty workforce has been met by massive conversions of internal medicine, nurse practitioners, and physician assistants to hospital and specialty workforce.

Specialty workforce needs can best be met by more patients seen per specialist not generic expansions with less vacation, more hours of patient care a week, and less pay per service performed.

Generic expansions fail to meet the workforce needs of the nation although such expansions do crowd even more physicians into 4% of the land area with already 90% of health resource expenditures, 75% of total physicians, 75 – 90% of specialists, over 90% of graduate medical education funding, and over 90% of National Institutes of Health funding.

Specific family medicine expansion is a best fit to meet primary care needs, the needs of the elderly, and the needs of 65% of the population in 30,000 zip codes with only 23% of current physicians as 53% of family physicians are found in these locations.

The basic health access needs will also massively increase. Lower and middle income Americans will be saddled with the additional consequences of lower and middle children, particularly males, that are less likely to make meaningful contributions to society. Young adults face unemployment, increasing lack of health care coverage, increasing burdens from health care debt, and new forms of taxation (child support, alcohol, lottery, cable, cell phone). Lower and middle income parents and grandparents will face the burden of caring for tens of thousands impacted by war injuries with overwhelming mental health and neurological needs (post traumatic, depression, disability, normal pressure hydrocephalus). Their top unemployment and suicide rates are only the beginning of the health and social consequences. More lower and middle income grandparents will be raising their grandchildren. Child poverty rates are increasing above 30% for married parents both working and both high school graduates. Access to basic health, decent child development beyond passive day care, and relief from mistreatments by cable, communication, cell phone, predatory sales people supported by irresponsible businesses, and government approved loan sharks would ease their burden but no help is on the way. These all dry up cash in lower and middle income neighborhoods, reduce the quality of life, decrease access to health, and decrease the ability to financially access health. Also these overwhelming needs will send more to basic health care (as well as more costly urgent, emergent, and specialty care), increasing costs without changing the quality of life or health.

Eventually the failures in cost, quality, and access will be understood as failures in the American lower and middle income child who becomes the patient, the parent, the nurse, the teacher, the public servant, and the administrator. The failures will be mostly due to an upper status America that has lost touch with the needs of most Americans, especially for basic health access, the health vehicle responsible for most of the care of lower and middle income Americans even though supplying much less care for the upper status types.

Delays in decisions, health policy failures, and changes in primary care workforce leave no other options other than a focus on family medicine graduates at the current time. The United States maximized primary care production in the 1990s with 300,000 Standard Primary Care years from all 5 sources of primary care. The health policy design was still inadequate to support sufficient primary care for 65% of the United States population, but progress was made toward this goal. Unfortunately United States primary care production for the 2008 graduates will be half of the 2008 level. Under current policy the United States will produce half of the needed health policy from now until 2020 when past primary care production, primary care needs for the most complex populations, and destruction of existing primary care are on a collision course. The United States will need a total of at least 5000 additional family medicine residency graduates with 25 Standard Primary Care years per graduate to address the 200,000 Standard Primary Care year gap in production between the current 150,000 to 180,000 and the 350,000 to 400,000 in annual production needed before 2020. This is also the best way to assure most needed health access for rural and for underserved populations. It will also require specific preparation, admission, training, accreditation, and support for health access facilities, teams, and practitioners.

Why Nurse Practitioners Are Not Primary Care Shortage Solutions