The Standard Primary Care Year

Promises of primary care are one thing. Actual delivery of primary care is quite another. Major journals and government reports discuss innovation and reorganization and various technologies applied "to save" primary care. These are an affront to all who understand primary care delivery as person to person interaction. When understanding the nature of primary care and the limitations of too few RN, MD, DO, NP, and PA as primary care workforce, the folly of innovation, reorganization, and technology can be understood. People interactions require people - patients that can access care and providers that can serve patients.

When reviewing articles, reports, comments, blogs, or media offerings about primary care, reflect about how few actually indicate how the United States will actually deliver the primary care. Despite adding 3 new and original primary care training sources (NP, PA, MPD) and despite a doubling of annual graduates produced by US primary care training (14,000 to 28,000), the United States primary care delivery result has decreased 25% for the class year of 1980 compared to the class year of 2010 (280,000 to 210,000).

Insanely, the US continues to spend more on training more and manages to get less primary care delivery result. Primary care training itself is actually 70% not primary care in result. What we have here, is a failure to communicate the lack of specificity regarding primary care. Common sense indicates that primary care delivery capacity for the United States is the result of specific preparation for primary care by candidates prior to training, selection of canidates specific to primary care, specific training in primary care that results nearly 100% entering primary care workforce, and policies that support primary care graduates to remain 90 - 100% within primary care for entire careers. All of these are required for efficient and effective and most experienced and most continuous and most high quality primary care.

Few recognize the following. 

A measuring tool that actually considers retention in primary care is required to return accountability to primary care training and national leaders - and eventually primary care delivery for most Americans left behind in basic health access. Deans of medical schools failing in primary care delivery must stop claiming 30 - 40% primary care result when the actual result is 10 - 15%. Entering primary care training is not sufficient to demonstrate production of primary care. Nursing, media, and government indications of advanced degree nursing or generic nurse practitioner training as solutions for primary care are also in error. Only the family nurse practitioner trained NP (50%) that actually remains in family practice employment or position (25% of total NP) is a primary care solution. The physician assistant that enters family practice is the substantial primary care, rural, and underserved contribution for all physician assistants.

Tools to measure primary care must reflect reality not assumptions or promotions
and certainly not distractions from solutions.

Over 200 million Americans (over 65%) reside in 30,000 zip codes where 40 - 100% of local workforce is primary care workforce. Health access, local economics, jobs, social organization, and leadership depend upon designs that must prioritize most Americans rather than just 35% of Americans in 3400 zip codes in 4% of the land area with top concentrations.

The Standard Primary Care Year is a common sense measuring tool based in reality, not fantasy. Graduates must do all of 4 criteria to deliver primary care - train in primary care, remain in primary care, serve long careers, and deliver signficant volume. Top primary care delivery goes to those with the longest careers, most primary care retention, most activity, and most volume. Lowest primary care delivery goes to those with the shortest careers, lowest primary care retention, lowest activity, and lowest volume.

The Standard Primary Care Year = Average Career Years X % remaining in PC for a career X % active for a career X % volume

Each is specific to primary care as in the % of those in primary care, the proportion active and also the % volume compared to the top volume primary care source (or family medicine set at 100%).

The SPCYr is a relative or comparative measure specific to the class year of graduation and the source of primary care (NP or Nurse Practitioners, PA or Physician Assistants, IM or Internal Medicine, PD or Pediatric, MPD or Medicine Pediatrics, FM or Family Medicine). The SPCYr not only allows comparison source to source but also comparison of a single source over different class years. Medical school graduates can be compiled by FM, IM, and PD to capture SPCYr contributions by individual school, school type (US MD, DO, Caribbean, international) primary care contributions. By combining all primary care training sources for a specific class year, the past or present or future primary care can be estimated. Rural primary care delivery can be estimated using the average proportion of primary care graduates of a source found in primary care. Graphic illustrating rural SPC year contributions The same calculations can involve specific types of locations that are underserved or that are outside of current concentrations of workforce.

When better measuring tools are used, the failures of the United States primary care design are obvious. When a nation doubles the annual graduates emerging from six primary care training sources and yet this results in a 25% decline in the primary care delivery capacity, the design is a failure for primary care and a success for non-primary care.

Health leaders can actually attempt to address deficits of primary care or they can continue generic expansions that have already not worked for 30 years.

        Years in a Career - Usually 25 years for age 40 65 (nurse practitioners) or 30 - 32 (foreign origin international medical graduates) due to delays in entry as compared to 33 - 36 years for US origin physicians (MD, DO, Caribbean) or physician assistants.

         Primary Care Retention - Using association sources and secondary databases the percentage remaining in primary care for an entire career on average for all graduates in a classyear is down to 15% or less for internal medicine, 25% for all PA grads, 25 - 27% total NP grads, 44% for PD, and 90% for family medicine.

         The percentage that remain active and in the United States delivering primary care, not part time or inactive graduates  - 60% for nurse practitioners and foreign origin international medical graduates compared to 70% for physician assistants and 85% for physicians.

         The volume of primary care delivered compared to other forms of primary care this can be compared to a standard such as the top volume delivered by family physicians 100% FM, 95% PD, 86% IM, 70% PA, 60% NP. The original article had to be revised as flexible primary care forms had even lower primary care retention levels.

2012 Class Year Estimates of Primary Care Delivery

 

NP not FNP

FNP Trained

PA not FP Start

PA with FP Start

FM Trained

IM Trained

PD Trained

MPD Trained

% Primary Care

15%

54%

15%

60%

91%

15%

39%

43%

Years in Career

24

24

33

33

33

32

33

32

% Remaining Active

70%

70%

75%

75%

84%

82%

82%

82%

% Volume Relative to FM

70%

75%

75%

80%

100%

86%

95%

95%

SPC Years Per Graduate

1.76

6.80

2.78

11.88

25.23

3.38

10.03

10.72

Annual Graduates 2012

 

 

 

 

 

 

 

 

28,340

4,000

4,000

5,500

1,300

2,800

7,300

3,000

440

Proportion of Graduates

14.1%

14.1%

19.4%

4.6%

9.9%

25.8%

10.6%

1.6%

195,164

7,056

27,216

15,314

15,444

70,631

24,710

30,077

4,716

Proportion of SPCYrs

3.6%

13.9%

7.8%

7.9%

36.2%

12.7%

15.4%

2.4%

 

 

 

 

 

 

 

 

 

SPCYrs per Grad for 2012

 

All NP

 

All PA

All FM

All IM

All PD

All MPD

6.89

 

4.28

 

4.52

25.23

3.38

10.03

10.72

Steady declines in primary care retention for NP, PA, IM, PD, and MPD have resulted in less primary care delivery per graduate. The doubling of NP and PA annual graduates each 6 to 12 years since 1980 has made this less apparent although most rapidly increasing the non-primary care result.

Solutions for primary care involve more Standard Primary Care Years per graduate, not steady declines as in fewer remaining in primary care.

Sources associated with family practice dominate primary care, rural primary care, and underserved primary care delivery. Flexible NP and PA sources that depart family practice or primary care are also departing needed primary care delivery.

The table illustrates Rural Standard Primary Care Years and Underserved (shortage, high poverty) Primary Care Years and contributions in Outside Primary Care Years. The % rural or % underserved or % Outside is specific to the primary care distribution of the source.  

Health Access Contributions for the Class of 2012

Rural (RUCA) Location

NP not FNP

FNP Trained

PA not FP Start

PA with FP Start

FM Trained

IM Trained

PD Trained

MPD Trained

Rural SPC Years/Grad

0.176

1.905

0.278

3.564

5.550

0.338

0.802

1.715

Location % for Career

10%

28%

10%

30%

22%

10%

8%

16%

35,661

706

7620

1531

4633

15539

2471

2406

755

Proportion By Source

2.0%

21.4%

4.3%

13.0%

43.6%

6.9%

6.7%

2.1%

Underserved (Shortage High Poverty Zip Code)

 

 

 

 

 

 

 

 

Underserved SPCYrs/Grad

0.212

1.021

0.334

2.138

3.784

0.305

0.902

1.286

Location % for Career

12%

15%

12%

18%

15%

9%

9%

12%

25,638

847

4082

1838

2780

10595

2224

2707

566

Proportion By Source

3.3%

15.9%

7.2%

10.8%

41.3%

8.7%

10.6%

2.2%

Outside of Concentrations (30,000 Zip Codes with 65% of the US Pop)

 

 

 

 

 

 

 

 

Outside SPCYrs/Grad

0.617

3.742

0.975

6.534

13.369

0.948

2.807

4.288

Location % for Career

35%

55%

35%

55%

53%

28%

28%

40%

85,954

2470

14969

5360

8494

37434

6919

8422

1887

Proportion By Source

2.9%

17.4%

6.2%

9.9%

43.6%

8.0%

9.8%

2.2%

Specific contributions of workforce require specific (SMART) estimates. Projections fail, especially during periods when fewer remain in primary care, family practicem, rural, and underserved careers.

Compiling the contributions helps to determine the proportion of primary care delivery or delivery in various locations most important for health access.

Despite lower proportions of annual graduates, family practice sources deliver greater proportions of primary care or needed primary care - but dedication to family practice careers is required. NP and PA departures from family practice depart needed health access. Family medicine by design is more likely to remain and is a more difficult decision for medical students to make because it is the most permanent primary care source that often requires a location other than the typical 3400 zip codes in 4% of the land area inside of concentrations. Lowest percentages of family physicians are found in top concentrations such as zip codes with over 200 physicians rural or urban (4 - 5%), US MD schools (4%), and the most densely populated counties (2 - 3%). In contrast these are locations preferred by non-family medicine sources.

A second method can be used to calculate the Standard Primary Care year over an entire lifetime in the career of a physician or non-physician. This can include the changes in the percentage that are active and the percentage remaining in primary care that also change over a lifetime. A graphic captures this best with the years in a career from age 30 to 65 on the horizontal axis and the vertical access representing the year to year primary care contributions using the product of primary care retention percentage, percentage active, and percentage volume.

The area under the curve represents the Standard Primary Care Year contributions specific to the specialty and to the class year of graduates.

Graphic Illustrating the Standard Primary Care Year

Graphic illustrating rural SPCYr contributions

This method tends to capture the greater contributions in the first years with lesser contributions in later years.

Medical School Type and Career Choice and Most Needed Health Access

When it comes to primary care, remaining in primary care is the most important factor. Health policy now drives flexible forms away from primary care in this destructive policy period.

SPCYrs per Grad

Reference Points for 2012 Graduates

35 SPCYrs

A perfect score of 35 SPC years is an entire 35 year career from age 30 to age 65 with 100% primary care retention for the entire career, 100% active for the entire career, and the volume of a family physician with a 100% volume rating (top volume).

26 30

US origin family physicians

24 - 26

All 3000 family medicine residency graduates

15

Duluth Medical School 1970s to Present - entire production

12  14

Medical schools (allopathic or osteopathic) with health access focus in training and family medicine graduates over 28%

11

Pediatric and Medicine Pediatric Residency Graduates 

8 - 9 

Ross University is in the 9 Standard Primary Care Year per graduate range and with 469 graduates and 115 family medicine graduates, Ross is the number 1 source of primary care in the United States.

7  9

Overall Osteopathic graduates

5  7

Allopathic public school graduates (US MD Nationwide)

Family nurse practitioner trained graduates

Osteopathic graduates selecting internal medicine

3 5

Allopathic public schools with fewer family medicine graduates

Total generic physician assistant graduates

Total generic nurse practitioner graduates

1 - 3

NP Grads not trained as Family Nurse Practitioners (50% of total)

Physician assistants not entering family practice initially

Allopathic Private, Top MCAT, Top Research Medical Schools typically with 1 to 4% choosing family medicine, 1 to 4% family medicine faculty, 1 to 4% found in rural or underserved locations

 
SMART Designs are Required for Primary Care and Basic Health Access
 
Meeting Primary Care Needs By the Latter Half of the 21st Century
 

Further analysis

Family medicine residency graduates will deliver multiple times more primary care over their career compared to any other primary care source as all others are flexible sources resulting in more found in non-primary care as compared to those retained in primary care, more active as compared to others more likely to be inactive or part time or missing, higher volume as compared to those lower to lowest in volume, and longer careers as compared to those with shorter or shortest careers.

Other sources not family medicine claim to be primary care solutions but such a solution requires more graduates and more training cost for less primary care yield and less primary care yield where the United States needs primary care.

For these reasons, schools and programs that yield the least employed in family practice will not be specific in primary care contributions or resolution of health access deficits.

The United States can attempt a 6th or 7th or 8th time to create a more permanent, broader, generalist provider that stays in primary care and in basic health access when all others fail to stay or it can finally realize the value of an existing source that has worked for over 40 years and has adapted to formal training without losing the health access result. Similarly it can find ways to fix NP and PA family practice outcomes as more permanent or it can continue to watch NP and PA contribute to non-primary care with 70% or 75% or 80% as flexible sources follow US designs.

The Family Medicine Multiplier

Nurse Practitioners Not FNP Trained - A single US FM residency graduate during a career will contribute 14.30 times the primary care delivery of a nurse practitioner who was not trained in a family nurse practitioner program. Time and again generic nurse practitioner expansions or expansions of advanced nursing demonstrate lack of a solution for primary care. Only 70% of total NP workforce is active as a direct care clinician. Half of total NP graduates deliver very little primary care during their careers. Only those specific to family practice are relatively specific to primary care and primary care where primary care is most needed. Only expansions of family nurse practitioners are a solution and only when they choose to remain in family practice for a career. The massive amounts that are needed to train negate the choice of NP other than FNP as a primary care solution. Adult and pediatric NP programs and individuals can contribute, but once again the contribution specific to health access must consider an entire career, the ability to resist conversion to nonprimary care, and the ability to distribute where needed.

Physician Assistants Not Starting in FP - A single FM residency graduate will contribute 9.06 times the primary care of physician assistants not starting in FP employment. This also confirms that generic expansions fail for primary care as over 80% of PAs entering the workforce fail to enter family practice. Studies indicate drift from family practice and primary care over the years after graduation, even during the 1990 - 2000 policies much better for primary care (Larsen and Hart). Massive growth over 200% for non-primary care compares to the recent 100% expansion and just 30% more numbers entering primary care - numbers that will depart steadily in the next 33 years after graduation.

7.45 Multiplier for Internal Medicine Residency Trained Graduates - Internal Medicine is no longer in a position to contribute significant primary care due to substantially higher cost, low primary care yield, steady departure from primary care after graduation, and limited distribution.

3.71 Family Nurse Practitioner Graduates - About 50% of NPs train in family practice, but only 50% stay in FP after training as FNP (25% of total NP grads) It is the FNP grads remaining in family practice that represent the predominant contribution of nursing to direct clinician primary care delivery (not advanced, not generic NP). If there were some requirement that forced FNP to stay 90% in family practice over a career, the FNP would contribute about 11 - 12 SPCYrs per graduate or about the same as the PA beginning in family practice. Even so, late entry and lower activity and lower volume and much lower primary care retention results in multiple times more graduates that must be trained to result in the primary care delivery of a single family medicine residency graduate.

2.52 PD Residency Trained Graduates - Because pediatric primary care is saturated in the locations where pediatricians choose to locate practices, pediatric residency expansions fail for primary care delivery capacity increase and have failed for about the last decade of class years. Movement away from primary care, lower activity, and preference for part time and academic positions as well as practice locations already saturated in primary care indicate that expansions of pediatricians are contraindicated for the purpose of resolving US health access deficits.

2.35 Medicine Pediatric Residency Trained graduates - Problems tracking MPD are likely to translate to more required. MPD graduates that remain in MPD for an entire career do have substantial primary care contributions and significant distribution, but only 20% remained in MPD for the first 15 years for graduates prior to 1990 and departure rates have only increased. Any medical student choice other than family medicine is a choice that fails in specific health access resolution.

2.12 Physician Assistant Graduates Beginning Careers in FP - Assuming 60% retention in  primary care (likely an overcall), family practic physician assistants are the only source that can come close to family medicine in training cost per yield of primary care and again only the component that stays in family practice matters. Family practice physician assistants have a maximum distribution such as 30% found in rural practice and 30 times the rural health clinic location of other PAs and 6 - 7 times the CHC location of other PAs but are down to less than 20% of those entering PA workforce.

For the entire PA workforce about 24% of PA workforce is family practice out of about 30% of PA workforce in primary care. These figures are known to be a bit high due to studies of non-responders by AAPA. Also primary care PAs may be more likely to be part time. Continued departures are likely to translate to even more graduates required to equal the contribution of a single family medicine residency graduate. PA graduates make less in primary care compared to other PAs and this shapes less workforce by less retention and lower continuity as PAs also gain 4% by leaving their continuity practice.

Continued departures from family practice choice in NP and PA, coupled with stagnant family medicine, has resulted in stagnant basic health access for decades - by design. Also the family practice workforce acts to limit the primary care and the distribution in other sources - another defect of a flexible design and too little national spending upon primary care.

NP and PA annual graduates with a massive expansion since 1980 doubling each 6 - 12 years have failed to result in the expected increases in primary care delivery. This is entirely due to lower yield of primary care in the design and movements to even lower yield as fewer have entered and remained in primary care - also by US design and the hiring practices of systems, teaching hospitals, and other employers. Tens of thousands of primary care NPs and PAs were hired to fill teaching hospital workforce gaps alone.

Hospital, hospitalist, subspecialist, urgent, and emergent care numbers continue to increase yearly with fewer remaining in primary care and family practice. With over 70% not found in primary care, NP and PA sources are dilute primary care solutions at best. Flexible primary care sources are diverted away from primary care by US designs that send far more to non-primary care as compared to primary care.

The United States will once again graduate about 28,000 from IM, NP, PA, MPD, PD, and FM programs in 2012 but this will result in only about 195,000 Standard Primary Care Years of future primary care delivery or about 25% less than the class of 1980 derived from half as many primary care graduates or 14,000.

Despite adding 3 new sources since 1960 and 14,000 more annual graduates since 1980, the US is producing even less primary care per class year.

Steady declines in primary care retention have resulted in a decline from about 18.6 to 6.8 SPCYrs per graduate from 1980 to 2012 for the entire national primary care production.

Family medicine with less than 3000 annual graduates remains at zero growth from 1980 to 2012. With only 10% of total primary care graduates, family medicine will deliver 36% of the primary care for the class of 2012 just about to enter the workforce.

Primary care delivery capacity increases have been seen only from 1965 - 1980 and briefly in the 1990 - 1995 policy period. All other time periods have resulted in declines in primary care delivery.

As far as numbers of primary care (raw numbers not adjusted for primary care delivery), only 1965 - 1980 doubled primary care numbers. Non-primary care numbers have doubled each 15 years since 1965. Three dimensions of non-primary care expansion (expansion, increased proportion, conversion of primary care to non-primary care) with closely related health care cost increases have dwarfed primary care and the ability of the US to address health care costs - by design

The decades misguided United States primary care effort still remains focused on innovation, reorganization, and technology rather than understanding that primary care is first and foremost about the people that deliver primary care - the primary care RN, MD, DO, NP, PA, and other team members.

Primary care delivery is limited by deficits of people that are actually involved in direct services primary care - which is limited by primary care spending in addition to increases in the cost of delivery primary care. When spending is insufficient and distorted away from direct primary care delivery, ever less primary care delivery and primary care workforce is the result.

The costs of delivering primary care continue to go up and include more different types of costs such as locums, recruitment, retention, health information technology, practice technology, more personnel in billing or screening, more personnel to deal with outlier patients, more patients and patient information addressed with little or no reimbursement (hospice, hospitalist, urgent care, responsibility without authority or reimbursement), and more personnel actually working for government or insurance on cost savings for government or insurance but trying to overcome these barriers to get needed care for patients. The primary care RN at 270,000 across the nation or substantially more than primary care physicians is prevented from active direct patient care participation by the US design (negotiating with insurance companies and other providers rather than patient contact).

The reimbursements in primary care are going down. Primary care spending has been decreasing with Medicaid cutbacks. Primary care spending from Medicare has been limited by aberrant designs and failure to realize the serious problems facing primary care. Primary care delivery has had to move to alternative reimbursement increasingly due to failure of the traditional design for all except higher income locations. Primary care Medicare spending is set for a 29.5% cut on January 1, 2012 along with all other physician fees.

The designed fee cuts will markedly decrease the primary care delivery capacity specific to locations where elderly are concentrated. These are 30,000 zip codes with about 68% of the elderly and 65% of the US population that depend most upon primary care and family practice. Family practice that remains in family practice is twice as likely to be found in these locations outside of concentrations as noted in 53% of the family medicine physicians found there (and 50% of remaining family practice NP and PA workforce) as compared to half as many for any other source. These 30,000 zip codes are most dependent upon Medicare and Medicaid, the sources likely to take the most cuts. Unemployment, inadequate health care coverage, and lack of health care coverage are likely to increase in these 30,000 zip codes.

I implore family medicine and primary care leadership not to focus on small successes such as a few more annual graduates a year due to few other choices from limitations in GME. I applaud the recent attempts to focus on primary care revenue. I hope for more efforts to address primary care cost areas.

I encourage primary care to re-educate health leaders to understand primary care as most Americans understand primary care - primary care is about people, person to person, one caring for another. If you do not have the people to deliver the care year after year for the same people in the same locations learning more and more about how to deliver more care more efficiently and effectively, you do not have a design that works for most Americans.

Bob Bowman

 Health Access Failure in Design: Flexible Primary Care Instead of Permanent

Beyond Policy Declines: Other Influences Moving Primary Care Up or Down

Basic Health Access Concepts to Review

www.basichealthaccess.org

www.physicianworkforcestudies.org

www.ruralmedicaleducation.org