Too Many Specialists On the Way Once Again
Robert C. Bowman, M.D.
Debates of specialist versus primary care workforce have been divisive and counterproductive. Basic realities require basic health access in a horizontal dimension and also a vertical dimension of specific specialties for specific health care needs.
The nation fails to support both basic health access and specialty care and has a design that compromises basic health access primary care because of design favoring specialty and hospital care.
Few understand Basic Workforce 101 Principles
Workforce decisions must be made 35 years in advance of the intended workforce.
If there are shortages of all physicians, basic health access physicians, or specialty physicians, it is too late to address the changes when the shortage begins. It is possible to make up the gap in specialty care physicians, but when too many are produced there is overshoot and the nation's medical schools have not decreased production, even when indicated. The "overproduction" of primary care has not been demonstrated as a problem as primary care physicians and non-physicians have demonstrated the ability to fill new workforce needs in areas such as emergency care, hospitalists, and various specialties. What the nation has yet to demonstrate is the ability to produce and retain enough primary care.
The appropriate consideration when measuring workforce production is a comparison class year to class year.
Studies of workforce are often based on active graduates in their first practice locations. These are grossly distorted compared to studies over decades of contributions. More appropriate measurements involve estimates of the next three decades of health care delivery assigned to the class year of graduation as in the Standard Primary Care Year tool. Past studies can also confirm the findings of the Standard Primary Care year estimates.
The United States quadrupled primary care production from the 1970 to the 1980 class year. This was a result of a doubling of the percentage remaining in primary care and a doubling of the medical school graduating class at the optimal health policy time. This resulted in rebuilding of basic health access as well. Also the Medicare, Medicaid, and other policies of the time acted to rebuild health care delivery in practice locations previously left behind. Those left behind were the usual suspects rounded up and left behind (rural, lower income, middle income, elderly populations, more normal and less exclusive). These are also the populations most closely associated with greater primary care levels. With increased funding to these populations for health care and with increased funding for primary care, optimal health access improvement was the result.
If the US had kept up this level of primary care production relative to the population and if the US policy design for primary care was a permanent primary care form as in other nations (not flexible steadily departing in a career), it would have had sustained basic health access primary care workforce. This graphic also illustrates the failure of 15,000 more internal medicine, nurse practitioner, or physician assistant annual graduates to improve primary care delivery.
Specialty Physicians, Nurse Practitioners, and Physician Assistants Continue to Increase Rapidly While Primary Care, Family Medicine, and non-physician primary care remains flat
Workforce Is Huge with Well Over 1 million and Growing Rapidly
Think Huge As in a Big Elephant Not Able to Move Fast and Unable to Live in Areas Without Water and Unable to Eat Enough to Survive if the Elevation of the Land is more than a Few Feet since so many calories must be consumed and processed to survive the energy cost. Hannibal brought the Roman Empire to its knees with a smaller fighting force and this required him to make very few errors. One major error was attempting to bring elephants across the mountains. Hannibal won time after time with near perfect strategies. The lesson of failure to change was also painfully transmitted to Roman leaders. The Romans survived because they changed strategies (and because Carthage deserted Hannibal). The United States has failed in health access for decades and it still refuses to adapt the strategies that have worked for over a century.
The most consistent failed strategy has been expansion. Even this most basic strategy of graduating more fails for primary care production. This is because the US fails to understand much at all about the primary care that it has designed. US training programs, especially IM, NP, and PA, are actually specialty workforce training programs.
The US physician and non-physician workforce is huge, slow to move, and clustered around water and food. In a literal sense, health care is in coastal counties as demonstrated by Hurricane Katrina taking out most of Louisiana health care. The US will have more such devastation of health care capacity from floods, hurricanes, and earthquakes and will have other great losses of life during pandemics and local disasters. A design that concentrates health care resources and emergency care in 4% of the land area clustered together not uncommonly in vulnerable locations, is a poor design.
Specifically 90% of health care funding related to physicians is transmitted to zip codes in 4% of the land area. The current health system with this design requires an enormous amount of federal, clinical, and state water and food to survive. It is not able to adapt. It also wants to consume even more. About 75% of physicians are unable and unwilling to move beyond this 4% of the land area to areas of need that are higher in difficulty (higher in elevation, more complex, primary care careers). What it cannot do is deliver the most needed health care. By admission, by training, and by policy recommendations it has consistently devastated primary care and basic health access.
Workforce that involves well over 1 million physicians, nurse practitioners, and physician assistants is already set in place. Changing such a huge cohort takes a generation to address. The generation for a physician is 35 years or the age from 30 to 65. As will be noted, specialty care changes are already in place. Primary care is another matter. Even if the United States returned to sufficient primary care production that would meet health access needs, it would take 35 years of this production to return to sufficient primary care and basic health access. This would require at least 12,000 annual primary care graduates that stayed 90% in primary care and remained 90% active for 35 year careers delivering 90% of the volume of the current volume leader (family practice) with this delivery 15 – 20% in rural locations and 15 – 20% in underserved locations.
The United States Can Produce the Necessary Primary Care But Makes Other Choices in Design and Implementation and Even Fails to Realize When Primary Care is No Longer Primary Care
Physician assistants and nurse practitioners designed to remain 100% in basic health access primary care would have been a great boost to health access, but with less than one-third in primary care and less than one-quarter remaining in the family practice mode (only one for significant rural or underserved contributions), the basic health access contributions have been steadily lost over time. What is worse is that even experts believe that NPs and PAs can take on basic health access and primary care even with a smaller and declining fraction of graduates remaining in primary care (down to 30% and falling). Also problems remain when Congress still considers internal medicine primary care when studies have demonstrated 50% then 40% then 20% and now only 10% of graduates fail to remain in primary care.1-5 Studies also reveal dysfunctional primary care training in internal medicine that can drive students and residents away from primary care.6 Then 25,000 to 30,000 internal medicine primary care physicians have left primary care in the past 6 years for hospitalist careers7 with even more lost to hospital, specialty, and other careers outside of primary care, as has been the case for past decades of internal medicine as it moves form more general and distributed to more concentrated with each passing class year and each year after graduation. The result is greatest concentration in top concentrations of physicians and greatest concentration in the counties with the top concentrations of people. Pediatric workforce changes have also been away from distribution and toward concentration with rural and with underserved locations less likely to be served.8, 9
With regard to primary care, workforce that does not begin in IM, PD, FM, NP, or PA training does not become primary care (and most IM, NP, and PA fail to become primary care).
With regard to so-called primary care training, most “primary care” graduates do not enter primary care and even less primary care is retained. This is mainly because internal medicine with 8000 graduates a year, nurse practitioners with 7000, and physician assistants with 7000 are flexible primary care training forms that depart primary care during training, at graduation, and each year after graduation. In other words, they can go either way, to primary care or to specialty care. Without permanent primary care, primary care cannot remain permanent. Better estimates of primary care contributions in the future are made using the Standard Primary Care Year.
There is little or no return from specialty care to primary care.
Another novel idea that did not work was the attempt to convert specialty care to primary in the 1990s. This lasted about as long as there was grant funding to make the attempt. Other than conversions of front line serving physicians such as emergency room physicians to more of a continuity type of practice situation, conversion of specialty care to primary care was a failure. The Masterfile also reveals steady movements away from primary care by class year.
Graphic on Primary Care Retention
Studies by Larsen and Hart and studies of physicians in the Masterfile demonstrate that departures from primary care are basically one way.10 http://depts.washington.edu/uwrhrc/uploads/CHWSWP105.pdf in Table 3 an important finding is also apparent that is present in annual Physician Assistant surveys. The greatest departures involve the departure from family practice careers to other careers. With the departure from family practice, the loss involves significant primary care, rural, and underserved workforce. This departure from 1990 to 2000 is significant also because of the supportive primary care policy of the 1990s. Even with new graduates moving toward primary care and family practice, existing graduates were departing. Once again the defect of failure to have permanent primary care is illustrated.
Even during 1990s policies that were supportive of primary care and returned new physician assistant and new internal medicine graduates back to a majority starting in primary care, the graduates melted away from primary care steadily over the past decade that moved from supportive of primary care to destructive.
The end result has been a decline in all sources of primary care from 20 Standard Primary Care years per graduate to 6 SPC years per graduate. It is not a surprise that expansions of graduates, especially in the types of graduates with the least primary care per graduate, fail to address basic health access needs.
To address primary care needs, a defined primary care production and retention must be carefully estimated, coordinated, and implemented decades in advance.
This is important for all workforce, but particularly critical for primary care. This is because
The difficulty of primary care production and retention is resolved in other nations by separation of primary care training, accreditation, and support.
The Physician Shortage
As always the insatiable demand of Americans to avoid death at all costs has fueled the current move to more specialty and hospital care and more and more specialty and hospital physicians and higher and higher costs associated with health care.
Association of American Medical Colleges staff and other workforce experts have lobbied for increased physicians for several years. It has been apparent that the primary motivation for expansion has been expansion of specialty physicians. Now expansion has become reality.
Until recently these specialty promoters have been careful not to claim increase in primary care from expansion, which is a correct interpretation on their part. In recent months, the ante was raised as legislation in Congress would send 1 billion additional dollars to medical schools and teaching hospitals in a carefully crafted bill to be able to claim some impact on primary care, but since the expansion would involve internal medicine, such an expansion is guaranteed not to increase primary care. This is because people in the United States do not understand that internal medicine training is no longer capable of greater than 10% primary care production of graduates. The 1970s top primary care source is now the lowest contributor with less than 10% of primary care. (graphic on primary care changes) Even past class year contributions have greatly diminished with 30,000 internists departing primary care for hospitalist careers and even more have departed for specialty and hospital careers.
Even a doubling of primary care graduates failed to produce more primary care in the past decade. This is because primary care is actually produced and retained at much lower levels such that even massive expansion (3100 to 6500 annual graduates in physician assistants from the 1998 to the 2008 class year) have been unable to keep up primary care (AAPA data).
For nurse practitioners 1998 to the present class year, actually 50% less primary care delivery is involved. This is inevitable with decreases of 50% or more in the percentage entering and remaining in primary care. Since nurse practitioner annual graduates did not increase, there can be no claim of increased primary care delivery.
But Does the US Need More Specialty Physicians When Massive Changes in Specialty Physician Production Have Already Been Implemented?
The United States now has over 50% increases in specialist physicians for allopathic and osteopathic US graduates in the past decade. There are steadily declining percentages of graduates in primary care resulting in fewer numbers of graduates remaining in primary care even with increasing graduates during expansion.
Changes in Physician Career Choices for Recent Graduates
Changes in Non-Physician Graduates To Become Specialty Workforce For decades the massive increase in non-physicians has favored specialty workforce with higher percentages of increase. Again the reason is failure in primary care retention in NP and PA flexible primary care forms.
Sufficient specialty care workforce appears to have been addressed with over 50% increases in recent (and future) class years of US medical school graduates, international graduates with similar movements to specialty care, massive conversions of previous class years of internal medicine primary care graduates to hospital and specialty care, and massive conversions past, present, and future physician assistants and nurse practitioners to specialty care. With movements of non-physicians and nurses to specialty workforce, substantially more specialty workforce capacity has been added and will continue to result from the current changes. The same is not seen for primary care production and retention which remains at insufficient levels in addition to losses from conversions of active primary care graduates.
Physician Career Choices for Recent Graduates At best the primary care graduates remain flat while past, present, and future decades of population growth and growth of the most complex populations needed more primary care has not been addressed.
The Next Environment of Too Many Specialists
At some point nations must realize the facts of life and death and the consequences of advancing technology. The most basic fact is that humans die. The next most basic fact is that humans prefer not to die, and will expend whatever resources that they can to prevent death in themselves or loved ones. This is not true in all people or cultures, but it is a fact of American health care and a major reason for massive growth of specialty care.
Translated to policy this means that health care, with higher and higher costs of care for fewer and fewer gains in life impact, will break the budgets of business and government. This should be enough to raised concerns in physician leadership and even in specialty physicians. But the past lessons have been forgotten.
In some ways, their lack of fear is justified. The United States, other than a few short years to prevent the economy from collapsing in the 1990s rather than the 2000s, has not reigned in health care costs. But others will remember the 1990s changes. The small impact of a temporary cost control resulted in the largest run of economic viability in recent history in the United States and a recovery from recession. Memories are rather short term in this area, just as memories fail to recognize that war, energy, and health care costs at the same time are a bad combination.
The economy, economic viability for businesses, and the reality of budgets for schools, state governments, the federal government all demand that cost be reigned in. This time will come.
Non-Physicians: Less Costly and More Easily Controlled: Great Value for Health Employers
The growth of nurse practitioners and physician assistants has been significant. Specialty physicians, nurse practitioners, physician assistants, and employers all benefit from the current situation. Non-physicians generate more revenues as specialists and also cost substantially less in salaries and benefit and support costs compared to high cost specialty physicians. Even what appeared to be a massive shift during the 1990s, was only a blip on the radar scope with primary care per graduate continuing downward. At the current rate of growth in some specialties, there will be more nurse practitioners or physician assistants compared to physicians. Nurse practitioners are already over twice as likely to be in cardiology, oncology, endocrine, mental health, and geriatrics. With 7000 nurse practitioner graduates and increases likely, the percentage advantage will become a numerical advantage.
Strategies for maximum corporate profit will involve the fewest specialty physicians with the most non-physicians, nurses, and support personnel. Nurse practitioners and physician assistants save two thirds or more in personnel costs compared to many specialist physicians. In economic downturns, with health care reform, with changes in reimbursement, or with limitations in specialty care, the equilibrium shifts. Currently the nurse practitioner and physician assistant additional revenues and profits go to employers. In the future, more competitive health care environments will force health systems to compete based on efficient care – or the US will not be competitive with other nations.
Changes in reimbursement must level the playing field between subspecialty care and all other forms of health care. This will result in declines in reimbursement for subspecialty care. Specialty care must not be allowed to replicate to the point of crowding out all other health care, especially basic health access.
References
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