Primary Care Health Policy

Primary Care Years: New Measures of Total Workforce Contribution

Primary Care Workforce Summary

Changes in Admissions Impacting Primary Care Choice and Distribution Beyond Major Medical Centers - Students with the most connections to major medical center areas of the nation before and during training are the most likely to gain medical school admission and are the least likely to leave major medical center training locations for practice. Well-connected higher status students are increasing rapidly in admissions and are replacing lower and middle income types of students that have long had greater levels of distribution and the highest levels of choice of primary care and family medicine. Changes in Admissions in Allopathic Medical Schools

Declines in Family Medicine Greatly Diminish Physician Distribution and Workforce Versatility - Family medicine, the only career choice that can convert the non-distributional student types to meet the nations most pressing health care needs has been cut in half in US MD Grads in the last decade. Only the medical students taking osteopathic routes and those escaping to Caribbean medical schools have managed to maintain the supply of the US born graduates that distribute at the highest levels. All but a few allopathic private schools are no longer a reliable source of family physicians and all but a few allopathic public schools are declining. The nation has stable osteopathic levels but osteopathic expansions may only yield the same relative number of family physicians without health policy changes.
Collapsing Choice of General Internal Medicine

Dependable Primary Care and Distribution - Family medicine levels of primary care and distribution have remained constant despite adverse health policy that has impacted all other forms of primary care. Family medicine graduates remain in primary care at over 90% levels, maintain practice locations outside of major medical centers with over 50% of graduates, and maintain sustained 20% or above rural location for all class years and 10% or above underserved location. These distributions are all twice the level of other primary care types. Primary Care Retention   Family Medicine Central: National Comparisons of Workforce

New Escape Mechanisms for Primary Care and Rural Workforce - Changes in Visa regulations allow international graduates to bypass rural commitments and go straight to major medical center locations. This means significant losses in a major source of underserved rural primary care and mental health in addition to losses of rural physicians in all specialties.

Changes in admissions and health policy mean great and growing difficulties for primary care access, particularly in urban underserved and rural locations. Family medicine retains a consistent contribution over the decades, resulting in multiplier effects when compared to other types of primary care. Facilitating Physician Distribution

For primary care contributions over a three decade span of workforce, the nation would need to graduate at least 2.15 NPs, 2.36 PAs, 4.51 IM physicians, or 3.42 MPD physicians to obtain the same workforce effect as 1 family physician.

Dividing the total contribution of a theoretical 60,000 graduates over 30 years yields 0.88 FTE of primary care per FM graduate, 0.41 FTE per NP, 0.374 per PA, 0.195 per internal medicine (IM) grad, and 0.257 per medicine pediatric (MPD) graduate.

Overall each primary care graduate averages only 0.424 FTE of primary care as compared to studies of the 1960 physician primary care graduates that managed 0.71 FTE per primary care graduate. The only primary care specialty to exceed this is family medicine.

Current trends indicate that the nation will need 3 or 4 PAs or NPs for 1 FTE of primary care or for the same contribution as a family physician within a few years. The nation will need double this component to graduate rural practitioners at the same rate as family physicians. Considerations of the numbers needed to train to supply rural or underserved areas are important and shift the balance toward family medicine, with fewer needed. This is a concept regularly discussed by Howard Rabinowitz.

Although failures of health policy support for primary care and major medical center hiring practices are the major reason for loss of primary care, the direct indication is fewer NPs and PAs working with family physicians. Before 1984 over 55% of physician assistants worked with family physicians and rural practice levels were well over 25%. Training up to this point prominently involved rural family physicians. By 1996 only 40% of all PAs worked with FPGP physicians and 25% of PAs were in rural locations. Now PAs are 17% rural and family physician supervisors are 28.5%. Also 11.5 percentage points of PAs work with FPs and have urgent care duties, a debatable form of primary care or efficient primary care.

Head to Head comparisons of family physicians and physician assistants indicate that both have similar total rural contributions, slight advantages for PAs for isolated rural areas, and slight advantages for FPs in larger rural and small rural areas. These studies involved PA levels for the year 2000, levels that have declined by 1 percentage point a year while FP rural contributions have remained a steady 24% for 30 years. It is not known which types of rural PAs have declined in recent years.

Allowances for less hours, part time work, urgent care, paperwork, administration, teaching, and losses to other careers mean even lower primary care contributions. Some 65 75% of nurse practitioners and physician assistants are currently in major medical centers or will be in the next few years.

Unsustainable Growth Policies with Undependable Primary Care Result - The only thing that has maintained rural and underserved levels of PAs and NPs is rapid program growth, which is now slowing. Without plugging the leaks in all forms of primary care created by health policy defects, the nation is wasting much of its past, present, and future investment in this area. The driving forces are clearly better salaries, hours, benefits, and opportunities in major medical centers that have discovered new potentials for this versatile workforce. PAs and NPs approached the cost to productivity ratios of the limited forms of family medicine found in major medical centers. However PAs and NPs can generate more reimbursement and greater efficiencies by working for those paid at much higher rates beyond primary care. These include replacing significant numbers of higher paid physicians, supplementing their efforts at greater reimbursement, or improving their generation of revenues per unit of time. In addition, NPs and PAs have lower benefit packages and are less able to negotiate for other financial incentives compared to physicians.


Head to Head: Physician Assistants in 2000 Compared to Family Physicians in State and National Location

Health Care Workforce Estimates

Education - Distributions of education set the stage for improvements in health care cost, quality, and access

Current Active Health Care Policy Issues

Top Workforce Outcomes Rankings

Admissions Package

Changes in Specialty Choice 1987 - 1999

Changes in Admissions in Allopathic Medical Schools

Cost, Quality, Access, and Physician Workforce Expansion

Medical School Expansion 2004 - 2017

Distribution: The 70-30 Distributions That Complicate Physician Distribution

The One Per Cent Solutions that Resolve Distribution Problems

Flawed Physician Workforce Beliefs

Distribution Theory

Family Medicine Physician Distribution

Physician Workforce Studies

Leveling Military and Rural Support Programs

Why Doctors Do Go To Small Towns

Shaping a Nation: Physicians Who Serve

Facilitating Rural Health with Rural Faculty

Academic Medicine's Season of Accountability and Social Responsibility

Major Medical Centers

Research Related Regarding Workforce

Physician Workforce Studies

Robert C. Bowman, M.D.



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