Changing Primary Care Contributions 1970 - 2015

Robert C. Bowman, M.D.

 

Summary

 

With departures of Nurse Practitioners (NPs), Physician Assistants (PAs), and internal medicine residency graduates (IM) from primary care over time, the changes are most obvious for primary care and more intense for rural and underserved locations. Family medicine will continue to graduate 1/3 the annual graduates, but will increase in share of primary care, rural, and underserved location to remain the dominant contributor in each with 40 - 60% of total primary care.

 

 

Introduction

 

The United States has attempted a number of different basic health access interventions is recent decades. These include the creation of Medicare and Medicaid, a revival of family medicine/general practice, the creation of nurse practitioners and physician assistants, and specific interventions directed to rural and underserved communities and those serving them. Notable policy impacts on primary care involve increases in choice of family medicine and primary care for the class years of 1965 1978, a doubling of medical student positions from 1970 1980 (resulting in quadrupling of primary care numbers), and various direct support interventions involving underserved and rural communities. 

 

 The following table represents estimates of the changing primary care contributions, based on current health policy, recent trends, and distributions of practitioners

 

Regarding primary care, rural, and underserved contributions.

  1. The United States will depend more and more upon family medicine, not because of support or because of emphasis, but because family medicine remains while all others respond to serious problems related to health policy

  2. Physician assistants and nurse practitioners will fail to gain in primary care share of health care delivery due to failures in design, implementation, health policy, and failure to recognize their value resulting in inactivity, major medical center careers, and corporate employment

  3. Internal medicine levels will continue to decline, particularly in rural and underserved contributions

  4. Pediatric contributions will not change

What this means

  1. Those hoping to relegate primary care to non-physicians are mistaken in their assumptions.

  2. Workforce planners greatly underestimate current secondary and tertiary capacity when they fail to include the massive shifting of NPs and PAs and other assistants in their calculations. They should be aware that NPs and PAs are increasing sources of major medical center care including the replacement of physicians, supplementation of physician services at much lower cost, and improvements in the revenue generation capacity of major medical center physicians.

  3. The nation must do much more to understand the major determinant of physician, NP, and PA employment and training, major medical centers

  4. Changes in health policy are unlikely any time soon and have taken years or decades to implement. Improvements in NP, PA, or IM primary care, rural, or underserved distributions are unlikely and should continue to decline slowly

  5. NP and PA associations are likely to grow more divided and more distant from primary care, rural, and underserved orientation.

 

 

Primary Care Contributions

 

 

 

 

 

 

 

Year

1970

1975

1980

1985

1990

1995

2000

2005

2010

2015

Total

113562

125540

152765

181851

211612

227715

264027

327685

354303

378660

PA

30

2016

5967

8793

9922

12215

13766

19999

26184

31288

NP

432

3024

5098

7258

10990

14100

19642

31586

30370

27972

IM

38000

45600

55575

67450

81700

83600

96169

95000

95000

95000

Peds

17100

20900

26125

31350

38000

41800

48450

55100

61750

68400

FM

58000

54000

60000

67000

71000

76000

86000

126000

141000

156000

PA

0.0%

1.6%

3.9%

4.8%

4.7%

5.4%

5.2%

6.1%

7.4%

8.3%

NP

0.4%

2.4%

3.3%

4.0%

5.2%

6.2%

7.4%

9.6%

8.6%

7.4%

IM

33.5%

36.3%

36.4%

37.1%

38.6%

36.7%

36.4%

29.0%

26.8%

25.1%

Peds

15.1%

16.6%

17.1%

17.2%

18.0%

18.4%

18.4%

16.8%

17.4%

18.1%

FM

51.1%

43.0%

39.3%

36.8%

33.6%

33.4%

32.6%

38.5%

39.8%

41.2%

 

 

 

 

 

 

 

 

 

 

 

Rural PC Workforce

 

 

 

 

 

 

Year

1970

1975

1980

1985

1990

1995

2000

2005

2010

2015

Total

22998

23529

27078

30209

33730

36145

41124

53544

58717

63736

PA

11

714

1933

2585

2669

3054

3001

3560

4451

5319

NP

76

505

775

994

1341

1551

2161

3475

3341

3077

IM

3800

4560

5558

6745

8170

8360

9617

9500

9500

9500

Peds

1710

2090

2613

3135

3800

4180

4845

5510

6175

6840

FM

17400

15660

16200

16750

17750

19000

21500

31500

35250

39000

PA

0.0%

3.0%

7.1%

8.6%

7.9%

8.4%

7.3%

6.6%

7.6%

8.3%

NP

0.3%

2.1%

2.9%

3.3%

4.0%

4.3%

5.3%

6.5%

5.7%

4.8%

IM

16.5%

19.4%

20.5%

22.3%

24.2%

23.1%

23.4%

17.7%

16.2%

14.9%

Peds

7.4%

8.9%

9.6%

10.4%

11.3%

11.6%

11.8%

10.3%

10.5%

10.7%

FM

75.7%

66.6%

59.8%

55.4%

52.6%

52.6%

52.3%

58.8%

60.0%

61.2%

 

 

 

 

 

 

 

 

 

 

 

Underserved PC Workforce

 

 

 

 

 

 

Year

1970

1975

1980

1985

1990

1995

2000

2005

2010

2015

Total

8776

11292

14505

16289

18619

21344

24760

31015

32668

34555

PA

7

411

1038

1293

1310

1454

1501

1980

2330

2472

NP

101

617

887

1067

1451

1678

2141

3127

2703

2210

IM

2660

3192

3890

4722

5719

5852

6732

6650

6650

6650

Peds

1368

1672

2090

2508

3040

3344

3876

4408

4940

5472

FM

4640

5400

6600

6700

7100

9017

10511

14850

16045

17752

PA

0.1%

3.6%

7.2%

7.9%

7.0%

6.8%

6.1%

6.4%

7.1%

7.2%

NP

1.2%

5.5%

6.1%

6.5%

7.8%

7.9%

8.6%

10.1%

8.3%

6.4%

IM

30.3%

28.3%

26.8%

29.0%

30.7%

27.4%

27.2%

21.4%

20.4%

19.2%

Peds

15.6%

14.8%

14.4%

15.4%

16.3%

15.7%

15.7%

14.2%

15.1%

15.8%

FM

52.9%

47.8%

45.5%

41.1%

38.1%

42.2%

42.5%

47.9%

49.1%

51.4%

 

FPGP docs and IM docs were over 80% of the primary care workforce in 1970. The IM share will decline to 25% by 2015. FM started over 40% and decreased to 33%. Family medicine responded to national reinvestment in primary care and support of areas outside of major medical centers and the 1995 1997 group peaked FM production and the FM share of primary care. The result since this time has been steady primary care contributions of those remaining in family medicine plus declines in other types of primary care. These declines will result in family medicine moving back over 40% of primary care by 2015 and could be higher if departures from primary care accelerated above the current rate for IM, Med Peds, NP, and PA.

 

NP and PA shares of primary care will remain below 10% (less than 16% combined) as departures from primary care match primary care contributions from expanded annual graduations. Future changes will be determined by expansions of NP and PA programs and training positions. Although some project declines in NP and PA graduations, I think that we can expect PA program expansions to continue. This is likely as major medical centers have found new ways to benefit themselves and PAs with expansion. NP programs face the challenge of faculty for both nursing schools and nurse practitioner programs. The lack of faculty stolen away by increased clinical reimbursement is a rate limiting step for the growth of NP and nursing numbers. Significant declines are not likely either. Major lobbying efforts are expected to restore some faculty support, but are not expected to reverse losses of NP from primary care. More NPs and PAs that will not be found in primary care, rural, and underserved areas later is a huge problem.

 

Frankly health policy changes such as RBRVS changes or primary care improvements may not help NP and PA, as major medical centers have discovered their versatility and cost savings compared to more expensive physician types, their ability to expand specialty services, and their ability to generate more volume of services and productivity in conjunction with specialists.

 

One thought is that the impact of NP and PA on academic centers may be much like managed care impacts. With losses of referrals, the major academic centers faced cuts and tended to cut their generalist types of specialists. They had to keep their monopoly services and those with the highest reimbursements. Those cut happen to be the best teachers. Those replacing them will not be doing teaching. The teaching load will also not likely be shifted to the subspecialty folks either. Neglect or shifting to even more primary care responsibilities for medical education are likely.

 

The other result of NP and PA conversions is that the nation has new sources of specialists that enjoy the significantly enhanced reputation of primary care, rural, and underserved mission without delivering even a majority of graduates in to primary care, rural, or underserved care. Even government cuts based on such analysis will not matter as government supports of training are likely to be minimal compared to major medical centers. The physician workforce numbers will not consider this, although MedPac reports show strains in primary care access out of proportion to primary care.

 

Rural Changes - FM share is larger and will increase

 

PA share of rural primary care will grow to 8%, mainly with increased PA grads, but the levels are likely to fall over time as PAs return to major medical centers as do all other nonFP forms of primary care. NPs will remain about 5% of rural primary care workforce. IM will continue at 15% and peds will remain about 11%. Again the only way these are maintained are new graduates and those who have rural origins. In family medicine, the share of rural primary care will steadily increase back above 60% as others fall away from primary care and rural locations.

 

Underserved Changes FM share will increase

 

Underserved zip codes have poverty at zip over 20% or federal designation of CHC, NHSC, whole county at zip. Underserved distributions over the next decades will remain much the same for most. This includes a 7% share for PA, a declining share for NP to 7 8%, 19% for IM, and 16% for peds. The family medicine share will climb over 50% of underserved primary care practitioners despite 1/3 the level of family physician grads compared to NP and PA. Staying in primary care and avoiding major medical centers over time are the two key factors for distribution of practitioners.

 

Major Medical Centers are medical school zip codes or have 75 or more total active physicians at a zip code (not exhaustive as incomplete and does not count PA or NP). Major medical centers are not considered underserved areas. MMCs have 75% of physicians, over 65% of NPs and PAs and other forms of primary care, and only 50% of FPs. MMCs hire the most family physicians, including the most during the 1995 1997 class years with maximal FP choice. It is likely that MMC attitudes and behaviors are the primary shaping force of all physician workforce and practitioner distributions, including family medicine. The medical students trained 100% in major medical centers are also in close contact with these attitudes and behaviors, a likely shaping force in career decisions, somewhat influenced by health policy. With improving primary care health policy, MMCs hire more in primary care, influence retention in primary care, and influence workforce for the nation. With poor support for medical education and primary care, MMCs minimize primary care investments, and use primary care sources outside of primary care.

 

Robert C. Bowman, M.D.

rbowman@unmc.edu

 

 

What Could Have Been Maximal Primary Care Training Capacity - designs could insure that 55% of IM are found in office based practice, that 18% of physicians are involved in family medicine, and that all NPs and PAs were delivering primary care. What does the lack of appropriate design cost us?

 

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

 

Family Medicine Central: National Comparisons of Workforce

 

Physician Workforce Studies

 

www.ruralmedicaleducation.org

 

 

 

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