Three Dimensions of Non-Primary Care vs Zero Growth in Primary Care

Promotors of generic expansion have commonly mentioned primary care workforce increase. At best primary care workforce remains a side effect of expansion. Training and spending and accreditation in primary care remain subservient to non-primary care interests and influences. Even primary care associations are compromised by members and leaders influenced primarily by non-primary care influences. The US should not expect an increase in primary care because this is what has been designed. Non-primary care is quite another result.

Primary care projections are actually quite easy to make. The best estimates are guided by recent decades. Recent decades of stagnation in primary care indicate no growth. Primary care spending is stagnant, permanent primary car such as family medicine is stagnant, and flexible primary care sources have been departing primary care. The US will remain at zero growth even with expansions as fewer remain in primary care during training, at graduation, and after graduation. Predictions of primary care as no growth should be easy due to stagnation in primary care spending and increases in the cost of delivering primary care - major determinants that insure declines in primary care delivery capacity. This is a design that sends primary care steadily away from primary care.

Addressing Disbelief and Assumption

For those still not convinced, the opposite approach may help. Why not calculate non-primary care workforce increase? Predictions of non-primary care workforce are most difficult with three dimensions of increase in 4 sources of health professional workforce.

• Generic expansions of nurse practitioner, physician assistant, osteopathic (DO), and allopathic (MD) annual graduates
• Increasing proportions of NP, PA, DO, and MD entering non-primary care (from 60% past 70%)
• Primary care graduates steadily converting to non-primary care over their careers

People and politicians and even academics like to think in short term solutions and cures. Short term solutions are not possible in workforce. Workforce designs result in an annual graduate number and it takes  30 - 35 years or the average career length to change the overall workforce design (25 years for NP with shortest careers).

For example it took over 30 years of graduates from 1980 to 2010 in family medicine to translate 3000 annual graduates into 100,000 for the current workforce. Steady increases from 30,000 to 100,000 were seen over this time. The Health Resources and Services Administration projected family practice to increase to 144,000. This is not possible as the family medicine annual graduates remain fixed at 3000. Even with a doubling of family medicine to 6000 in 2011, family medicine would fall short. Internal medicine primary care projections are similarly in error. Projection methods are exposed as problematic for primary care, particularly when primary care does not remain in primary care. Poor understanding of the basics goes all the way to the top experts.

Other sources not bound by primary care limitations have increased in annual graduates although the result is far more non-primary care than primary care. Sources such as NP and PA have doubled in annual graduates each 6 - 12 years since 1980 and have moved from 50% to over 65% not in primary care. Steady departures from NP and PA primary care continue with teaching hospital, emergency care, and subspecialty diversions leading the way. The last PA doubling (100% increase from 3000 to 6000 annual graduates) resulted in over a 200% increase in numbers entering non-primary care and just a 30% increase in primary care entry (AAPA). This small increase of about 3% a year will be negated due to departures in the years after graduation as Larson and Hart noted even during the 1990s - a much better primary care time period.

Osteopathic increases in annual graduates could have resulted in more primary care under a different national policy design, but the expansions have been countered with declining family practice choice from 65% (prior to 1970) to 35% in the 1990s to 17% for no gain in annual family practice - the predominant DO primary care vehicle. Family medicine entry remains fixed at about 500 - 600 per year. Only the fact that family medicine is the most permanent primary care source results in any stability of osteopathic primary care output - but there is no gain either.

And US population growth continues and the elderly that use 2 to 3 times more primary care are doubling by 2030 and we might have increased primary care demand from expansions of health care coverage (might).

MD declines in primary care involve all sources. There is a decrease in family medicine from 14% to 7% of US MD graduates, half as many internal medicine graduates (20 - 25%) enter primary care as compared to 1990s levels (over 50%), and pediatric graduates have decreased from 70% to 40% remaining in primary care. A 30% US MD expansion will not cover the losses for an overall decrease in primary care delivery per graduate from by far the major source.

What If We Stopped at Current Annual Graduate Levels and at Current Proportions Entering Primary Care?

Even if the US stopped all expansions and held at the current levels without further departures from primary care, this would be 6,500 annual physician assistant graduates times 33 years per graduate times 75% non-primary care for 161,000 in non-primary care and 56,000 in primary care (predominantly employed in family practice). About as many physician assistants will be inactive as will be found in primary care.

The nurse practitioner maximum would be 200,000 given about 8000 annual graduates. These have most recently been 70% found in the direct clinician component with 35% found in primary care (HRSA Nursing 2008). This results over 25 class years in 90,000 for a non-primary care workforce and 60,000 in nursing (especially nurse staff) positions, and 50,000 in primary care (predominantly family nurse practitioners remaining in family practice employment). Primary care comes in third in priority for nurse practitioner workforce.

The physician contribution will remain 100,000 for primary care from FM, about 42,000 from primary care IM and 48,000 for pediatrics. The non-primary care result is 192,000 for IM graduates and 58,000 for PD graduates. Family medicine and medicine pediatrics both contribute about 10,000 each to result in 270,000 for non-primary care with a total of 196,000 for physician primary care.

The total would result in 280,000 in primary care and 525,000 for non-primary care and 60,000 for nursing - and this is just the result from primary care graduates.

The total non-primary care is already set for 1.4 million as a workforce and will be higher with annual graduate expansions and stable or declining primary care proportions.

What resulted in increased primary care delivery in the 1990s with substantial NP and PA primary care efforts working together with MD and DO is quite different. The boost in workforce effort from working together will be found predominantly in non-primary care.

The 1990s design was 29% for primary care for the 2020s result. The 2010 design is set for 16% primary care result or less. The non-primary care workforce result is important to examine.

In 10 or 20 years, we will once again revisit the continual major blunder in US health care workforce reports - the lack of a SMART design steady for 30 - 50 years in the future instead of oscillating wildly.

The consequences of non-primary care excesses are substantial. Those that have promoted generic expansions and non-primary care excesses will have once again visited more problems upon our children and grandchildren as fantasy does not translate into reality.

The financial and economic repercussions of health care design are still poorly recognized. The US has clearly found a way to limit primary care workforce and primary care spending. Low priority assures little growth in this spending relative to increasing non-primary care demands.

Non-primary care workforce is quite another matter. Non-primary care workforce has always found a way to escape cost limitations (increased volume, more testing). Non-primary care expansions have been a major reason for continued health care cost increases and will be a major reason why 2020 will bring 20% of the GDP spent upon health care. This leaves less and less for all other areas other than health care. Even worse is increasing costs for people intensive endeavors such state government budgets, local and school district budgets, federal costs, and American employers. Greater deficits and lesser productivity are programmed in place by failure of health care design.

Only Specific, Measurable, Achievable, Realistic, and Timely designs work - with permanent primary care the specific focus along with sufficient primary care spending to deliver primary care to an entire nation rather than just half.

A best guess is that about 10 - 15 years from now (sooner if health care costs are reigned in more) there will be too much non-primary care workforce. Of course those claiming economic benefits from expansion will still be claiming these benefits as health care consumes an ever larger proportion.

By the time we figure out the consequences of too much, it will be too late to stop the momentum as there will be another 15 to 30 years of increase even if annual graduate levels no longer increase. Once again it is easy to forget that an annual graduate level takes 30 years for full realization. Increases in non-primary care (or any workforce) that are too rapid inevitably overshoot the mark 15 - 20 years later. There are other consequences to consider. If nurse practitioner annual graduates double as in each 6 to 12 years since 1980 the consequences will be dire for basic registered nursing workforce depleted of more and more experienced RNs.

Another decade of expansion of non-primary care workforce will result in many other national financial and economic concerns. The US rapidly forgot the lessons of economic decline as the result of rapidly rising health care costs. Few now remember $1200 of the cost of a car required for health care. The cost is now higher. Not surprisingly manufacturing has been substantially removed from the United States due to past, present, and future health care costs.

The lessons of the 1990s remain valid - costs reigned in for even a short time set the nation on course for one of the longest recent runs in economic progress in recent US history - even with a brief design change.

Spending more on health care is not going to contribute to economics in any area other than economic ruin. Designs that result in too much non-primary care must also be reigned in if there is to be hope for economic recovery.

What can a study from Zip Code 10032 teach America about Primary Care?

This JAMA study from Zip Code 10032 appears to compare nurse practitioner care with physician care. The study aimed low, intending to demonstrate no difference between physicians and nurse practitioners. As we understand more and more about social determinants, it should be surprising that any differences will be found in populations with the most social determinant limitations, such as those in this study.

This study can only teach America about a small portion of primary care for primary care delivered 1995 – 1999 in and around zip code 10032 about people that live in or around zip code 10032 some of the time. This study presented in a national journal is one of the least relevant with regard to United States primary care and United States health care.

The study uses old data, the sites of practice were different and the nurse practitioners actually changed locations during the study. Zip code 10032 is one of the most densely populated in the US with transportation and access unlike most of the US. The patient population was 80% Hispanic, neither type of provider spoke the language well, and there was little consideration of language or culture. Given the substantial social determinant considerations, it is unlikely that any variations between providers can be demonstrated as in numerous studies illustrating social determinants as major limitations of outcomes.

What will emerge from this study is controversy. This was an obvious reason for the publication. What will escape notice is whether the study was representative or even useful given the limitations of the design and the passage of 12 years since the study ended.

A major problem in health professional literature is lack of relevance. Studies can demonstrate significant differences in areas such as pharmaceutical drug treatment without being relevant. The significant differences are so small in impact such that hundreds or thousands must be treated to result in a single improvement. This often involves more costs and often does not improve overall outcomes such as better health or longer life.

Another failure in relevance is that studies commonly involve populations that are not representative of the American people. For example certain populations can be studied over and over again while others have few studies. Drug studies once again tend to involve a very narrow range of patients. Health care studies also involve a narrow range. The classic studies illustrate care of the 1 person in 1000 found in academic centers where most studies are done.

People who can access health care can be studied while those who cannot access health care and those with limited health access are less likely to be studied, particularly when using databases involving services. No services means no studies. Those studied are more commonly higher income, more urban, and more likely to have health care coverage. Those studied are often those with access or too much access. This presents a problem since America understands less to much less about populations left behind or over half of the nation.

The studies that are funded follow the health spending patterns. About 85% of the research funding goes to 3400 zip codes clustered together in 4% of the land area where the nation has top concentrations of researchers, teachers, academic institutions, information systems, health professional associations, and subspecialists. Foundation funding follows the same pattern of all lines of revenue and the top level in each line directed to zip codes inside of current concentrations of people, income, health professionals, and health spending. Physician Distribution by Concentration

What is substantially left out of awareness, understanding, and health spending is over half of the American population and basic health access areas most important to half of Americans left behind such as primary care, rural health, and care for underserved populations.

JAMA has already demonstrated that it is capable of publishing articles that comprehend the impact of social determinants of health and variations in the quality of care to underserved populations (Hong, September 2010). JAMA has also demonstrated failure in this ability as noted in a recent article about Critical Access Hospitals. This has been addressed at Which is it JAMA?

Once again JAMA presents a study in a way that appears to indicate national representation. Although the subject of the study is a comparison of primary care nurse practitioners to primary care physicians, it is important to understand what the study represents and does not represent. It represents a finding of not much difference with regard to two different types of primary care providers in a certain setting. This study also involves a location and population that is one of the most atypical in the nation.

Before you jump to conclusions about bias on my part toward nurse practitioners, I urge you to review any number of writings that have consistently avoided a quality argument. Quality arguments make little sense in a land missing in primary care where social, environmental, and political decisions have so much influence beyond a provider. Even nurses have more influence as they often encounter patients before, during, and after care and typically encounter those that are in need of better quality of care. 

As an expert in basic health access, an area largely missing for most Americans, my bias is in favor of those missing from health access. My perspective is also an objective look at what studies can and cannot demonstrate – an area I commonly find not addressed in most primary care studies involving workforce. This also comes with the full knowledge that what I note is not likely to be as relevant in ten years if we actually begin to examine health care - from more correct perspectives.

This study is also lacking in this area. JAMA once again fails to indication important study limitations in areas such as relevance for the nation, the impact of social determinants of health, and understanding the context of care provision involving the study. Zip code 10032 and surrounding zip codes are the likely sites for care as well as the locations of residence for those accessing care during the study. The population density of the area is most atypical as there are 70,000 to 100,000 people per square mile. This is up to 1000 times the population density of the nation and 100 times the 1000 people per square mile where most people reside in the United States. The study area is just inside of a bullseye of top concentrations of health workforce and health spending surrounded by populations short of health access by our national design. Zip codes east and north of this map are designated as shortage zip codes (HPSA) completing the doughnut of top concentration surrounded by shortage.

Even populations inside of concentrations lack health access as implied by the study of course very little about their health access was reported by the study.

Zip code 10032 has

• A well developed public transportation system – important for health access and missing for most people. 
•  A top income level (but also a top cost of living and significant numbers in poverty)
•  A top concentration of primary care including primary care sources not listed such as training sites for MD, NP, and PA graduates. 
•  A top concentration of health professionals 
•  A national lowest level of primary care and family practice by percentage of the workforce (those most consistent in primary care and in breadth of primary care scope are often driven away by narrow scope and marginalization). Internal medicine and pediatric proportions are also highest in such areas - concentrations of people, income, and academics.
• Top concentrations of subspecialists - Such areas have highest utilization rates, and paradoxically most difficult times finding specialists – specialists find a way of increasing utilization that has defeated any and all attempts at reform. One possibility is that the patients were least impacted by primary care as their care was provided by ready availability of other venues from care in other nations to self care to local support to other primary care to subspecialty to neighbors and friends. This is much less of an issue in rural locations or in settings with a complete population studied. 
• New York has 1.39 times more physicians per person and this location is one of the highest concentrations in New York. About 85% of physicians are found in zip codes with over 75 physicians in New York. Only a few states with top health spending have such concentrations of physicians. In 2005 the one zip code of 10032 had over 900 physicians and likely has over 1000 now.
• New York state has about 20 to 1 richest to poorest or top income quintile to bottom income quintile and the practice environment around 10032 may be more divided similar to Washington DC at 30 to 1.
• Primary care may be most challenging for providers as relatively lower salaries also are compounded by highest cost of living.
• Highest cost of delivering primary care (or any care) also can be a limitation on the care provided during encounters.

Some of the study limitations include

• Over 80% of the patient recruitment involved Spanish language. There was not mention of Spanish language with regard to the patient encounters. There was a limited mention of Spanish language in the providers. The language factor was not included in the study outcome. Gender and other similar background areas have been noted to be important in measures of patient satisfaction. Patients matching up best in background to their patients tend to rate satisfaction higher and this may impact quality as well. This is a huge problem for primary care when so much of the interaction measured in an encounter is person to person.
• Only 1316 patients is a small fraction of those who could have participated. It is a tiny fraction of the local population and of the primary care and of the overall care provided. 
• There is not mention of what proportion of the care of the patient was delivered under study parameters. No conclusions can be made about overall care outcomes as the study was too short, too small, and too limited.
• Health care delivered in the late 1990s during a peak emphasis on primary care under managed care influence – arguably one of the most cost effective periods in primary care in the nation’s history. Since this time less efficiency is likely (tests, referrals). The significant investment of Columbia Presbyterian was noted since 1993 in the article.
• Nurse practitioners emphasis has changed as have the proportions remaining in primary care. Studies often imply a larger primary care role but fail to mention the limitations. Only 70% of total NP graduates are found active as direct care clinicians and only 35% are listed in primary care (HRSA Nursing Reports 2004 and 2008). Remaining in primary care is difficult for nurse practitioners as with physician assistants and physicians. Smaller portions of NP graduates train in primary care and this is even smaller compared to advanced nursing totals. Fewest years in a career also limit primary care contributions for NP compared to physician or physician assistant.

The article did not demonstrate much in the way of differences. This should not be a surprise for a number of reasons listed above and a few more. First, health care outcomes are far more likely to be driven by factors related to patients rather than type of provider. Patients or their mothers or their spouses have substantial say over encounters. For those not in the country for substantial period, there are even more outside determinants and influences. 

Does the study support quality of care as same or similar for nurse practitioners versus physicians?

Yes and no. The study statistics support same or similar care. Given the limitations of all workforce studies and failures of realistic attempts to control for important variables, it is safe to say that current workforce studies fail to have the ability to demonstrate differences in one or more key areas:

•  Too short, not comprehensive enough, not enough isolation of the study subjects from other sources of care, lack of randomization, failure regarding controls, and failure with regard to the inclusion of many controls as indicated by Hong in JAMA and the Oregon Medicaid randomized study.

Readers can decide whether JAMA, editors, reviewers, authors, sponsors, or key stakeholders such as nurse practitioners or health care associations or health insurance foundations have an agenda. As far as this editor, author, and reviewer can state after 28 years of delivering and teaching and researching health access, I see evidence of lack of critical review by reviewers, failure of editors in editing in areas such as demanding critical review and more limitations in the published article, and widespread campaigns involving multiple articles submitted in areas such as generic expansions of physicians or nurse practitioners, the value of primary care without much justification, generic sources of primary care as solutions for primary care that are 60% - 85% not primary care, and basic health care needs of most Americans largely ignored.

And matters are getting worse not better – in directions of health spending and in the health information sources that are supposed to guide our national leaders.

Journals, editors, health professional associations, and academic institutions focus on innovative models of primary care workforce and primary care delivery but fail to focus on more primary care spending more specific to primary care services - the only real way to increase primary care delivery capacity in the nation and to improve health access and to improve the quality of primary care - mainly by moving more patients into basic health access.

Our current design with too few remaining in primary care workforce insures least experienced in primary care and also more patients moving to little or no health access and

That is a problem for cost, quality, and health access for an entire nation.

Thanks to all 12,000 who have visited Basic Health Access in 2011.

Robert C. Bowman, M.D.        Basic Health Access Web    Basic Health Access Blog

SMART Basic Health Access     World of Rural Medical Education

Basic Health Access Blogspot 2011 - Summaries and Links for 2011

Dr. Bowman is the North American Co-Editor of Rural and Remote Health and a Professor in Family Medicine at A T Still University School of Osteopathic Medicine. He was the founding chair of the Rural Medical Educators Group of the National Rural Health Association, he was the long term chair of the STFM Group on Rural Health, he is the founding director of Priority Infrastructure at http://www.infrastructureamerica.org/ and he is the author of the World of Rural Medical Education, and Physician Workforce Studies

Meeting Primary Care Needs in the Last Half of the 21st Century - Really!. 

Clinician Specific Medical Education

SMART – Specific, Measurable, Achievable, Realistic, Timely

RPAP Is SMART and Has Been for Forty Years

Academics love innovation, new grants, and change. A weakness of academic focus is doing what works -  practical and relevant. Academics often have to be forced to do the practical and relevant. Such is the case with RPAP. The Rural Physician Associates Program has been practical and relevant for 40 years and has facilitated increased primary care and rural services where needed since the first 3rd year medical student began.

RPAP is well known to the people at HRSA. During this past two years at least three times I have reminded them about RPAP as a very inexpensive way to increase health services for those in most need - in rural underserved areas. Given the serious problem facing HRSA with designs that would increase primary care demand in the face of failing primary care supply, worse in underserved areas, one would think HRSA would do more.

HRSA has been busy elsewhere on reports and programs that are not SMART - specific, measurable, achievable, realistic, and timely. RPAP is SMART and has been for 40 years since the Minnesota legislature forced it on the University of Minnesota.

Why is RPAP SMART?

RPAP involves 60 medical students in their first and most important clinical year of training. RPAP students initially spent an entire year, receiving a small stipend to do so. Rather than typical rural rotations where students play at rural health for a few weeks or months, RPAP students become rural health care. It takes them a few months to orient, but they become efficient and effective members of the health care team. Verby noted $40,000 to $70,000 more in revenue generated during a year with an RPAP student as compared to a year without. This is a substantial increase in services delivered in a most needed location - exactly what areas lacking in primary care and rural health services need.

RPAP is essentially a successful public-private partnership between the state and the people of Greater Minnesota. It is not really much help to the University of MN as the funds go to students. RPAP costs about $800,000 a year but has so far returned over 3 billion in services just for the graduates that have practiced in rural MN. About 10% of RPAP graduates are found in practice in the sites where they trained - they save hundreds of thousands in orientation and initiation costs as this 10% hit the practice with previous experience and have had 4 years since their RPAP rotation to prepare specifically for their practice settings. RPAP is one of few mechanisms to build health access leadership - as with Jay Erickson and others who are holding medical education accountable to state needs. RPAP is also a reason why Duluth has retained 50% entering family medicine - a SMART design resulting in SMART primary care choice.

RPAP is too valuable not to replicate far beyond MN and far beyond MD training. Thousands of RN, MD, DO, NP, and PA students should spend their final year or two in continuity primary care setting, in a rural setting, or in an underserved practice. RPAP generally accomplishes all three at once as rural areas are primary care, rural, and underserved intensive care.

Once again I implore HRSA to lead the nation toward public private partnerships with rural communities and away from short term rural rotations that actually result in less rural health care delivered. Community Friendly focus has been noted long before my publication in the Journal of Rural Health summarized at http://www.ruralmedicaleducation.org/community_friendly_aspects.htm

Short term rotations cost workforce. The cost of nurse and preceptor time is too great. It takes 4 months length to break even (RRH), 6 months for students not to be overwhelmed, 9 months to not want to leave (Verby), but they get it and help provide effective team care. We are supposed to be pushing this by the way and dysfunctional primary care in academic settings has been highly unsuccessful in much other than driving medical students and residents away from primary care careers (Keirns). The opposite of dysfunctional and the opposite of too many learner in one place is a good thing for learning, integration, and maturation.

RPAP need not cost much to states or to academic institutions, because it gives rural communities what they want and need - future young professionals and their families - before, during, and after graduation. Rural nursing is in short supply - RPAP works. Family practice employed NP and PA are the most important non-physician clinician component - RPAP works. Initial nurse practitioner training designs did involve some that required 9 months spent with rural physicians in the field - essentially the RPAP design. MD and DO students need much better primary care, rural, and underserved training - RPAP works.

State and federal government will need to see accountable health professional education - Specific, Measurable, Achievable, Realistic, and Timely   RPAP has been SMART since its start.

10,000 students helping to deliver $30,000 more care each with little additional cost is a really good win-win-win - for the students, for the communities, and for the nation. Preceptor satisfaction, continuing education, doctor-patient relationship training, enhanced primary care training measures, and improved focus on competency are just a few benefits - by design. You want to stimulate youth interest in health careers - here is a vehicle that works inside of communities in need - by design.

It is not time for innovation and change. It is time to replicate what works and has worked for 40 years - RPAP is just one that should be replicated.

If you like this, tell HRSA over and over, tell your state, tell those who train students, but don't shorten RPAP or make it convenient. Make it work for those in need of basic health access - by design.

Meeting Primary Care Needs in the Last Half of the 21st Century

Achievable primary care is one of the weakest areas in the workforce literature. Enough annual graduate expansion of any primary care source will increase primary care, but steady declines in the proportion remaining in primary care in the years after graduation make this a less efficient and less effective process for the purpose of addressing primary care workforce.

With primary care graduates departing primary care
it is not possible to recover primary care. 

Despite projections of primary care increases by government and by major associations, the US is actually losing ground in basic health access primary care. Increases in cost of training, more graduates required for less primary care result, and increases in the costs of locums, recruitment, and retention insure failure in primary care delivery with the current voluntary and flexible design that facilitates departures from primary care.

Studies and reports that project primary care workforce place too much emphasis on annual graduate numbers. The US has created 4 new primary care sources and has doubled annual primary care graduates from 14,000 in 1980 to 28,000 in 2010 but this matters less than the decline from 18 Standard Primary Care Years per graduate to 7 SPCYrs. With less than one-third remaining in primary care, the United States must find ways not to lose primary care rather than throwing more dollars at more graduates that deliver less primary care per graduate.

More important than annual graduates is what each graduate accomplishes. This is more about years in a career, activity in US health care, volume, and primary care retention. The Standard Primary Care Year uses estimates of these four factors to generate a relative measure of primary care delivery for each source specific for each class year.

The figure of 400 million people represents a good estimate for a steady state US  population in the latter half of the 21^st Century as population growth slows. Health Resources and Services Administration recommendations of 95 primary care physicians per 100,000 can be adjusted to 110 primary care physicians per 100,000 as the result of aging changes effective for 2030 and beyond. This results in a need for 440,000 primary care physicians to reach a sufficient 110 per 100,000. Already it should be apparent that moving down in the last decade instead of up is not the path to sufficient primary care.


These levels can be converted to Standard Primary Care Year estimates by source to indicate how many annual graduates of each source will be required per class year for 30 class years to reach sufficient primary care.

Setting Primary Care Sufficiency: Total Workforce, Annual Graduates, and Primary Care per Graduate

Family medicine is most consistent in primary care retention and has reached a steady state. Family medicine can be used to convert total workforce to annual graduates to Standard Primary Care Years per graduate. This figure can be used to convert other sources to annual graduate requirements for sufficient primary care.

Family medicine at 3000 annual graduates for 30 years has resulted in 100,000 active family physicians for a workforce. The 100,000 for 310 million people is a workforce of 32.4 family physicians per 100,000.

In 30 years the US will have about 400 million people. For 400 million people at 110 primary care physicians per 100,000 this would require 440,000 family physicians.

For 440,000 family physicians rather than the current 100,000 this would require 4.4 times more annual graduates. The steady state 3000 annual graduates times 4.4 is 13,200 annual graduates for sufficient primary care defined as 110 per 100,000 for 400 million people.

These beginning annual graduate points and ending family physician primary care workforce numbers can be converted to Standard Primary Care Years. The SPCYr estimate of 24 SPCYrs for a family physician can be multiplied by 13,200 annual graduates for about 320,000 Standard Primary Care Years per class year. This is significantly above the recent annual yield of 200,000 SPCYrs per class year from six sources from 28,000 annual graduates (NP, PA, IM, FM, PD, MPD). Once again the SPCYr allows career years, activity, volume, and primary care retention to be considered such that all primary care training sources can be compared to each other and across the class years.  

One more adjustment is needed due to declines in family medicine of about 10% less per graduate in SPCYrs over decades of time. This results in about 350,000 Standard Primary Care Years annually required of 30 class years of graduates to result in steady state 110 primary care physician equivalents per 100,000 people.Note that this figure does not include a 10% - 20% fudge factor that should be included in all primary care estimates. This is because new workforce creations have consistently stolen primary care to result in substantally less tha predicted as noted with the creations of emergency medicine, geriatric, hospitalist, and urgent care workforce. Unanticipated losses also include tens of thousands converted from primary care to teaching hospital workforce due to resident work hours restrictions. Hospitalist changes also thrust more workload from hospital to primary care with primary care nurses most impacted. Increasing fragmentation and regulation by government and insurance also result in less efficient and effective primary care delivery.

The 350,000 SPCYr figure is not likely enough, but can be used to determine how many annual graduates are needed in each source to reach a level equivalent to 440,000 primary care physicians for 110 primary care physicians per 100,000. This can be used to estimate annual graduates for 80 and for 60 primary care physicians per 100,000 as well.


Annual Graduates Required to Reach Sufficient Primary Care for 2050 and Beyond

	FM	PD	NP	PA	IM
Higher SPCYr Estimate (requires least annual graduates)	12,709	25,995	66,667	63,738	51,237
Lower SPCYr Estimate (requires most annual graduates)	17,090	39,063	115,056	108,025	114,379
Using Highest or Best Case Estimate in Each Factor
Primary Care Retention	90%	44%	40%	26%	25%
Active for Career	90%	90%	70%	80%	90%
Years in Career	34	34	25	33	33
Volume Adjustment	100%	100%	75%	80%	92%
Higher SPCYr Estimate	27.54	13.46	5.25	5.49	6.83
Using Lowest in Each Factor
Primary Care Retention	80%	35%	30%	18%	15%
Active for Career	80%	80%	65%	75%	80%
Years in Career	32	32	24	32	30
Volume Adjustment	100%	100%	65%	75%	85%
Lower SPCYrEstimate	20.48	8.96	3.04	3.24	3.06
Using the Average
110 per 100,000	14,899	32,529	90,861	85,882	82,808
80 per 100,000	10,836	23,657	66,081	62,459	60,224
60 per 100,000	8,127	17,743	49,561	46,844	45,168

Incredibly high levels of annual gradutes are required to reach sufficient primary care when the sole source of primary care is not permanent.


Permanent primary care sources most active for the most years at highest volume require the fewest annual graduates to reach sufficient primary care. Flexible sources less likely to remain in primary care with fewer years, lesser activity and lower volume  require more graduates than the United States can supply or afford.

The Impossibility of Reaching Sufficient Primary Care without SMART

Currently the US only graduates about 100,000 Registered Nurses, 30,000 physicians, 9000 NPs, 7000 Internists, 6500 physician assistants, 3000 pediatricians, 3000 family physicians, and 500 medicine pediatric physicians each year.


RN workforce demand will increase substantially in the next 20 years for the same elderly and health care coverage increase reasons as primary care. Too few enter and remain as RNs already. Increasing nurse practitioners by tens of thousands of annual graduates to reach sufficient primary care would devastate RN workforce. 

The last physician assistant expansion doubling actually increased primary care numbers entering the workforce by only 30% - a level likely to be negated in future departures from primary care. Physician assistants and nurse practitioners are widely sought by a wide range of employers with new specialties created with each passing year. Win-Win-Win non-primary care benefits to the practitioner, employer, and specialist physician are innate in the US policy design and insure departures from primary care.

Low primary care yield defeats generic expansions as a primary care workforce intervention. Generic physician expansions of medical students or generic expansions of graduate medical education positions are just not specific to primary care. Even expansion limited to primary care GME positions fail as pediatric and internal medicine expansions fail to yield much primary care workforce increase. About half of family nurse practitioners deliver the predominant primary care of all nurse practitioners. Expansions without retention are mostly about non-primary care workforce result. Three dimensions insure too much non-primary care. Meanwhile primary care remains stagnant by design.

Only SMART expansion works – specific, measurable, achievable, realistic, and timely. A best approach is a primary care source that delivers more primary care than family medicine for about 12,000 annual graduates needed at a cost of 12 billion per year for sufficient primary care. This compares to the current 16 billion for 28,000 annual graduates with half enough primary care delivery capacity result (all costs of higher education and training).

Specific is the least costly because it is most specific. Primary care sources that are flexible have become 55 – 80% not primary care in yield in the United States. Sources claiming to be primary care solutions are not good solutions. Specific language is required. Advanced nurses and generic nurse practitioners are not primary care solutions.Only the nurse practitioner that remains in family practice employment (25%) is a good primary care solution. Requiring permanent family practice is the only way to reach this solution. Only the physician assistant that remains in family practice is a good solution as demonstrated by consistent primary care delivery and consistent distribution where needed but again this is only 25% of physician assistants and only 20% of new graduate PAs. Schools such as Duluth manage 50% family medicine despite the policies that drive medical students away from a permanent primary care source, but 100% entry is possible in an even better design.

What is clear is that there has been little thought and even less planning

with regard to sufficient primary care workforce.

Rapid increases in the cost of training make these even more challenging. Also primary care delivery capacity per graduate is likely to decrease with quality focus or collaborative care emphasis – models that result in lower volume per primary care graduate. Departures of primary care workforce to urgent, emergent, hospital, and subspecialty workforce will also result in fewer Standard Primary Care Years per graduate. New workforce is created each few years that steals from primary care. Historically this has included emergency medicine, geriatrics, sports medicine, and hospitalists. Resident work hours restrictions alone converted tens of thousands of NPs and PAs away from primary care.

The United States has actually avoided expanding the most permanent primary care source for over 30 years. It has chosen to expand the sources least likely to remain in primary care. These have not been SMART choices specific to primary care and indicate choices made for other reasons – including non-primary care workforce, academic interests, and teaching hospitals.

Longer training also defeats primary care workforce. Each additional year of training results in 3 - 4% less workforce yield - resulting in even more graduates required to reach sufficient workforce. Two more years required for nurse practitioner doctorates in all nurse practitioner graduates in 2015 will result in an 8 - 10% loss of NP workforce and will substantially raise the cost of training.

The consequence of increased cost of training with less workforce result
has not even been recognized

as yet another move in the opposite direction from sufficient primary care.

Family medicine and other sources remaining in family practice have demonstrated consistent distribution to the elderly, poor, near poor, CHC, rural, and underserved populations as well as 53% found in 30,000 zip codes with 65% of the US population most left behind in health access. Expansions involving IM, PD, most nurse practitioners and most physician assistants are expansions of graduate types known to fail in distribution. This is also why hybrids or combinations of primary care are a bad idea.

Better than family medicine is required for efficient and effective primary care recovery using SMART principles, but family medicine is a starting point.

HRSA Nursing Reports for 2004 and 2008 were used for NP data as well as Advance for NP and PA. AAPA data was used for PAs. HRSA 2008 Physician Projections were used for sufficient primary care. Other references came from the Standard Primary Care Year literature, Ferrer, Mold, and Rosenblatt.

Robert C. Bowman, M.D.  Basic Health Access Web   Basic Health Access Blog

SMART basic health access - Specific, Measurable, Achievable, Realistic, Timely

Summaries and Links to Fifty Basic Health Access 2011 Blogs

Dr. Bowman is the North American Co-Editor of Rural and Remote Health and a Professor in Family Medicine at A T Still University School of Osteopathic Medicine. He was the founding chair of the Rural Medical Educators Group of the National Rural Health Association, he was the long term chair of the STFM Group on Rural Health, he is the founding director of Priority Infrastructure at http://www.infrastructureamerica.org/ and he is the author of the World of Rural Medical Education, and Physician Workforce Studies