Comparing Family Practice Sources

The nation’s MD, DO, NP, and PA graduates that remain in family practice are by far the most important solution for health access. Only family practice can be demonstrated to distribute according to the population and not according to concentrations of workforce or health spending. It is important to understand that not all sources remain in family practice in the years after graduation.

Family Practice Retention Using Different Measures

Advance for PA and NP surveys have more detailed information that goes beyond just training program. AANP data indicates training or main specialty, but is limited in actual work components. Workforce cannot be defined without important components that define the actual work - such as positions and employment – especially for the most flexible primary care training sources (NP, PA, IM) where over 65% of graduates are found outside of primary care delivery.

Family medicine remains over 90% in family practice employment throughout a career. The distortions of US health policy have driven away all sources from primary care except those most permanent - family physicians. Few other options are a good thing for health access for most Americans. In studies of 1997 – 2003 family medicine residency graduates only 2% had entered additional training by 2005. About 1 percentage point was found in either geriatrics or sports medicine and 1% entered obstetric, surgical, psychiatric, or other training including primary care training. There was no deterioration across the six graduating classes (about 2% across each class) – another indication that family practice is an enduring choice for family physicians. Family medicine residents have consistently been the marker to compare retention in career choice.

Retention within family practice insures a consistent rural level of 22% or more for all graduating classes found in rural locations (3 times other physicians), over 14% found in high poverty underserved locations (2 times other physicians), and over 50% (2 times other physicians) found in 30,000 zip codes outside of concentrations of physicians with 65% of Americans.  Family physicians are found at 30 per 100,000 across the wide range of populations and locations in need.

Nurse practitioner training can claim 50% of graduates trained family practice, but only 25% of NP workforce remains in family practice employment. Also since NP workforce is the most recently graduated workforce due to recent rapid expansions, further departures to even lower FP proportions should be expected with additional years after graduation. Unlike family physicians that are relatively fixed in family practice, nurse practitioners have many other opportunities and locations and specialty choices at greater rates of pay. These also generate more revenue for employers than primary care. These strong forces work year after year to divert nurse practitioners away from primary care, rural, and underserved locations – even when they train in family practice.

Physician assistants have followed the physician design shaped by the health policy construct. This has resulted in declines from over 40% to less than 20% entering family practice in the past 25 years. The newest PA graduates should follow the pattern of the last few decades by continuing to depart primary care and family practice in the years after graduation. This was noted across the primary care friendly 1990s by Larson and Hart.

Physician assistants dedicated to family practice have what may be the top rural proportion at 30%. Other PA types that are all below the 15% in rural practice PA average. Family practice PAs are 30 times more likely to be found in a federally qualified rural health clinic, 6 times more likely to be found in Community Health Centers, and 2 – 4 times more likely to be found where needed when compared to other PA types (AAPA). Departure from family practice moves physician assistants away from all locations and populations in need of health access.

The secret of health access is retention in family practice. When comparing SMART solutions, those dedicated specifically to family practice activities and duties day in and day out are most important. Most retention, most active in practice, most volume, and most years helps make the most for SMART Basic Health Access

Rural Workforce 2000 to 2010

Uncle Sam says "I want you" to serve in rural locations. Uncle Sam's design says "I don't want you" to serve in rural locations. Dozens of special programs can no longer hide the fact of an aberrant basic design that fails rural Americans.

The last major contribution that has remained specific to rural locations is family medicine. Family medicine during the decade from creation until the 3000 annual graduate level in 1980 has been the only consistent contribution for rural workforce increase. Other sources old and new have steadily departed primary care, family practice, and more general types of careers. These are all departures away from rural locations and toward top concentrations of existing workforce - according to Uncle Sam's design for health spending and health workforce. .

From 2010 to 2020 the nation can expect declines in primary care retention and lower proportions in rural locations. No projections of rural workforce from 2010 to 2020 should consider increases in rural primary care short of rural sites paying substantially more each year for locums, recruitment, and retention. More dollars required just to get primary care and hold it is another indication of the wrong direction - away from efficient, effective, and sufficient primary care. Generic expansions simply fail to work. More specific focus is needed

Family Medicine – The Good News Was More for 2000 to 2010, The Bad News is No More By Design

Family medicine has increased its rural primary care delivery from 2000 to 2010 primarily because it added more graduates than departed when progressing from the 1980 to the 2010 graduating classes. This is at an end as the design of 3000 annual graduates for 33 class years has filled out to its maximum workforce at 100,000 strong (33 yrs x 3000 grads). Now that 3000 are entering and leaving each year, equilibrium has been reached. This has been the good news.

The bad news is that there will be no more family medicine workforce increases since annual family medicine residency graduates continue to remain at or below 3000. Family physicians have reached the maximum design level of 30 per 100,000 for the broad range of populations in need. This design level will be decreasing as the US population grows without any increase in family medicine. 

Family medicine, like all primary care sources, will continue to be widely sought out by all who are desperate for primary care for the next 30 years. Family medicine will remain multiple times more likely to be seen by elderly, poor, near poor, disadvantaged, urban, CHC, and other populations left behind. ...(Ferrer, others)

Overall US primary care design failure together with the neglect of family practice workforce will make it more difficult for rural sites to compete. Expansions of family medicine would have addressed all of these needs most specifically, but there have not been expansions in this one SMART source.

Paying more to get less for those that already have the least is clearly the US design
that will most impact rural communities for 2010 to 2030 just as in 1980 to 2010.

Nurse Practitioners: Maximum Expansion With Minimal Increase

There is little reason to expect a signficiant increase in direct care clinician nurse practitioners in rural areas. The AANP data had 22.5% of 102,829 direct care clinicians found in rural locations in 2000. This declined to 17.5% rural for the 2010 sampling based on 135,000 direct care practitioners in their database. Simple math indicates about 23,147 direct care rural NPs for 2000 and 24,030 for 2010.

The "good news" is that NP numbers in rural areas have reached family medicine numbers. This is entirely due to massive expansions that have doubled NP annual graduates each 6 to 12 years since 1980. Going from half as many annual graduates as family medicine to 3 times as many to result in the same rural workforce is not good news. The bad news is that FM and NP are not likely to change much. For 2000 to 2010:

A 35% increase in direct clinician workforce with a 4% increase
in direct clinician rural workforce

is not a good indicator.

Nurse practitioner rural contributions are stagnant for the same reason as primary care stagnation and underserved stagnation - too little national spending for rural, primary care, and underserved components. Rural spending deficits are a direct impact. Rural workforce is also 40 - 100% primary care and about 40% of underserved workforce is found in rural locations. Family practice, rural practice, underserved practice, and primary care are most closely associated with one another and with failures in the US designs.

The absolute lack of health spending is complicated by relative spending much greater elsewhere as the US design results in so much spent on non-primary care services and so much more spent inside of concentrations. The result is less and less primary care and more and more workforce found in existing top concentrations of workforce.  

The NP workforce moves elsewhere by design to concentrate in top concentrations as in PA, MD, and DO workforce. Flexible sources of primary care (NP, PA, IM, PD, MPD) are versatile workforce that continue to move to more different specialties and locations with each passing class year and each year after graduation – movements away from basic health access. Flexible designs are most vulnerable to the distortions of the US design. 

Departures of nurse practitioners away from family practice during training, at graduation, and each year after graduation are a reflection of this flexibility. This is a simultaneous loss of all forms of basic health access in one career change alone. About half of total nurse practitioners train in family nurse practitioner programs but only 25% are found employed in family practice. Rural primary care per graduate declines are essentially about departures from family practice.

Why Ignore Basic RN Workforce?

Basic registered nurses are a major commonly ignored rural workforce and are also a major ignored primary care workforce. The current 270,000 primary care registered nurses are a greater number than the current 220,000 primary care physicians. Low pay is common to all primary care careers. Only school nurses are paid less than primary care nurses.

Physician Assistants - More Elsewhere But the Same for Rural Primary Care

The physician assistant doubling of annual graduates in the past 10 – 12 years has already indicated little change in primary care, rural, or underserved contributions despite the doubling – all the result of fewer entering and remaining in family practice. The 200% increase in non-primary care numbers during this doubling indicates the US design influence. Movements away from family practice and locations in need of family practice are shaped by the designs.

The family practice PA is 30 times more likely to be found in a federally qualified rural health clinic and is 6 – 7 times more likely to be found in a Community Health Center. The PA remaining in family practice positions has 30% rural location rates nationwide. Family practice declines from 36.5% of PA workforce in 2000 to 25% by 2010 have resulted in a decline from 23% to 15% of all PAs in rural locations. Only 20% of newly minted physician assistants are entering family practice. There are also indications of departures steady over time even if policies improve (as indicated with steady departures of those tracked from 1990 – 2000 by Larsen and Hart).

Internal Medicine and Pediatric Contributions

Internal medicine has experienced a massive decline in primary care retention for major losses of rural primary care that will continue starting 2000 until at least 2030. How low this goes depends upon how few remain in primary care below 20%. Distribution to rural areas is not likely to improve and will also be more costly. Internal medicine and pediatric specialties are greater in number and in subspecialization - an indication of even fewer for rural workforce. Pediatric primary care graduates continue to prefer academic and higher income locations where workforce is already concentrated (Cull).

Surgery Contributions

With movements of newer residency graduates away from general surgery, general orthopedics, and general obstetrics-gynecology, these movements also represent lower probability of rural location.

SMART Formulas

Only family physicians remain where needed. Only family physicians have not been expanded in annual graduates for 30 years – by aberrant US designs that concentrate workforce in top concentrations leaving most Americans behind – especially rural Americans.

Upcoming Blog Subjects

Consequences of Expansion and of Low Primary Care Retention: Workforce Least Experienced in Primary Care

Patients visiting family physicians will generally be visiting primary care clinicians that are likely to have the most primary care experience. Other sources that have expanded rapidly (NP, PA), other sources that depart primary care steadily in the years after graduation (NP, PA, IM), and other sources with lower volume (NP, PA) are likely to have less to much primary care experience.

Quality Is Much More About Patient Factors and Much Less About the Provider

Less experience in a workforce does not mean differences in patient care outcomes. Research studies with proper designs are likely to continue to show no difference in the quality of care for different types of providers. The reason is that patient outcomes are more about the patient and less about the provider. Underserved patient outcomes were demonstrated to be lesser and the reason had to do with the characteristics associated with being underserved. Rural patient outcomes are going to be lower because the patients are from rural locations. Studies that attempt to paint rural hospitals, underserved clinics, or physicians serving the underserved as lower quality represent flawed research designs.

Studies attempting to compare types of providers are often comparing apples to oranges – common even in major government reports and major journals. Research often influenced by physician leadership has distorted research to give too much credit to providers of care - and too much of the blame as well.

It is sad that we forget over and over that health care access, health care cost, health care status, and health care quality are mostly about the patient. Failure in perspective is also a primary measure of arrogance and poor awareness of the needs of most Americans left behind.

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

Countdown to the 2012 Primary Care Armageddon

There are about 132 days until January 1, 2012 when Medicare will be forced to cut fees to physicians by a flat rate of 29.5%. These cuts have already been enacted by Congress. To prevent this action, the current Congress would need to take action – a major problem with this Congress.

Before the end of the year you will hear much about these cuts and why these should not take place. This has been the case each year for a number of years. The fact of the matter is that many of the physician fees should be cut, but there are some fees that should not be cut. Primary care cuts are a very bad idea at the current time.

Even if Congress does miraculously decide to act in a timely fashion, with time enough to allow those delivering services to prepare (too late already), it is likely to cut fees paid for services in a simplistic way. These cuts will include primary care fees along with all others. Across the board cuts are likely as few in this nation understand important differences such as the difference between primary care and non-primary care.

Non-primary care is the area that has substantially increased the cost of health care in the United States for decades. Soon 20% of our Gross Domestic Product will be health care services. This is best indicated by a doubling of non-primary care workforce each 15 years since 1965. More than a doubling is possible in the next 15 year period. Physicians, physician assistants, and nurse practitioners are two to three times more likely to be found outside of primary care as compared to those inside of primary care.  Non-primary care has also demonstrated that it can maintain profits even with attempts at cost cutting.

Non-primary care services are the services needed by the fewest Americans for only a few years of their lives delivered in only a few locations. Primary care services are those needed by nearly all Americans nearly all of the years of their lives needed in nearly all locations. The reason for primary care problems is that the national design favors the few rather than the needs of nearly all.

Non-primary care interests have been providing ever more services for fewer. Primary care has been forced to do more with less - for decades. Primary care has reached a breaking point. This is not about profits or physicians. It is mostly about what is most important – people in need of primary care.

More Americans than ever need primary care. Seniors will double in numbers in the next 20 years and seniors need two to three times more primary care. With serious deficits of primary care and all sources of primary care moving to fewer remaining in primary care, it is the worst possible timing for any cuts in primary care fees.

Primary care is the area most closely associated with basic access to health care services. US designs have resulted in only one doubling in primary care workforce, from 1965 to 1980. Stagnant primary care delivery capacity has been the rule since this time. Primary care has been associated with health care cost savings although this may be more about increased costs due to non-primary care excesses.

Unlike non-primary care that has many options to preserve and maximize profits, primary care has few options. Primary care has no waste to cut. Primary care budgets are mostly about people who deliver primary care services. Cuts in primary care result in cuts in personnel and cuts in primary care services, or closures of clinics delivering primary care.

Primary care has not increased as those that invest in health care have far better investments to make. Primary care has rarely enjoyed investors or investment capital as primary care does not come close to 30% revenue over the costs of delivering care. Non-primary care services have increased most rapidly because it has attracted the most investors. This is logical given higher reimbursement for non-primary care services. To Understand Workforce One Must Follow the Money.

Primary care spending remains just 5% of total health spending – a pittance compared to the needs of 310 million Americans and barely enough for 140 million – by design.

For 30 years primary care graduates have been driven away from primary care - by design. Rather than a real design for primary care with real primary care spending, the United States has a patchwork of patches. The 1965 – 1970 redesign doubled primary care delivery capacity – for the only time in the nation’s history. The 1990 patch worked for a few years. The 2010 fix never came and is not likely. About every 20 years a fix has been needed for the primary care revenue design because the costs of delivering primary care have gone up faster than reimbursement.

This is the message Congress needs to hear from seniors and from most Americans. This message should be passed out to patients and posted in primary care offices:

If Congress does not act by January 1, 2012 to prevent the scheduled 29.5% cut in primary care reimbursement, this primary care office will have to reduce services or close. Many other offices will be forced to do much the same. Primary care is down to the basics - people serving people. We have no fat to cut. Long ago the designs for health care in this nation forced those delivering primary care to be very dedicated just to deliver primary care.

As your responsible provider of care, we want to inform you of this possibility so that you can make other arrangements if need be. As long as we can, we plan to keep serving you. We hope to keep serving you right here in this office. Whether we are able to do so depends mostly upon you and what you do.

We hope to help you keep having a nice day.

Finance-me-cratic Constants in the Bureaucratic Universe

America has come to a standstill in many important areas - health, education, leadership, and more. Recessions have always found ways to blame any number of individuals or types of people. In fact, recessions have a common cause involving the relationship between finance-me-crats, aristocrats, and bureaucrats.

(Note Finance-o-crats was changed to Finance-Me-Crats - a better term with those that have self-interest above nation and political party.)

"Let me end my talk by abusing slightly my status as an official representative of the Federal Reserve. I would like to say to Milton and Anna: Regarding the Great Depression. You're right, we did it. We're very sorry. But thanks to you, we won't do it again." November 8, 2002 by Ben Bernanke (the current Chairman of the Federal Reserve), as he agreed with Friedman in blaming the Federal Reserve for its role in the Great Depression. Bernanke should remember that

"Hell hath no fury like a bureaucrat scorned." -- Milton Friedman

The bureaucratic mentality is the only constant in the universe.  Leonard McCoy, M.D. (Bones of Star Trek) - There are a number of timeless quotes from docs fighting with bureaucrats to keep health care alive where people need health care. The first female Native American physician came to be because she witnessed bureacratic health care and vowed to bring health care to people in most need of better health.

Smaller portions of Americans left behind have grown to become most Americans left behind and sadly few realize that the very designs of health care leave them behind. In American financial, education, and health wealth follows designs. Health care follows the finance-me-crat pattern of more for fewer with high profit and little responsibility.

Take equal parts aristocrat, bureaucrat, and finance-me-crat - mix for 100 years and you have the American health care design  - one size fits none. - RCB

To recover as a nation and to prevent further economic distress across the globe, America must bail out from the financial crises aided and abetted by finance-me-crats (investment cost and risk greater than reward with those responsible escaping responsibility)

and the real estate bubble burst aided and abetted by finance-me-crats (investment cost and risk greater than reward with laws protecting finance-o-crats in case of bubble burst)

and the student debt loan bubble about to burst aided and abetted by finance-me-crats (investment cost and risk greater than reward with laws protecting finance-me-crats in case of bubble burst).

Scandals rock college sports aided and abetted by finance-me-crats while responsible university leaders looked the other way (and those responsible seem to mock the destruction heaped on so many lives and reputations).

Health care spending ends up less and less in the hands of those who deliver health care with more and more spending ending up in the hands of finance-me-crats and those making profits shaped by finance-me-crats. We spend ever more for ever less result for all Americans except finance-me-crats and finance-me-crat wannabes.

Health insurance reforms needed for decades to reign in health insurance laws appear to be on the way out along with other reforms. The health insurance design was set up by finance-me-crats in each state to guarantee maximum profit with little risk or responsibility while individuals and their families suffer the consequences and sometimes can get justice at even consequence to a decent life.

Also finance-me-crats benefited from increased profits by blaming the new reforms that had not taken effect - a nice strategy to deceive the American people about the new reforms. In other words, reforms have failed and will fail to address the basic finance-me-crat modus operandi - maximal profit regardless of consequences with little investment or risk by redesigning American business and government.

Finance-me-crats have also found ways to spin media perceptions so that areas such as health care appear to be under government control when the real control is in the hands of finance-me-crats and those that they can hire, collaborate with, or influence.

Congress is constantly distracted and distorted in composition and in behavior by finance-o-crats who shape special laws governing insurance, real estate, college loans, health insurance, and taxation including decades of special tax protections for the ultrawealthy at federal and state levels.

Special interest groups led by finance-o-crats and protected by Supreme Court decisions funnel billions of dollars into divisive interests. Millions can flow from outside of states to shape elections inside of states allowing maximal control for minimal cost and little responsibility. A few billion injected in the right direction can divide the nation and divide states and divide political parties. Such behind the scene designs succeed in preventing identification of finance-o-crats as a major problem - along with frustrating the American people about becoming involved in governing.

And when the nation was at its knees desperate for some cash to help recover much of the nation from the abuses of finance-me-crats, the finance-me-crats, always first at the feeding trough, were quickest to react and were the first to waste the recovery dollars for themselves and for their allies. This spending resulted in limited recovery for maximal cost and the spending also illustrated finance-me-crat disdain for the great responsibility of using government funding wisely or for recovery.

Perhaps America should focus more on the role of finance-me-crats who have done what the founders of American government tried to avoid for 200 years - voting the US treasury into the pockets of those with too much government influence.

This one is certainly less like the usual basic health access posting, but if we continue to send more and more concentrations of spending to those already with concentrations, we will not have basic health access or much of anything involving basic services. Daily Yonder Article on Primary Care Cuts Planned Jan 1, 2012

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

To Follow the Money, Follow the Workforce   Health spending patterns shape health workforce and vice versa.

Why Do Government Reports Project Increasing Primary Care When Fewer Enter and Remain in Primary Care?

Health Workforce Designs for Health Access Have Tried Everything Except What Has Worked for Health Access.

A Major Reason for Runaway Health Care Costs: Three Dimensions of Non-Primary Care Expansion while Primary Care is Shutout 3 to 0.

Still the Health Access Solution for Most Americans: Family Practice

Health access workforce solutions have always been and will always be the broadest scope generalists. Other workforce even with slightly greater specialization or limitation in age range or limitation in scope will remain limited in distribution. Other sources fail to remain in primary care and fail to distribute outside of locations where workforce is already saturated at top concentrations

Inside of Concentrations - About 3400 zip codes clustered together in 4% of the land area enjoy top health spending per capita, all lines of revenue, and the top reimbursement in each line. This is where 72% of workforce and 70% of all primary care except family practice is concentrated. These zip codes with top concentrations of physician workforce are dominated by hospital, academic, and subspecialty interests – the same interests that dominate health professional associations and health education associations and the panels that influence government designs for revenue and for workforce. Consistent steady force applied over 100 years can accomplish amazing design changes - and the consequences of the resultant design.

A design that favors basic health access is the opposite from a design favoring concentrations of workforce in concentrations of workforce. Basic health access design is a design that results in the most broad scope generalists and a design that preserves general types of specialists. This is a design that is most likely to result in practice location in 30,000 zip codes with the 65% of Americans that found outside of concentrations. This is also a design that favors economic recovery for most Americans.

One problem with emergent recovery designs is that those most consistently at the feeding trough are already in place. Those outside are left behind when new funding emerges. Not surprisingly Americans have been frustrated with the feeding trough and with those feeding - but especially by being left behind.

Designs that favor those inside of concentrations favor those that already have the top economic impact per person from health care. According the the AMA, office based physicians contribute about 2 million per physician. In zip codes with 200 or more physicians with 11% of the population this translates to $10,000 to $15,000 per person in local economic impact. Practice locations outside of concentrations receive $800 to $2000 in office based physician economic impact. The differential is much worse when considering non-office based contributions as the hospital, academic, and research economic impacts are even greater at 80% to 90% inside of concentrations due to higher proportions of such workforce inside of concentrations.

When you follow the workforce, you follow the health spending. This is the traditional design that concentrates health spending with health workforce concentrations instead of distributing health spending according to the population distribution.  

Designs that result in recovery in primary care involving family practice and redistributions of primary care spending where primary care is most needed are designs that favor economic recovery for the people in these locations that are more likely to be lower income, middle income, poor, near poor, rural, underserved, disadvantaged, and complex in health care needs.

The existing design is not capable of addressing economic impact for most Americans. Economic impact from medical education is incredibly concentrated with 50% of 500 billion dollars a year concentrated in a few dozen zip codes in six states – states that already have top physician concentrations (AAMC data). Generic expansions of graduate medical education also fail to distribute health spending or health workforce. Ultimate concentrations of workforce follow top GME spending.

While health care and medical education and physicians are important to economic impact, the current designs fail to benefit most Americans. Those influencing the design are also unlikely to allow the designs to change as they control hundreds of billions of dollars each year in health care spending. Only a small portion need be diverted to influence Congress, government information, the media, insurance companies, health systems, and others important to the design. Those outside of concentrations have no effective lobby for two major reasons. First they are outside and second they are outside delivering the care needed by most Americans nearly all of their lives.

Family practice MD, DO, NP, and PA graduates are found distributed most consistently according to the population, but only when they remain in family practice employment. Family practice retention over a career is the critical component for basic health access. Family practice retention is 95% for family medicine residency graduates but only 20 – 30% of total NP or PA graduates are found in family practice employment. Physicians becoming family physicians can be tracked steadily departing top concentration locations across birth to medical school, medical school to residency, residency to practice, and to subsequent practices. The choices that lead to family practice lead to improved distribution.

A design that favors departures of primary care graduates from primary care and departures of non-physician clinicians from family practice is the same design that concentrates workforce and health spending inside of concentrations.

Permanent broadest scope generalists are the requirement for health access as such permanency forces distribution where needed. Flexibility in workforce allows a switch rather than a fight and stay or a move to a place better suited for primary care. The ability to switch away from family practice is not a good characteristic for the basic health needs of most Americans.

Family medicine residency graduates have long set the mark for retention within career. Non-physician clinicians that choose and remain in family practice have the same or better distribution as compared to family physicians although they have lesser productivity over a career (volume, years in career, activity in practice).  Rural primary care also illustrates the differences as well as non-physician clinician declines in health access contributions per graduate.

Non-physician clinicians have been proposed as primary care solutions, but generic expansions have not been good primary care solutions for NP, PA, MD, or DO. The generic solution is not specific to primary care or to family practice.       Permanent … broad scope… generalist.

The reason for rapid expansion of NP and PA workforce is great versatility. This versatility is also the reason for departures from primary care and from family practice. Non-physician clinicians are by far the most flexible workforce with a wide range of specialty and location choices. New specialties and subspecialties are being created and numbers continue to increase in each specialty. This all comes at the cost of lower retention in family practice over the years after graduation. The United States now has to graduate two to three times as many NPs and PAs to get the same primary care, rural primary care, or underserved primary care. This indicates a design steadily moving away from health access where needed and toward top concentrations. 

Departures from family practice and from primary care insure location departures from rural or underserved or outside practice locations – a consequence of greater concentration inside. Fewer broadest scope generalists insures more concentration. More will distribute health access as long as health spending is directed to support those who do distribute. Ever lower concentrations in locations outside of concentrations, shrinking health spending outside of concentrations, increasing population growth outside of concentrations, and increasing demand from patient populations outside (elderly, lower and middle income) will also result in greater shortages. The United States unfortunately has indications of nearly all of the above for even less basic health access result in the future. Primary care itself has no indication of any increase in the face of rapidly increasing demand.

Permanent retention in broadest scope general practice is required for distribution to 60% of the urban population and 70% of the rural population – those in most need of primary care workforce in locations with primary care is 40% to 100% of the local workforce – and the economic impact of health care upon the community.

When local primary care is controlled by those outside of the community, this can lead to even less local economic impact. With primary care revenue insufficient for the cost of delivering primary care, it is likely that local primary care for the purpose of local health care will be less likely. Those supporting primary care from outside may have agendas not specific to local primary care or local health care.

Consistent changes in physicians, physician assistants, and nurse practitioners to subspecialized and hospital based careers force ever higher concentrations and lesser distribution. Graduates are less likely to be found in family practice, generalist careers, or general types of specialties that have demonstrated better distribution. A recent example of a design change was the conversion of tens of thousands of primary care nurse practitioners and physician assistants to become teaching hospital workforce to replace the gap resulting from resident work hours restrictions. Movements from generalists to teaching hospitals represents the maximal possible change toward concentration in a relatively short period of time. This is made even worse by studies that indicate that health care quality has not improved in teaching hospitals with the resident work hours restrictions.

Consequence without benefit is not a good design change. Movements of tens of thousands of internists from primary care to hospitalist careers also result in changes in practice location. Substantial responsibilities have been shifted from hospitals with greater resources to primary care with less to least resources. Primary care nurses are being pummeled with greater fragmentation, more responsibility, and no improvement in support. Hospitals have saved substantial costs and generate more revenue – with consequences for those outside. Primary care needs respect, much higher priority, and suffiicient funding to deliver primary care rather than constant marginalization.

All workforce except for that associated with family practice employment can be tracked moving toward concentrations and away from primary care steadily over time. Family medicine is the only permanent family practice source and is therefore the source most resistant to concentration. Already this has resulted in family medicine multiple times more likely to be found serving the elderly, poor, near poor, rural, disadvantaged, Community Health Center, and shortage area populations left behind (Ferrer, Mold, Rosenblatt, Bowman).

Lower and middle income and fixed income populations are most dependent upon family medicine with practice location a key determinant. The elderly that are most likely to be on fixed incomes are a prime example of a population that must move away from the highest concentrations of cost of living to more reasonable locations. In the process older and oldest Americans must depart concentrations of primary care, stroke centers, and heart attack centers to locations with less access to a wide range of services (Perotta). Over the next 20 years the elderly and all others left behind will be left even further behind.

The one source that could have addressed their needs, family medicine, has not been expanded in annual graduates for 30 years. After a generation with zero growth of annual graduates, family medicine has reached its design level of 100,000 for 3000 per year. Unfortunately the elderly and all others most dependent upon family medicine have now entered a 20 year period from 2010 to 2030 with most rapid growth in primary care demand.

Most Americans do not need 30 more years of more of the above designs that fail most Americans in one or more dimensions. What they need is more spending outside of concentrations, less spending inside of concentrations, more spending upon primary care, less spending in non-primary care, and more spending on the health care needed by nearly all Americans nearly all of the years of their lives in nearly all locations.

Whether you call broadest scope generalists MD, DO, NP, or PA does not matter. What you must make sure of is that whatever is produced, stays permanently as broadest scope generalists in primary care. This is the only design that works for most Americans and Americans most in need of health care. When people propose solutions, ask them the "P" words - permanent, primary care, and population-based distribution. Better yet, have them sign a binding contract to deliver more than promises by SMART designs. 

Revisiting Physician Distribution by Concentration Coding

Geographic coding often involves concentrations of people relative to land area such as rural or urban or most urban. Why do studies of physician workforce use coding based on ratios of people to land area? Why not use ratios of health workforce or physician concentrations as compared to people?

Top concentrations, marginal concentrations, and underserved concentrations are more relevant to those seeking care, and are most relevant for basic health access where local or adjacent zip code care is a priority.

Geographic coding such as rural versus urban actually has problems when compared to physician concentration coding. Isolated rural and small rural locations (Cooperstown NY, Marshfield WI) can have top concentrations of physicians. Rural Concentrations of physicians are about 3% of United States physicians and about one-third of rural physician workforce.

Also using workforce concentrations, types of workforce can be compared. One important area stands out. The MD, DO, NP, and PA family practice employed component is the only component that distributes according to the population and therefore according to primary care demand. All other primary care, specialty, hospital based, and subspecialty choices are more likely to be found in zip codes with increasing concentrations of physicians. Claims of better or best distribution are only about family practice and only when graduates stay in family practice.

What matters with regard to physician workforce is the ratio of physicians to the population. Patterns of workforce concentration can also be compared to various populations. Top concentrations create their own consequences, as in doughnuts of zip codes with shortages of workforce that surround clusters of top concentration zip codes. This is a design that results in the most barriers to health access. Primary care is also concentrated inside of concentrations, with the exception of family practice.

Physician Distribution by Concentration Coding emerged from immersion research involving secondary physician databases. With physicians in 2005 compiled by zip code, patterns of concentration were more easily understood.

Top concentrations tend to be subspecialty, academic, and hospital in focus with a vertical orientation of the design.

Most Americans are found in zip codes that are horizontal or health access in focus, dominated by primary care and generalists and general types of specialties.

This presents a problem because the workforce most needed by most Americans is the workforce least produced and least retained by American designs.

What emerges is the fact that those influencing health professional training and multiple Congresses and Presidents over many decades are found in top concentrations with benefits bent steadily this direction with little real competition. The health care delivery most promoted as outstanding to the world arises from these zip codes. The fact is that the United States has a Super Center design with a super sized consumption of health care spending and health care workforce and health care consequences – including lesser health and wealth for substantial portions of the United States population. More details and category characteristics can be found at Physician Distribution by Concentration.

Concentration Coding Categories

	Physicians per 100,000 Population (280 is avg)	% of Office Based Economic Impact /  % of US Physicians	% of Total US Pop / % of FM Docs	Physician to Pop and FM to Pop Ratio
Super Center 200 or more physicians, < 1% land area	1100	51.1% 46%	11 - 12% 20% of FM	4 to 1 1.8 to 1
Major Center 75 to 199 docs,  3% land area	400	28.3% 22%	22% 27% of FM	1 to 1 1 to 1.2
Marginal Urban higher income and lowest poverty	150	13.5% 20%	35% 25% of FM	1 to 2 1 to 1.25
Urban Underserved lower income and higher poverty	80	2.3% 4.5%	13% 7% of FM	1 to 3 1 to 1.5
Marginal Rural average income and average poverty	130	2.7% 4%	8 - 9% 10% of FM	1 to 2 1 to 1
Rural Underserved lower income and higher poverty	105	2.2% 3.5%	8 - 9% 9% of FM	1 to 3 1 to 1

Highest poverty urban or rural sites have about 60 physicians per 100,000. AMA Economic Impact of Office Based Physicians used with AMA Masterfile 2005

Graphics of the PDC Coding

Inside of concentrations = Super Center and Major Center zip codes with one-third of the population and highest concentrations of physicians, health workforce, economics, income, facilities, health spending, and economic impact from health care. Zip codes inside of concentrations are also clustered together in small portions of states, counties, and cities for least accessible health care. Inside of concentrations are even higher concentrations of health spending and economic impact per capita.

Outside of concentrations = Marginal or Underserved zip codes with two-thirds of the population and same or greater proportions of elderly, poor, near poor, rural, underserved, disadvantaged, and complex populations as well as lower health resources and health spending.

Two geographic patterns are common with lesser concentrations. These include large areas of low concentrations and doughnut patterns. Doughnut rings of lower to lowest workforce concentration surround zip codes with highest concentrations of workforce. Doughnuts can be urban or rural. New York City urban zip codes surrounding Manhattan indicate highest central and lowest peripheral concentrations. In the Midwest highest metro concentrations are surrounded by nearby rural zip codes, at least until urban sprawl overtakes low concentrations.

The most subspecialized workforce is found at 60 – 65% inside of Super Center zip codes in 1% of the land area with 11% of the population. About 80 – 92% are found inside either Super Center or Major Center concentrations along with 85% or more of residents in training, faculty, and research physicians. Training dollars and research dollars follow these concentrations of workforce as do concentrations of health spending for the most specialized procedures.

Designs developed over the past 100 years have consistently favored those most inside of concentrations. Zip codes inside of concentrations can access all lines of health service revenue and reap the highest levels of revenue in each line. Zip codes inside can recruit staff, nursing, clerical, and practitioner workforce away from primary care and from lesser concentrations due to greater health spending – by design.

Primary care is assured the least experienced personnel and workforce by designs that send the most experienced inside of concentrations leaving those most inexperienced and those most dedicated behind on the front lines. New designs by states and insurance companies may result in even less primary care spending sending even more workforce away from basic health access to top concentrations – or the US could continue the old design of too little revenue for the increasing cost of delivering primary care for steady, albeit slower declines.