As noted previously, all primary care RN, MD, DO, NP, and PA are greatly needed. But the probability of actually being in primary care over a career of contribution is small for new graduates in RN (10%), MD (20%), DO (30%), NP (25%), and PA (25%). Steady departures from primary care are seen for all except the small part of MD and DO that is family physicians. Family physicians are the only remaining primary care result that is relatively permanent but are only 7 – 8% of US MD and Non-Citizen IMG choose FM along with about 16 – 18% of DO and 25% of Caribbean US Origin.
The NP and PA primary care effort has stagnated because fewer have remained in primary care. The case can be made that unless more health spending is injected into primary care, the NP, PA, IM, and PD contributions will actually shrink. Family medicine is stagnated by 30 years of no increase in annual graduates from the 1980 level of 3000 per year.
One would think that common sense observations would reveal the myth of NP or PA or any flexible workforce increasing in primary care delivery - given fixed low primary care spending with double digit increases in the cost of delivering primary care.
But common sense appears to be the one quality lacking in the US health care design. Only a permanent primary care source by training (FM) or by obligation or by restriction can result in primary care graduates actually delivering the primary care indicated by graduation from a primary care program. NP and PA graduates are not permanent primary care by training or by obligation and they are no longer restricted to primary care or underserved locations.
Generic expansions fail for MD, DO, NP, and PA with such low and falling proportions of primary care in the years after graduation. Questions should be raised.
Why Does the United States Persist in Myths such as
- Midlevel Primary Care as solutions for primary care with fewer and fewer remaining in primary care over time.
- Generic expansions as solutions for primary care - expansions that cannot work because of US policy for 30 years (same for NP, PA, MD, and DO).
- Innovation and reorganization as solutions for primary care - innovations that also cannot work because of policy for 30 years.
- Generic expansions of internal medicine as solutions for primary care where it takes 8 graduates to result in 1 FTE of primary care.
- Any expansion of pediatrics - Pediatric expansions for 15 years have demonstrated the futility of expansion for primary care and cannot increase primary care delivery. It would take two major changes. Graduates would have to decide to change their location preferences away from saturated locations and the US would need to inject more spending into primary care for children above the rapidly increasing cost of delivering primary care (not cuts or freezes in reimbursement).
Given US policies bad since the 1980s and worsening, only specific designs (SMART) work such as family physician specific or long term obligations or restrictive legislation forcing permanent primary care. These are the only Specific, Measurable, Achievable, Realistic, and Timely interventions given the fact that US policies drive all but permanent sources away from primary care, especially in the last 15 class years.
Why Do Myths Persist?
An obvious reason is that major players have much to gain. Perhaps it has to do with substantial gains for those that benefit by the US policy design. After capturing what will be 80% of physicians, the designers benefit with over 70% of NP and PA graduates as non-primary care workforce. NP and PA leaders benefit by being able to claim primary care.
Those benefitting can be tracked by substantial movements to teaching hospitals, academic institutions, hospitals, surgical workforce, emergency rooms, and the largest subspecialty practices. Flexible workforce such as NP and PA are valuable in a variety of specialty, hospital, and academic roles individually or together at the same time.
Those in the US that do not understand the difference between flexible or temporary primary care and permanent career choices or first career choices compared to an entire career contribution help contribute to the problem as seen in government and foundation reports, media postings, major journals, and statements of various deans and workforce experts.
Perhaps the midlevel emphasis is also a reaction to physician domination. Association with male domination may bother females and there is the feminist movement to consider. Government personnel, those in non-physician health professions, and a variety of lobbyists (when not working for medicine) may have an axe to grind. Physician leaders, associations, and lobbyists do have a way of getting other health professionals and their associations stirred up. Others believe that their own type of health care is superior. A number of alliances exist with for-profit corporations and others who may help the cause of advanced nursing. Some have consequences.
Poor Understanding of the Mechanisms of Midlevel Departure from Basic Health Access
A common problem is that few understand how much benefit there is for NP and PA that depart primary care and basic health access settings. The benefits accrue to the individuals converting, to the employers that facilitate conversion, and to the hospital and teaching hospital and subspecialty physicians in the largest group practices. Movement away from primary care and from the more underserved locations is assured with lowest health spending in multiple dimensions. Movement is assured toward the highest concentrations of workforce joining others that already receive the most lines of revenue and the highest reimbursement in each line.
NP and PA Benefit - Basically all health personnel receive higher to highest salaries when departing primary care. Nurses, physician assistants and nurse practitioners in particular are documented as paid the least in school health, primary care, and community health arenas. The most experienced follow the designs to hospital and subspecialty settings. This is where health spending is the highest and where all lines of revenue are found with the highest reimbursement in each line. This is set in place by the academic, hospital, and subspecialty designers. Primary care appears increasingly to be a job for those new, those part time, and those transitioning. The best opportunities are subspecialty and hospital where NP and PA graduates can enjoy significant flexibility, autonomy, variety, and financial reward. This contrasts with primary care where working harder matters little as there is less funding available even if those in charge of primary care clinics wanted to reward their major contributors. Pay increases usually do not cover the rising cost of health insurance and other deductions from paychecks.
Employer Benefit - Major health care employers shape designs for health workforce and health spending. Health care employers receive greater revenue from subspecialty PA and NP services and lesser revenue from primary care efforts. Flexible workforce can fit a number of situations from the most office based to intensive care settings and from multiple physicians and other team members to few.
Subspecialist Benefit - Subspecialty physician practices receive more revenue by adding NP and PA subspecialists. The subspecialty physicians in the practice do not lose revenue when adding NP or PA professionals. When a subspecialty physician is added to the group, the other established subspecialists decline in revenue generation. In other words NP and PA provide services that complement and do not compete. Guess which type of addition is likely to be preferred? (Cardiology example from The Lewin Group). The study indicated that the largest groups benefited the most – those that are most likely to be in the top concentrations of workforce. This sends NP and PA not only away from primary care but also to the top concentration locations.
Subspecialty physicians can generate more revenue with NP and PA additions for other reasons. The NP or PA at the clinic can see patients while the subspecialists are making more money doing more procedures and more expensive procedures. Hospital NPs and PAs can do much of the rounding, also preserving physician time for high revenue generation areas.
NP and PA expansions can “throw out a net” to gather ever more referrals and ever more procedures sent to colleague subspecialty physicians. Each contribution generates more revenue more than one way. Such a net can also suppress competing practices and corner the market – an increasingly successful tactic in health care used by health care insurers, large systems, academic institutions, and practically all except those attempting to deliver basic health access services. Those backlogged with more patients to see than subspecialists can get things updated with a PA or NP professional – and quicker to be seen can result in difficulties for others who remain backlogged. This is an important consideration when there is so much demand for subspecialty workforce (even though some of this is too much done for too little result and also more is due to the decline of primary care and the decline of managed care).
While it appears that there are benefits, the NP and PA changes over the years include less and less primary care and fewer remaining where needed. Only the family practice employed NP or PA can be demonstrated to consistently serve the 65% of the population in 30,000 zip codes in need of primary care and the family practice employed proportion has declined the most over the past 30 years.
The next post is about The Black Hole of United States Subspecialization that also has impacted MD, DO, NP, and PA workforce and that effectively prevents recovery of primary care and recovery of the US economy.
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
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
Disclaimer: Dedicated primary care MD, DO, NP, PA, and RN professionals are quite remarkable. All that separates them from non-primary care careers is their dedication, their commitment, and their desire to serve. Every other influence via policy and training sends them away from primary care. Those departing primary care for non-primary care are also not to blame as this is what the designs favor. Those who are dedicated and those who are herded away from primary care and toward existing top concentrations of workforce deserve better designs, better representation, and an accurate depiction of the United States health workforce situation. When only a few shape the designs and decisions, most health professionals and most Americans are left out by design.
