The cost of primary care training can be compared to primary care delivery over a career. Additional calculations can integrate the proportions of graduates found in certain locations to generate the contributions in rural primary care, underserved primary care, and primary care delivery outside of concentrations (in 30,000 zip codes with 65% of the US population left behind). The cost of training per unit of primary care is much less for family medicine. Other sources that yield less primary care per graduate are inefficient primary care sources.
Real Measures of Efficient and Effective Primary Care
The United States does not require more primary care in 3400 zip codes where primary care is saturated. The United States must have primary care that has demonstrated the ability to locate outside of concentrations. This must be kept in mind. Internal medicine, adult NP, pediatricians, and pediatric NP sources all result in lesser primary care delivery and lower proportions compared to the best primary care sources.
The categories for NP and PA divided into family practice or not family practice as the family practice component contributes the lion’s share of the midlevel primary care, rural, and underserved contributions. The physician figures involve those attending United States or Caribbean medical schools. Graduate medical education does deliver some primary care and does contribute to revenue generation and these items were not included.
Cost of Training Relative to Primary Care Delivery over a Career
Cost of Training | Cost per SPCYr | Cost per Rural SPCYr | Cost per Under-served SPCYr | Cost per Outside SPCYr | |
NP not FNP | $380,000 | $215,420 | $2,154,195 | $1,795,163 | $615,484 |
FNP Trained | $380,000 | $55,850 | $199,463 | $372,330 | $101,545 |
PA not FP Start | $440,000 | $158,025 | $1,580,247 | $1,316,872 | $451,499 |
PA w/FP Start | $440,000 | $37,037 | $123,457 | $205,761 | $67,340 |
FM Trained | $950,000 | $37,661 | $171,185 | $251,072 | $71,058 |
IM Trained | $950,000 | $280,653 | $2,806,532 | $3,118,369 | $1,002,333 |
PD Trained | $950,000 | $94,756 | $1,184,452 | $1,052,847 | $338,415 |
MPD Trained | $1,050,000 | $97,957 | $612,228 | $816,304 | $244,891 |
When the focus is primary care delivery from primary care training, substantially more graduates are required when sources remain in primary care at low levels.
Recent cost of training figures are listed at the table at the end of the blog and include cost of living and cost of all higher education and training (post high school). These are also figures that are appearing optimistic due to ever higher cost of higher education and even more problems that will drive primary care to lower retention and less primary care delivered over a career. Family medicine would also decline but not to the same degree as the more flexible sources.
Only family medicine is efficient for the purpose of primary care delivery. If a few family medicine leaders succeed in adding a year to FM training, this would decrease career length by 4% and would add about $120,000 to training cost resulting in a $5000 increase to $43,000 per SPCYr. More importantly millions of additional Americans would be left behind with a smaller FM workforce.
Pediatric expansions are unable to increase the primary care result. More graduates over the past 10 years have merely replaced those departing. There simply are not the openings for PD primary care where PD primary care is willing to locate. Internal medicine appears to be much the same with more moving away from primary care. For all practical purposes, any expansions for the purpose of primary care physician production must be specific to family medicine. Only permanent primary care obligations could improve flexible IM, PD, MPD, NP, and PA results.
The nurse practitioner training cost will increase substantially in 2015 with two years more required training (up $120,000) and an 8 – 10% decrease in the years in a career. This results in a 33% increase cost per primary care year for family nurse practitioners – an increase from $55,850 to about $73,486 per Standard Primary Care Year. The major NP primary care and health access delivery rests on the shoulders of family nurse practitioners as so few outside of family practice contribute to primary care and primary care where needed.
Family nurse practitioners are 50% of NP graduates, but only 50% of FNP graduates remain in family practice employment.
There is a better decision for nursing leaders who desire to be truthful and maintain their assertion of primary care delivery from nurse practitioners. The appropriate move is to permanent primary care family practice rather than permanent doctorates. Without that move, nurse practitioner claims of primary care contributions must be qualified to only a small portion of NP graduates.
Currently nursing workforce leaders and various foundations that promote NP training as solutions for primary care are greatly exaggerating the benefits and are minimizing the cost.
Only the few NP and PA graduates that get certified and enter the workforce and enter family practice employment and remain in such employment contribute at significant levels, but even these melt away over time. Such is the power of non-primary care compared to primary care in the US design.
The Basic Calculations of the Standard Primary Care Year
% Primary Care | Years in Career | % Remain Active | % Volume | SPC Years Per Grad | |
NP not FNP | 15% | 24 | 70% | 70% | 1.76 |
FNP Trained | 54% | 24 | 70% | 75% | 6.8 |
PA not FP Start | 15% | 33 | 75% | 75% | 2.78 |
PA with FP Start | 60% | 33 | 75% | 80% | 11.88 |
FM Trained | 91% | 33 | 84% | 100% | 25.23 |
IM Trained | 15% | 32 | 82% | 86% | 3.38 |
PD Trained | 39% | 33 | 82% | 95% | 10.03 |
MPD Trained | 43% | 32 | 82% | 95% | 10.72 |
FM with greatest retention, years, activity, and volume delivers the most primary care in a career. Nurse practitioners not training in family practice or physician assistants not starting in family practice (80% of entering PA) contribute least along with internal medicine. The reason is so few remaining in primary care.
Distribution By Location Type
Rural % | Under-served % | Outside % | |
NP not FNP | 10% | 12% | 35% |
FNP Trained | 28% | 15% | 55% |
PA not FP Start | 10% | 12% | 35% |
PA with FP Start | 30% | 18% | 55% |
FM Trained | 22% | 15% | 53% |
IM Trained | 10% | 9% | 28% |
PD Trained | 8% | 9% | 28% |
MPD Trained | 16% | 12% | 40% |
Optimistic early practice estimates were given for all except FM. The actual proportions of other sources decline due to departures from family practice and from primary care over their careers. Only continued retention in family practice keeps optimal distribution. Only family medicine is retained in family practice for career long retention, documented in the FM figures from the AMA Masterfile and the Robert Graham Center.
Cost of Training Considerations
College | Health Prof | Graduate | Cost of Living | |
NP not FNP | $30,000 | $100,000 | $70,000 | $180,000 |
FNP Trained | $30,000 | $100,000 | $70,000 | $180,000 |
PA not FP Start | $120,000 | $125,000 | $195,000 | |
PA with FP Start | $120,000 | $125,000 | $195,000 | |
FM Trained | $120,000 | $200,000 | $300,000 | $330,000 |
IM Trained | $120,000 | $200,000 | $300,000 | $330,000 |
PD Trained | $120,000 | $200,000 | $300,000 | $330,000 |
MPD Trained | $120,000 | $200,000 | $400,000 | $330,000 |
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
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