Flexible Fails and Permanent Primary Care Prevented

The United States has a health policy construct that actually prevents recovery of primary care. Primary care revenue support is insufficient to keep up with the increasing cost of delivering primary care. New types of costs burden primary care practices further. Meanwhile the rewards for non-primary care choices have increased. The rewards are greater for primary care graduates that depart primary care. The rewards are greater for employers who receive more revenue when graduates convert from primary care.

Accelerating cycles of primary care deficits are the result of US policy.

1. The cycle starts with primary care deficits.
2. Innovative academicians create new sources of primary care. The designs are generic to workforce needs and are not specific to primary care or most needed primary care.
3. Despite more sources and increased graduates in each source, there is less primary care result per primary care graduate. Studies contribute to the confusion as they only measure first career choices which fail to capture steady departures from primary care in the years after graduation. Only about 30% of US primary care training results in primary care delivery.
4. Innovators propose to fix primary care with more types of primary care and further expansions of annual graduates. Others say that primary care can be fixed with reorganzation (continuity home) or innovative payment designs. No such proposal can work without changes in the US policy construct that increase primary care retention in professionals and other personnel - this requires more primary care spending, especially in 30,000 zip codes with lowest spending by design.
5. US policy does not change and this results in less retention of primary care graduates within primary care careers with flexible primary care graduates departing primary care during training, at graduation, and each year after graduation.
6. The result is ever more non-primary care with continued deficits of primary care.   

The 1980 primary care class year including six primary care sources with 14,000 graduates at 18 Standard Primary Care Years per graduate for 250,000 Standard Primary Care Years for the 1980 class year. The 2012 graduates of six sources will be 28,000 in number but the yield will be only 7 SPCYrs per graduate for a result of 195,000 SPCYrs. Standard Primary Care Year 2012

Since 1980 the United States has had substantial growth of population and primary care demand but the response has not been Specific, Measurable, Achievable, Realistic, or Timely with regard to primary care or the health access needs of most Americans. Tragically the needs are greatest in locations where the elderly, poor, near poor, rural, and underserved populations are found - in 30,000 zip codes that have lower than average to lowest primary care concentrations.

Permanent primary care family medicine is a real solution for primary care and for 200 million Americans in 30,000 zip codes, but permanent primary care choice is actually prevented by policy. Only medical students can choose permanent primary care as nurse practitioner and physician assistant primary care is flexible by design. Only medical students can choose family medicine residency training. Nurse practitioner and physician assistant family practice employed components make the same substantial contributions where needed, but only when remaining in family practice. NP and PA graduates found in family practice employment have decreased to 25% of total graduates. Even when entering family practice with its substantial primary care, rural, and underserved outcomes; the retention is not permanent. Family medicine retains primary care and rural and underserved components because of permanent family practice result.

If the United States only had permanent primary care as the source of primary care, it would know exactly how many graduates were needed each year to supply sufficient primary care. Meeting Primary Care Needs in the Latter Half of the 21st Century 

Even with a permanent source, insufficient primary care support will result in a permanent source converted to flexible. Workforce cannot remain where it is not supported. Family medicine has had greater primary care retention in the past. It is possible that this final permanent primary care source could be defeated to flexible and non-primary care. This is quite easy to accomplish as all that is required is for the current design to continue to keep revenue paid below the rapidly increasing cost of delivering primary care.

United States Policy Prevents Permanent Choice as Graduates Prefer Flexible Primary Care Training Sources To Keep Their Options Open or Outright Choose Non-Primary Care

It is not possible to recovery primary care with flexible sources. The US primary care training design is 90% flexible and only 10% permanent. Also the flexible training outcomes have steadily decreased in primary care result per graduate. Ever more graduates are required and even with expansions, the primary care deficit is not erased. A permanent primary care source has different outcomes by design.

The current US design facilitates Three Dimensions of Non-Primary Care Growth with Zero Growth in Primary Care

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

Accelerating Cycles of Primary Care Decline

Disruptive innovation was created as an attractive term, but innovation that is disruptive fits primary care best at the present time in the United States. Innovation is actually distracting and distorting primary care away from solutions. The last three innovative primary care training forms (NP, PA, MPD) are 60 – 75% not primary care in contributions over a career. This is a contrast with 60 – 75% primary care at their beginnings decades ago. Such rapid declines are not the result of a single cause and effect. Multiple factors accelerate the cycles of primary care decline.

Some of these changes actually accelerate primary care decline on their own. Others work to decrease primary care workforce capacity and cascade to result in another downward cycle.

This is an outline page indicating the first few factors involved in primary care decline by design.

The United States Design includes

• Ever Higher Costs of Primary Care Delivery - force cuts in personnel, less support, less volume, repeat cycle of decline - a 12% annual cost increase for 6 years doubles the cost of delivering primary care. Coupled with a freeze in primary care fees or a minimal increase, the cost of delivering primary care will continue to kill off primary care delivery and workforce.
• More Primary Care Cost Types - More types of personnel or equipment often not specific to primary care delivery, less budget remaining for primary care specific personnel, cuts, declines in primary care fees and delivery, repeat cycle of decline
• Flexible Primary Care Training + US Policy + Voluntary Choice - This is a policy driven equation for the United States that by its very nature has resulted in ever less primary care per graduate arising from primary care graduates. Tracking class years over time the US primary care per graduate level has declined to one-third the 1980 graduate level or from 18 SPCYrs down to 7 for recent graduates.    Graphic Listed
• Dysfunctional Primary Care Training – drives residents and medical students away from primary care (Keirns, Academic Medicine) - situations played out right in front of medical students are not a good idea for primary care career selection or retention
• Hamstrung Primary Care Workforce – Top priorities of insurance and government have been cost cutting for 30 years with worsening in the past 15 and worsening in most recent years. The primary care nurse is a primary example of a primary care professional that cannot participate as actively in direct patient care delivery due to the design. The design forces nurses to contact insurance companies just to get needed prescriptions, referrals, hospitalizations, goods, and services. Also they must collect information needed for care from our fragmented system. New jobs and duties such as risk management also are about cost cutting, not care delivery. What helps fail primary care is primary care professionals that are forced to do other activities other than delivering primary care - by the US designs that have been cost cutting in nature for 30 years. SMART designs are specific to enhance primary care delivery - not defeat it before it can arise.
• Training of Primary Care Is Not Primary Care Specific – Training has never been SMART or primary care specific for RN, MD, DO, NP, and PA. For 100 years the focus has moved ever more hospital and academic and subspecialty. The models that are different and are primary care specific are few and small in number, in numbers of graduates, and in national impact. The training in any training program will be shaped by the outcomes of the graduates. With fewer entering primary care and even fewer remaining in primary care, the training changes to fit graduate needs. If this is not so, the program dies for lack of graduates as graduates are interested in preparing for the jobs that exist and that allow them to do well. When programs send a minority in primary care and those attracted desire non-primary care careers, the program composition will change to fit non-primary care. Only a permanent primary care source can withstand this. Of course this is why family medicine has been a lower priority choice - due to its permanent primary care outcomes.

This is just a beginning of cycles of decline. Anyone trying to tell you that the US has more primary care or that primary care is doing well

- is selling something.

Cost of Training per Unit of Primary Care Delivery

Policy Protected Primary Care is Permanent - Family Medicine

Why Do Primary Care Myths and Misinformations Persist?

Fifty Years of Failed Primary Care Workforce Innovation

To Follow the Money, Follow the Workforce 

Failing Primary Care Explained By Policy Failure 

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

Does Primary Care Experience Matter?

Few studies critique primary care workforce sources - especially the popular sources promoted as primary care solutions. The public receives information via the media that is even more distorted and promotional in nature.

One area to consider is experience in primary care delivery. Readers are cautioned that experience in primary care may not translate to quality for any number of reasons, but experience may be important to certain populations, workforce designers, and those in need of the most complex primary care delivery. Those most experienced in primary care contribute substantially to primary care continuity teams. It is difficult to see how continuity is aided by primary care sources with the least experience in primary care and with the least retention within specific primary care practices. 

Consistency in Primary Care Experience

Patients visiting family physicians are likely to visit sources with the most primary care experience. Family medicine is a mature stable workforce with about 3% of the family medicine workforce arising from each class year for the past 33 years. Least increase in annual graduates and maximal retention within primary care is a combination that results in most primary care experience. 

Rapid Expansion Leads to Less Experience

Primary care sources that have expanded rapidly (NP, PA) contribute to a workforce that is less experienced in primary care. A doubling of annual graduates each 6 – 12 years since 1980 results in substantially more non-physician clinicians who are new to primary care and to all other specialties as well. 

Years of Experience 

Years of Experience	Nurse Practitioner 2003 AANP	Nurse Practitioner 2007 AANP	Family Physician 2007 and Beyond
0 - 5 years	61%	45%	18%
6 - 10 years	23%	29%	15%
11 - 15 years	6%	15%	15%
16 - 20 years	3%	4%	15%
21 - 25 years	4%	3%	15%
26+ years	2%	4%	22%

The nurse practitioner data represents generic years of direct care clinician experience. The family physician proportions are 90% specific to primary care experience. Slowing of expansion has led to slightly more experience in recent NP workforce, but experience remains far less than the steady state year to year contribution of FM. Also nurse practitioners will rarely reach 26 or more years as entry into primary care averaging age 40 will result in 25 years of experience by age 65. Departures in the years after graduation will result in only the most dedicated with substantial years of primary care experience.

Departure from Primary Care in the Years After Graduation Leads to Less Experience

Certain primary care sources depart primary care steadily in the years after graduation (NP, PA, IM). Those who begin in primary care often depart primary care. Even physician assistants in primary care departed primary care from 1990 to 2000 under improving primary care policy conditions (Larson and Hart). Primary care retention woes lead to delivery by those least experienced as those more experienced depart primary care.

Lower Volume and Less Primary Care Experience

Primary care sources with lower volume (NP, PA) are likely to have less primary care experience. Fewer encounters, encounters less complex, and encounters with lesser responsibility can all contribute to lesser primary care experience.

Less Primary Care Specific Focus in a Source of Workforce

Sources of training that contribute a minority of graduates into primary care workforce can have training that is also distorted away from primary care. Graduate outcomes are powerful influences upon training. Internal medicine is over 75% not primary care in result. The consequences include dysfunctional primary care training that may drive medical students and residents away from primary care choices (Keirns, Academic Medicine).
Nurse practitioner and physician assistant graduates are found over 65% outside of primary care delivery as direct care clinicians. This could fall to 75% outside of primary care if expansions slow down and non-physician clinician workforce gets a chance to age. Steady departures over time have a number of consequences that few are willing to discuss.

It is tough for training programs or health professional associations to remain focused upon a minority of graduates, alumni, or members.

Payment Designs that Impair Continuity

AAPA studies indicate physician assistants departing for another primary care practice for a 4% increase in pay and departing primary care for a 10% pay increase. Payment designs that favor certain practices and non-primary care career choices distort flexible primary care workforce sources the most. Low pay for primary care tends to drive all primary care sources toward lower continuity and away from the practices with already least primary care workforce.

Does Less Experience Translate to Lower Quality?

Less experience in a workforce does not necessarily mean differences in quality. Research studies will 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 patient environment and are less about the provider. Practices that include experienced primary care team members can benefit from the experience in ways helpful to those delivering care who are less experienced.

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. 


Any design that hopes to result in more experience to deal with the increasing complexity of primary care and any design that hopes to result in more continuity…

Must result in greater support of the primary care personnel such that they can remain in primary care and in their current sites – by design.

Steady and consistent is not exciting, but it is Specific, Measurable, Achievable, Realistic, and Timely.

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.