Number One Two Three in Health Access

Solutions for health access primary care workforce

• Enter primary care practices at highest proportions after training
• Stay in primary care practice at highest proportions in the years after graduation
• Have the longest health professional career lengths
• Remain active in practice during a career at the highest percentages
• Deliver the highest volume of primary care when active in primary care delivery.
• Are most likely to be found in 30,000 zip codes with 200 million Americans and only 25% of total workforce (Practice Locations Outside of Concentrations) and
• Are least likely to be found in 1000 zip codes with only 11% of the population and 50% of the workforce (Super Center Concentrations).

Only family medicine residency graduates meet all of these criteria for graduates past, present, and future. Only family medicine residents have not been increased beyond the 3000 annual graduates first reached in 1980. The US primary care design has also not changed for primary care numbers since 1980 while the non-primary care design has doubled each 15 years since 1965.

Only a broadest generalist primary care source can best meet the needs of over 65% of elderly, poor, near poor, rural, underserved, lower income, middle income, disadvantaged, children in need of health care workforce, and shortage area populations.

Number 1 is United States Origin Family Medicine from a US Medical School	25 Standard Primary Care Years	Estimated Range of 23 – 30 Standard Primary Care Years depending upon age at workforce entry, gender, retention in primary care
Number 2 is United States Origin Family Medicine from a non-US Medical School	22 - 25 Standard Primary Care Years	A slight delay in entry to practice is likely to result in the potential for lesser workforce, but there may be no difference
Number 3 is non-US Origin Family Medicine from a non-US Medical School	20 – 22 Standard Primary Care Years (but broad range)	Medical education in other nations commonly results in younger age but those working toward US training and practice face delays that result in older age entry to US workforce

Standard Primary Care Years Estimates for 2012 

First career and practice location choices are simply insufficient to assess primary care sources. The Standard Primary Care Year is an important estimate of future primary care delivery assigned to the class year of graduation. 

Pediatric and Medicine Pediatrics	10 – 14 SPCYrs	Less than half and likely less than 40% will remain in primary care.
Physician Assistant Beginning Family Practice	12 SPCYrs	Steady departures over the years after graduation limit outcomes.
Nurse Practitioners Trained as Family Nurse Practitioners	6 – 8 SPCYrs	Half will be active as direct care clinicians in family practice employ. Fewest years and lowest volume result in substantially fewer SPCYrs.
Internal Medicine	3 – 5 SPCYrs	Few enter primary care and departures continue after graduation.
Physician Assistant not Starting in Family Practice	1 - 3 SPCYrs	Family practice is the predominant PA primary care vehicle
Nurse Practitioners not FNP trained	1 – 2 SPCYrs	Family nurse practitioners are the predominant NP primary care vehicle

Nurse practitioner and physician assistant contributions to rural or underserved locations in need of workforce are multiple times greater when employed in family practice as compared to NP and PA not family practice employed. NP and PA graduates not employed in family practice remain below average in needed practice locations. About 25% of NP and PA workforce are found active as family practice clinicians although declines could result in fewer.

Comments by any number of “workforce experts” about family medicine from any US origin or non-citizen source should be supportive about expansion, about selection specific to family practice, and about training specific to family practice. This entire blog was posted because non-citizen family medicine has received comments and even testimony to Congress that has not been flattering. What matters is health access delivery where needed. Even if only 7% of non-citizens average family medicine choice, this choice is an important one for 200 million Americans left behind and about to have even more difficulty.

Generic expansions of health professional training not specific to permanent family practice (MD, DO, NP, and PA) should be understood as solutions for non-primary care and practice locations that already have top concentrations. Flexible designs fail for primary care and for 200 million Americans. Flexible designs are represented by NP, PA, and IM training that can result in any number of non-primary care careers. For nurse practitioner or physician assistant training to be SMART Basic Health Access Solutions, they would have to find a way to permanent family practice by a permanent design change. Generic and flexible is failed health access.

Specific family practice is the SMART solution for health access for 200 million Americans left behind and falling further behind by design.

Physician Distribution By Concentration Zip Code Practice Locations Inside and Outside of Concentrations

More about the Standard Primary Care Year

Three Dimensions of Non-Primary Care Expansion and Zero Growth in Primary Care Design

Thanks to all 12,000 

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 a

Rural Rearrangements of the Deck Chairs

Comprehensive Rural Programs Are Not Enough to Overcome US Maldistribution By Design

There is no evidence that Rural Programs in Medical Schools actually increase rural workforce when considering the outcomes of the parent schools. Even with expansions of annual graduates in the parent schools, there has been no improvement. There is nothing wrong with rural programming. It is possible that health access outcomes could decline without rural programming or it might be possible to demonstrate problems resulting from inadequate preparation for the demands of rural practice. The fact is that rural programming has not been able to overcome overall changes in the US health design. Rural programming has not been able to keep up with population changes that increase demand such as increases in elderly, poor, and lower income patients. Lack of health spending for rural populations is the likely reason why rural programming or generic expansions are unable to improve rural access to care. In some ways rural programming can be seen as preventing solutions for health access that require increased spending in primary care, in rural locations, and in locations underserved for workforce.

New Rounds of Publications Emerge

Comprehensive Rural Programs have been promoted as health access solutions in new publications. Unfortunately the efforts of Duluth, the Rural Physician Associates Program, the Rockford program, and the Physician Shortages Area Program have not improved the rural, primary care, or family medicine outcomes when considering the parent schools of these programs - the University of Minnesota, the University of Illinois, or Jefferson.

Defeat of Rural Programming Due to Individual School Family Medicine Collapse or Decline

Declines in family medicine for Mercer from 32% to 3% will take Mercer from a top ranking proportion of graduates found in rural, found in underserved, and found in rural underserved areas to less than the national average.

The WWAMI program has long been promoted as a solution for states in need of workforce, even as states such as Alaska spend 1 million more dollars a year on primary care recruitment, retention, and locums costs alone. WWAMI has the same problem as all rural models - it leaks. The graduates have not been required to stay instate or in needed careers. The graduates are not admitted with a commitment instate or to family medicine or to rural practice or to underserved practice. The major WWAMI (Washington, Wyoming, Alaska, Montana, Idaho) state needs remain the same - family physicians. With inadequate family physicians, locations in need of workforce are forced to pay more and more to get the same or less workforce.

Marginal and underserved rural proportions have certainly not improved for the University of Washington in the AMA Masterfile. There was an 11% proportion prior to WAMI and down to the 8 - 9% level for 1994 - 2000 graduates. The 20 - 30% family medicine level is now down to one-third this level. The rural contribution of the University of Washington have not improved at best and there are indications of steady declines. 

The main reason for success and failure appears to be the same reason. During 1965 to 1980 the United States poured billions into health care and much of this went to marginal and underserved locations with high proportions of Medicare and Medicaid patients. The 1980s cost cutting designs with increasing costs of delivering care and less revenue resulted in declines. Then the 1990s again injected funding specific to rural locations and primary care where needed for a few years before returning to cost cutting and major declines across all graduating classes of MD, DO, NP, and PA.

The University of Washington and the University of North Carolina have also been used as examples of medical schools that can accomplish dual roles of research and health access. Together all of the parent schools with rural programming actually barely keep above the US average regarding needed rural outcomes.

• Medical schools that do much better for rural outcomes are medical schools in rural locations.
• Osteopathic public medical schools have also been outstanding sources of rural physicians, instate physicians, and family medicine.
• Medical schools in the South also contribute more rural physicians, but this has to do with higher levels of rural population
• Medical schools in the Midwest also contribute more rural physicians for the same reasons - a state with a higher proportion of rural workforce.

What is most evident is little change at all - before or after rural programming.

Thirty Years of Health Access Workforce Prevention

The creation of osteopathic public medical schools was only 1970 to 1980 and further osteopathic public schools have been prevented for 30 years. At the heart of the successes of all the medical schools associated with rural workforce is family medicine, also prevented from expansion for 30 years by the US design. This remaining permanent primary care choice is difficult when primary care is marginalized, when the practice locations most common to family physicians receive the least health spending, and when many of the locations preferred by medical students are locations that have lowest percentages of workforce in family medicine. Family physicians can be tracked as steadily moving away

The University of Nebraska is another example of declines in instate, primary care, and rural workforce due to changes in family medicine and admission. The University of Nebraska has established a number of different rural programs involving 8^th grade to retention in rural practice. Unfortunately a decline to 2 - 3% family medicine choice for the great majority entering from major metro origins defeats the overall rural programming (last 4 matches at UNMC). The proportion entering from out of state and instate metro areas continues to increase (40% to 50% to 60%) and this proportion has 4 to 5 times lower choice of family medicine than in recent decades. It is difficult to fill graduate programs that do address Nebraska’s health access needs without family medicine choice. As more UNMC graduates depart the state for training and for practice, UNMC will no longer be able to keep up its contribution of half of Nebraska workforce - particularly as seniors double from 2010 to 2030.

Chen in Academic Medicine suggested that rural training tracks triple rural location in the graduates of a family medicine residency. Actually this is not specific to rural programming. simple choice of family medicine is enough to triple rural location, even when controlling for physician origins, type of medical school, and state practice location type.

Rural programs and tracks are small. Rural efforts are dependent upon sources of students that are declining (lower and middle income origin, lower and middle population density origin, children not of professional parents, rural interested, family medicine interested, first generation to college). Graduate medical education rural efforts can only exist when programs fill their residency positions (more difficult, not the best fit types chosen). Also the higher proportions of health access workforce in existing rural programs is easily overcome by the much lower and declining health access outcomes of much larger non-rural or traditional components.

The existence of such rural programming within a state or school appears to rearrange who chooses such programming without actually increasing desired outcomes. The outcomes are worse when considering entire careers of contribution due to lack of instate retention, declining primary care retention in the years after graduation from primary care training programs, and declining retention in rural locations.

Only complete school designs have made top contributions to rural workforce including rural located medical schools and osteopathic public schools. Only the family medicine proportion can be consistently demonstrated to have top health access contributions. Except in a few states (states that tend to have top workforce concentrations that drive FM out), family medicine is also associated with top instate retention. This is noted in University of Kansas graduates choosing family medicine that have 16 times greater instate rural location compared to U of KS grads not choosing family medicine. Family medicine has been the result of admission of students with factors contributing to instate most needed health access and family medicine contributes to instate most needed health access.

Graham Center Policy One-Pager    Comprehensive Medical School Rural Programs Produce Rural Family Physicians    While the title is true, the parent institutions do not have overall rural workforce gains. Also the parent institutions have barely above average rural contributions.

Which Medical Schools Produce Rural Physicians - a 15 year update

This is Blog Number 50 for Basic Health Access Blog begun in 2011.

Rural Medical Education Specific Blogs and Links

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.

Atlas of Basic Health Access at the World of Rural Medical Education

Barriers To Primary Care Innovation Regarding Training: Too Many Stages in the Path Too many steps, Too many separations, Too many leaks in the pipeline, Too little yield across the segments, Too many accreditations, Too many funding sources, Too many (non-health access interested parties) determining training curricula, and very few focused on basic health access

Pounding Poverty Providers with Pay for Performance Designs that send even less dollars to those who care for most Americans are the reason for health access problems. Pay for Performance designs make matters worse resulting for gains in revenue for those that care for patients who naturally have better outcomes and no gain for those who care for the more complex patients. 

Speak Your Piece: Measuring Rural Health Care  Rural health care providers are paid less to provide treatment to a population that is more likely to be poor than those in the cities. Now medical researchers are saying rural hospitals don't provide the same quality of care as those city institutions that have more money and richer patients. Well......Which is it, JAMA? Where is your consistency in articles regarding quality of care? If you choose some authors that consider social determinants and other important limitations but ignore these factors in other publications, this causes confusion. 

Rural Primary Care: Stark Realities All primary care sources have declined in primary care per graduate and in rural primary care delivery per graduate. The rural Standard Primary Care Year contributions over the class years illustrate the declines in rural primary care delivery.

Non-Specific Rural Pipelines or Specific Long Term Obligations  Voluntary choice allows potential rural physicians to steadily leak away with each year of training and practice. Only very specific shaping is most likely to result in early, middle, and late career rural contributions. 

Preparing for Health Care Cuts This is not good news for rural workforce. No administration in the past 30 years has really understood the problems that result in insufficient rural workforce and matters may be even worse in 2012 and beyond.

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

Why Do Primary Care Myths and Misinformations Persist?

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

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

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. 

Fifty Years of Failed Primary Care Workforce Innovation

For fifty years nurse practitioners and physician assistants have been promoted as primary care solutions, but the primary care result has been negated by a movement from 65% primary care to over 65% non-primary care.

The promises of the past have not been realized in the primary care of today. Declines across fifteen class years of recent graduates indicate even less primary care delivery per graduate in the future.

NP and PA graduates were few prior to 1980. Since 1980 the NP and PA annual graduates have doubled in number each 6 to 12 years. After 50 years of development, after 50 years of promises and after 30 years of massive expansion, where is the health access workforce?

Such writing is never fun. This is not the way to win friends and influence people. Sadly the United States has demonstrated an impressive ability to continue to promote solutions that do not work, innovations that fail, and reorganizations that delay primary care recovery. Perhaps by pointing out innovations that have failed, more will begin to objectively review recent innovations and reorganizations - and the US policy reasons why they all fail. 

Why do health professional associations, nursing workforce leaders, physician associations, government reports (all the way to the highest levels such as the Institutes of Medicine), entire issues of journals, and various foundations persist in the myth?

Why continue to promote NP and PA graduates as primary care solutions?

Any flexible workforce that can go either direction cannot be called a primary care solution. Too little primary care spending and much more health spending for non-primary care assures the final non-primary care result.

It is time to call the midlevel effort in the United States a failure for basic health access result - a most commonly stated reason for the creation of NP and PA.

This is no disrespect to dedicated NP and PA graduates that remain in primary care. The US result is entirely the fault of US health policy. Versatile NP and PA graduates have found great favor in non-primary care workforce.

How much smaller does the result need to be after decades of diminishing return on investment? The United States can expect less than 25% of the recent NP and PA graduating classes to serve in primary care during their careers with even lower proportions serving in primary care where needed.

The US designs insure NP and PA primary care to be the least experienced in primary care delivery. Departures from primary care during training, at graduation, and each year after graduation assure least experience and least years in primary care from NP and PA graduates. Lowest activity levels, one or more year breaks away from any health care delivery, lowest volume, and increased pay for movements to different primary care practices assure least experience and least continuity.

Why is this evidence ignored decade after decade?

This is not about the quality of care, which is more about the patient than the provider for well over half of American patients. This is about experienced primary care RN, NP, PA, MD, and DO workforce as well as health care team members. When those in primary care benefit from departing continuity practices (4% salary gain) and benefit even more (10%) by departing primary care, lower primary care experience is the result.

Because of US policies, it is simply not possible to extract much primary care out of midlevel graduates or any flexible workforce source that can go both ways – to primary care or to non-primary care. Even during the 1990s, physician assistants were tracked by Larsen and Hart as departing steadily over a 10 year period during arguably the most favorable primary care policy in the past 30 years.

The evidence is clear. NP and PA workforce in the United States has followed US policy designs from basic health access beginnings to become non-primary care workforce most commonly found in zip codes with the top concentrations of physicians in the United States. The pathways for NP, PA, MD, and DO workforce indicate steady departures from basic health access for the past 50 class years of graduates and across the years after graduation from training.

The departures include fewer and fewer entering and remaining in primary care as well as fewer and fewer entering and remaining in family practice – the source most important for 200 million people and the source most commonly found where health spending is lowest by United States designs.

Generic Expansions Are Not Smart 

SMART Primary Care : Family Practice Contributions...

Still the Health Access Solution for Most American... 

To Follow the Money, Follow the Workforce 

Failing Primary Care Explained By Policy Failure 

Cost of Training per Unit of Primary Care Delivery

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

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

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