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

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. The Standard Primary Care Year is multiplied by the proportion of the primary care component found in rural areas.

Declines in Rural Primary Care Delivery per Primary Care Graduate

Family Medicine has declined also, but other sources have had greater decreases due to substantial departures from primary care.

Estimated Rural Primary Care Year per Graduate Changes By Class Year 

	PA	NP	FM	IM	PD	MPD	Average
1965	3.07	1.77	7.08	2.27	2.72	4.84	3.14
1980	3.18	1.77	6.92	1.86	2.36	3.90	3.22
1995	2.55	1.63	5.86	1.38	1.70	2.88	2.52
2010	1.21	1.03	5.12	0.39	0.90	1.63	1.31
2025	0.94	0.82	4.49	0.28	0.68	1.22	1.03
2040	0.86	0.75	4.28	0.25	0.51	1.05	0.92

Even though the nation has continued to generically increase annual primary care graduates, this costly intervention is not capable of addressing rural primary care needs. The reason is steadily lower rural primary care delivered per graduate.

SMART requires specific emphasis upon primary care and rural primary care for dependable health access contributions. Not SMART is costly generic expansions of annual graduates that depart primary care and rural locations steadily over time.

Family medicine contributes by far the most health access per graduate, but has also declined in primary care and in rural primary care. Family medicine has long set the standard for least departure from the career of training. Family medicine still represents a standard. All primary care sources have moved to shorter careers and less activity. Declines in other sources represent compounded losses due to departures from primary care. 

The family physicians of the 1970 - 1980 era also had 30% rural rates as for this one time in history the United States increased spending upon rural areas and underserved areas and primary care - the three health spending areas most impacting rural primary care. Family medicine as the broadest generalist primary care source of the time was ideal for the new opportunities created by the new design. This was also the last major design change, the last expansion of family medicine, and the last expansion of primary care delivery capacity.  

Stagnant spending in rural, underserved, and primary care areas are the real reasons for declines in rural primary care with workforce only a reflection of designs that send health spending elsewhere.

Nurse practitioner and physician assistant primary care contributions would have remained stable - if NP and PA workforce remained family practice for entire careers. But departures from family practice during training, at graduation, and each year after graduation have simultaneously defeated primary care, rural, and underserved NP and PA contributions. Teaching hospitals alone have converted tens of thousands from primary care to hospital and subspecialty workforce.

Departures from health access are about the great versatility of NP and PA workforce. They have gained widespread acceptance in non-primary care and far beyond rural locations. Departures from basic health access result in significant gains in salary for the graduate and result in significant gains in revenue generation for the employer. Such is the design that reward non-primary care and services delivered in top concentrations of workforce.  

New physician assistant entry into family practice has been cut in half to 20% in the past 15 years (AAPA) and only 25% of total nurse practitioners contribute in family practice employment (Advance for NP and PA surveys). Physician assistants in family practice have 30% rural location rates (2 to 4 times other PA types), 30 times the rural health clinic rates compared to other PAs, and 6 times the Community Health Center location rates (AAPA). 

Family medicine residency graduates continue to remain steady in primary care delivery per graduate as well as the proportion found in rural locations - SMART factors that result in SMART contributions. Rural primary care remains most consistent in family medicine.

NP and PA primary care and rural primary care contributions nationwide for the United States  still continue to increase slowly. This is due to a massive expansion of non-physician clinicians 1980 to 2010 with a doubling of annual graduates each 6 to 12 years. Even without further expansion, the NP and PA workforce will continue to grow for 25 more years as the design level of annual graduates fills out to become more workforce.

Sadly this workforce will not have the same primary care emphasis. Decreasing retention in family practice over this time period has resulted in 3 times more PA graduates required for the same PA rural primary care delivery and twice the NP graduates required for the same rural primary care delivery compared to 1980. Longer training and lower yield of primary care and rural primary care translate to much greater costs of training for the same or lower yield of health access workforce.

Sources other than family medicine require 4 to 10 graduates to contribute the same rural primary care over a career as a single family medicine residency graduate.

Rural health care delivery by non-primary care sources may also be more difficult as non-primary care physicians and non-physician clinicians are moving to more subspecialized types least likely to distribute to rural locations in need of workforce. Rural practice location rates have been higher in the general surgeons, general obstetric-gynecologists, general orthopedists, and general IM specialists - careers less preferred by emerging graduates.

Major journal articles, health professional association reports, and government actions have indicated serious errors with regard to awareness of primary care and rural health care. Inappropriate comparisons, overestimates of future primary care, failure to emphasis specific solutions such as family practice, and continued payment design flaws plague rural health access. Recent government errors include bonus payment designs for physicians in shortage areas that did initially failed to work for broad scope generalists common to rural locations and bonus payments that required the use of a form not used by rural health clinics. Government spending upon primary care training is least specific for rural primary care as only 30% of funded graduates will actually be found in primary care and even lower proportions will be in the family practice component most essential for rural primary care. Epidemic poor awareness is the culmination of 30 years of progressive failure.

Most of all, leaders exhibit poor understanding regarding design failures for primary care for those most dependent upon primary care. Primary care is 40 - 100% of local workforce for rural areas in need of primary care and family practice is 40 - 100% of that local primary care. As other specialties decline in concentration with decreasing concentrations of people, income, and health care coverage, family practice MD, DO, NP, and PA remain.

Generic and innovative does not work. Specific and achievable does work.

Spending upon rural primary care must be addressed for any increase in rural primary care workforce or rural primary care delivery. Changes 1970 to 2010 indicate the reasons. As family medicine filled out from 40,000 to 100,000 over a 40 year period, this permanent primary care source actually displaced more flexible sources from primary care and from rural primary care. Increases in NP and PA family practice also contributed to displace IM, PD, MPD, and non-family practice PA and NP. Generic expansions fail for primary care or for rural primary care, especially during a time of stagnant support for rural primary care delivery and increasing costs of delivering primary care.

Recovery of primary care requires SMART - Specific, Measurable, Achievable, Realistic, Timely  

States are already spending millions more each year for locums, recruitment, and retention costs without increasing primary care delivery. This is not SMART.

Pounding Poverty Providers with Pay for Performance from 12/2011 indicating more ways to send funding elsewhere.

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