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

Why are 2008 HRSA Projections of Primary Care Workforce indicating substantial increases when the reality is decreases in primary care?

Primary care workforce is substantially less than annual graduate numbers depict due to departures from primary care during primary care training, at graduation, and each year after graduation.

The Health Resources and Services Administration projection of 2020 physician primary care was last posted in 2010. This document indicates increases in primary care that are impossible for internal medicine and family practice. To properly guide the nation, HRSA must not wait for new data or studies. It should remove the erroneous projections. This major document represents much good work tainted by the primary care projections.

	Family Medicine	Internal Medicine	Pediatrics
Annual Graduates since 1980	3000 and steady for zero growth for 30 yrs	About 1% annual growth to 7200	About 2% annual growth to 3200
% Primary Care Entry	85% - surveys, office based retention, COGME 91%	20 - 25% for senior resident surveys and COGME	44% for senior resident surveys and COGME
2010 Primary Care	100,000	80,000 – 90,000	45,000 – 50,000
2020 Primary Care	100,000	60,000 – 70,000	45,000 – 50,000
2030 Primary Care	100,000	40,000 – 50,000	45,000 – 55,000
Steady State 30 yr Entry	3000 per year	1400 per year	1400 - 1600 per year
HRSA 2020 Primary Care Projection Exhibit 18	143,350 family/general practice	155,330 IM Primary Care	72,730 for PD Primary Care
Past Entry into Primary Care in recent years	2500 - 3000	3000 – 3500	1200 - 1400
Annual Primary Care Entry 2010 to 2020 to reach HRSA 2020 Projections	Double from 3000 to 6000 FM Grads 2010 to 2020	Five times entry requiring all 7000 IM Grads to stay in PC	Double the current annual entry to 2600 each year 2010 to 2020

Family medicine has not changed and given 30 years of zero growth, is not likely to change. Internal medicine primary care retention has been cut in half in primary care entry in the past 15 years and 20,000 internists, typically those younger, have entered the hospitalist workforce in recent years. The decline in primary care internal medicine is a worst case scenario for the elderly doubling 2010 to 2030. Any increase in annual graduates in family medicine would have been most specific for the elderly, poor, near poor, rural, CHC, and other populations in most need of primary care.

Pediatric experts have indicated saturations of pediatric primary care in the locations where pediatricians locate primary care practices (Cull, Committee, Freed). Because PD primary care is saturated, increased pediatric annual graduates have resulted in lower proportions remaining in primary care. Expansions of PD annual graduates have demonstrate lack of an ability to increase primary care via expansion. 

Government and foundation reports indicate nurse practitioner and physician assistant contributions to be made in primary care. It is true that primary care contributions have increased, but it now takes 2 to 3 times more graduates for the same primary care, rural primary care, and underserved primary care delivery since 1980. This is because fewer remain in family practice employment – the predominant primary care, rural, and underserved delivery vehicle.

Government and foundation reports also are not specific and the media reports of these efforts are even worse. The reports imply indicate "nurse substitution for physicians" or "nursing as a solution" or "nurse practitioners as solutions." Generic solutions such as more nurses or more nurse practitioners are not specific primary care solutions. Specific solutions for primary care are only 1 in 50 nursing school graduates and only 1 in 4 nurse practitioner graduates that are specific to employment in family practice as a direct care clinician.

Retention in family practice for MD, DO, NP, and PA graduates

is the only significant primary care, rural primary care,

and underserved primary care solution.

Retention in primary care is required

for any source of primary care to result in primary care workforce.

How can viable workforce discussions proceed if major association, foundation, and government reports are in error? Getting beyond agendas to people in need of basic health access is the specific requirement for primary care to be able to address basic health access.

Projection methods for primary care fail when graduates fail to remain in primary care. Projection methods fail when assumptions intercede and displace reality. Common sense tests must be applied to be sure that projections during rosier times (such as the 1990s for primary care) do not result in inflated projections.

Studies must encompass entire careers of contributions using realistic estimates such as those based on years in a career, primary care retention, and activity levels. With only 30% of primary care graduates serving in primary care careers and wide variations in activity and years in a career, the folly of depending upon annual gradutes is quite apparent.

SMART measuring tools are required that assign future workforce to the class year of graduation. This is illustrated in the Standard Primary Care Year – a method that can Specifically Measure Achievable primary care in a Realistic and Timely way.

Meeting Primary Care Needs in the Last Half of the 21st Century

Achievable primary care is one of the weakest areas in the workforce literature. Enough annual graduate expansion of any primary care source will increase primary care, but steady declines in the proportion remaining in primary care in the years after graduation make this a less efficient and less effective process for the purpose of addressing primary care workforce.

With primary care graduates departing primary care
it is not possible to recover primary care. 

Despite projections of primary care increases by government and by major associations, the US is actually losing ground in basic health access primary care. Increases in cost of training, more graduates required for less primary care result, and increases in the costs of locums, recruitment, and retention insure failure in primary care delivery with the current voluntary and flexible design that facilitates departures from primary care.

Studies and reports that project primary care workforce place too much emphasis on annual graduate numbers. The US has created 4 new primary care sources and has doubled annual primary care graduates from 14,000 in 1980 to 28,000 in 2010 but this matters less than the decline from 18 Standard Primary Care Years per graduate to 7 SPCYrs. With less than one-third remaining in primary care, the United States must find ways not to lose primary care rather than throwing more dollars at more graduates that deliver less primary care per graduate.

More important than annual graduates is what each graduate accomplishes. This is more about years in a career, activity in US health care, volume, and primary care retention. The Standard Primary Care Year uses estimates of these four factors to generate a relative measure of primary care delivery for each source specific for each class year.

The figure of 400 million people represents a good estimate for a steady state US  population in the latter half of the 21^st Century as population growth slows. Health Resources and Services Administration recommendations of 95 primary care physicians per 100,000 can be adjusted to 110 primary care physicians per 100,000 as the result of aging changes effective for 2030 and beyond. This results in a need for 440,000 primary care physicians to reach a sufficient 110 per 100,000. Already it should be apparent that moving down in the last decade instead of up is not the path to sufficient primary care.


These levels can be converted to Standard Primary Care Year estimates by source to indicate how many annual graduates of each source will be required per class year for 30 class years to reach sufficient primary care.

Setting Primary Care Sufficiency: Total Workforce, Annual Graduates, and Primary Care per Graduate

Family medicine is most consistent in primary care retention and has reached a steady state. Family medicine can be used to convert total workforce to annual graduates to Standard Primary Care Years per graduate. This figure can be used to convert other sources to annual graduate requirements for sufficient primary care.

Family medicine at 3000 annual graduates for 30 years has resulted in 100,000 active family physicians for a workforce. The 100,000 for 310 million people is a workforce of 32.4 family physicians per 100,000.

In 30 years the US will have about 400 million people. For 400 million people at 110 primary care physicians per 100,000 this would require 440,000 family physicians.

For 440,000 family physicians rather than the current 100,000 this would require 4.4 times more annual graduates. The steady state 3000 annual graduates times 4.4 is 13,200 annual graduates for sufficient primary care defined as 110 per 100,000 for 400 million people.

These beginning annual graduate points and ending family physician primary care workforce numbers can be converted to Standard Primary Care Years. The SPCYr estimate of 24 SPCYrs for a family physician can be multiplied by 13,200 annual graduates for about 320,000 Standard Primary Care Years per class year. This is significantly above the recent annual yield of 200,000 SPCYrs per class year from six sources from 28,000 annual graduates (NP, PA, IM, FM, PD, MPD). Once again the SPCYr allows career years, activity, volume, and primary care retention to be considered such that all primary care training sources can be compared to each other and across the class years.  

One more adjustment is needed due to declines in family medicine of about 10% less per graduate in SPCYrs over decades of time. This results in about 350,000 Standard Primary Care Years annually required of 30 class years of graduates to result in steady state 110 primary care physician equivalents per 100,000 people.Note that this figure does not include a 10% - 20% fudge factor that should be included in all primary care estimates. This is because new workforce creations have consistently stolen primary care to result in substantally less tha predicted as noted with the creations of emergency medicine, geriatric, hospitalist, and urgent care workforce. Unanticipated losses also include tens of thousands converted from primary care to teaching hospital workforce due to resident work hours restrictions. Hospitalist changes also thrust more workload from hospital to primary care with primary care nurses most impacted. Increasing fragmentation and regulation by government and insurance also result in less efficient and effective primary care delivery.

The 350,000 SPCYr figure is not likely enough, but can be used to determine how many annual graduates are needed in each source to reach a level equivalent to 440,000 primary care physicians for 110 primary care physicians per 100,000. This can be used to estimate annual graduates for 80 and for 60 primary care physicians per 100,000 as well.


Annual Graduates Required to Reach Sufficient Primary Care for 2050 and Beyond

	FM	PD	NP	PA	IM
Higher SPCYr Estimate (requires least annual graduates)	12,709	25,995	66,667	63,738	51,237
Lower SPCYr Estimate (requires most annual graduates)	17,090	39,063	115,056	108,025	114,379
Using Highest or Best Case Estimate in Each Factor
Primary Care Retention	90%	44%	40%	26%	25%
Active for Career	90%	90%	70%	80%	90%
Years in Career	34	34	25	33	33
Volume Adjustment	100%	100%	75%	80%	92%
Higher SPCYr Estimate	27.54	13.46	5.25	5.49	6.83
Using Lowest in Each Factor
Primary Care Retention	80%	35%	30%	18%	15%
Active for Career	80%	80%	65%	75%	80%
Years in Career	32	32	24	32	30
Volume Adjustment	100%	100%	65%	75%	85%
Lower SPCYrEstimate	20.48	8.96	3.04	3.24	3.06
Using the Average
110 per 100,000	14,899	32,529	90,861	85,882	82,808
80 per 100,000	10,836	23,657	66,081	62,459	60,224
60 per 100,000	8,127	17,743	49,561	46,844	45,168

Incredibly high levels of annual gradutes are required to reach sufficient primary care when the sole source of primary care is not permanent.


Permanent primary care sources most active for the most years at highest volume require the fewest annual graduates to reach sufficient primary care. Flexible sources less likely to remain in primary care with fewer years, lesser activity and lower volume  require more graduates than the United States can supply or afford.

The Impossibility of Reaching Sufficient Primary Care without SMART

Currently the US only graduates about 100,000 Registered Nurses, 30,000 physicians, 9000 NPs, 7000 Internists, 6500 physician assistants, 3000 pediatricians, 3000 family physicians, and 500 medicine pediatric physicians each year.


RN workforce demand will increase substantially in the next 20 years for the same elderly and health care coverage increase reasons as primary care. Too few enter and remain as RNs already. Increasing nurse practitioners by tens of thousands of annual graduates to reach sufficient primary care would devastate RN workforce. 

The last physician assistant expansion doubling actually increased primary care numbers entering the workforce by only 30% - a level likely to be negated in future departures from primary care. Physician assistants and nurse practitioners are widely sought by a wide range of employers with new specialties created with each passing year. Win-Win-Win non-primary care benefits to the practitioner, employer, and specialist physician are innate in the US policy design and insure departures from primary care.

Low primary care yield defeats generic expansions as a primary care workforce intervention. Generic physician expansions of medical students or generic expansions of graduate medical education positions are just not specific to primary care. Even expansion limited to primary care GME positions fail as pediatric and internal medicine expansions fail to yield much primary care workforce increase. About half of family nurse practitioners deliver the predominant primary care of all nurse practitioners. Expansions without retention are mostly about non-primary care workforce result. Three dimensions insure too much non-primary care. Meanwhile primary care remains stagnant by design.

Only SMART expansion works – specific, measurable, achievable, realistic, and timely. A best approach is a primary care source that delivers more primary care than family medicine for about 12,000 annual graduates needed at a cost of 12 billion per year for sufficient primary care. This compares to the current 16 billion for 28,000 annual graduates with half enough primary care delivery capacity result (all costs of higher education and training).

Specific is the least costly because it is most specific. Primary care sources that are flexible have become 55 – 80% not primary care in yield in the United States. Sources claiming to be primary care solutions are not good solutions. Specific language is required. Advanced nurses and generic nurse practitioners are not primary care solutions.Only the nurse practitioner that remains in family practice employment (25%) is a good primary care solution. Requiring permanent family practice is the only way to reach this solution. Only the physician assistant that remains in family practice is a good solution as demonstrated by consistent primary care delivery and consistent distribution where needed but again this is only 25% of physician assistants and only 20% of new graduate PAs. Schools such as Duluth manage 50% family medicine despite the policies that drive medical students away from a permanent primary care source, but 100% entry is possible in an even better design.

What is clear is that there has been little thought and even less planning

with regard to sufficient primary care workforce.

Rapid increases in the cost of training make these even more challenging. Also primary care delivery capacity per graduate is likely to decrease with quality focus or collaborative care emphasis – models that result in lower volume per primary care graduate. Departures of primary care workforce to urgent, emergent, hospital, and subspecialty workforce will also result in fewer Standard Primary Care Years per graduate. New workforce is created each few years that steals from primary care. Historically this has included emergency medicine, geriatrics, sports medicine, and hospitalists. Resident work hours restrictions alone converted tens of thousands of NPs and PAs away from primary care.

The United States has actually avoided expanding the most permanent primary care source for over 30 years. It has chosen to expand the sources least likely to remain in primary care. These have not been SMART choices specific to primary care and indicate choices made for other reasons – including non-primary care workforce, academic interests, and teaching hospitals.

Longer training also defeats primary care workforce. Each additional year of training results in 3 - 4% less workforce yield - resulting in even more graduates required to reach sufficient workforce. Two more years required for nurse practitioner doctorates in all nurse practitioner graduates in 2015 will result in an 8 - 10% loss of NP workforce and will substantially raise the cost of training.

The consequence of increased cost of training with less workforce result
has not even been recognized

as yet another move in the opposite direction from sufficient primary care.

Family medicine and other sources remaining in family practice have demonstrated consistent distribution to the elderly, poor, near poor, CHC, rural, and underserved populations as well as 53% found in 30,000 zip codes with 65% of the US population most left behind in health access. Expansions involving IM, PD, most nurse practitioners and most physician assistants are expansions of graduate types known to fail in distribution. This is also why hybrids or combinations of primary care are a bad idea.

Better than family medicine is required for efficient and effective primary care recovery using SMART principles, but family medicine is a starting point.

HRSA Nursing Reports for 2004 and 2008 were used for NP data as well as Advance for NP and PA. AAPA data was used for PAs. HRSA 2008 Physician Projections were used for sufficient primary care. Other references came from the Standard Primary Care Year literature, Ferrer, Mold, and Rosenblatt.

Robert C. Bowman, M.D.  Basic Health Access Web   Basic Health Access Blog

SMART basic health access - Specific, Measurable, Achievable, Realistic, Timely

Summaries and Links to Fifty Basic Health Access 2011 Blogs

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