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

To Follow the Money, Follow the Workforce

Dramatic headlines now highlight profiteering in hospice services.This should not be a surprise to those who track workforce. Hospice has consumed steadily more nurses in recent HRSA nursing reports. When the nation sends more spending to a service, more workforce follows because workforce is required to be able to deliver the services.

Nurses have moved steadily toward higher pay and toward the most lines of revenue with the highest revenue in each line just like physicians, physician assistants, and nurse practitioners. All also move toward higher pay for less hours as well. About 85% of nurses are forced though hospital entry positions after nursing school - by designs that send the most spending to hospitals. Witness the current nursing problems as hospitals have already ratcheted back.

With 30% more spending compared to the costs of delivering care, health services expand rapidly - as in just about any other health care business. More profits draw more investors and result in more services - including those that might not be as needed. This is the case for health services other than primary care or public health.

Primary care physicians, nurse practitioners, physician assistants, and registered nurses get paid less - unless they convert away from primary care. Conversion is easy for these flexible sources of workforce. Conversion away from primary care is not simple for family physicians. Not surprisingly 70 - 85% of NP, PA, and IM primary care sources are found outside of primary care.

Only school nurses get paid less that primary care nurses for a variety of reasons including schools having to cut all types of personnel including teachers, teaching assistants, and nurses. Education and health systems are personnel intensive and therefore health care cost intensive and with increasing health care costs, the cuts must involve those most important to the delivery of education in the United States. School district budget officers have been telling this to us for years. Why don't we listen?

Why do we allow profiteering that results in such rapid health care cost increases? This is guaranteed to defeat our businesses, our economy, our schools, our health care delivery, and government budgets at all levels.Why did we forget the lessons of the 1980s when health care drove us to our knees and reining in health care costs for a few years allowed the economy to kick off the longest recent run of economic progress in the nation's history? We thought it crazy to pay thousands more for a car due to health care costs. Now we pay thousands more for education, for health care, for government, and more.

One way to cut back on health care costs is just to say no - that is to more workforce in certain areas. The US has doubled non-primary care workforce each 15 years by design changes resulting in ever more non-primary care workforce (See Three Dimensions of Non-Primary Care Increase) A design that rewards higher pay for non-primary care results in more growth and also more workforce moving to non-primary care, even those trained in primary care that are now 70% moving to non-primary care careers.

Generic expansions must stop and the US must have specific training in primary care that is forced to remain in primary care. This is partly for restoration of primary care and mostly about stopping the incredible cost increases for non-primary care.

Cutting back on non-primary care is a very good idea as no one has found a good way to rein in non-primary care spending. Primary care is already cut back. The cut back is due to too little primary care spending that has limited the primary care personnel and the services that can be provided. Primary care is personnel intensive and has relatively few codes that have not had major improvements in reimbursement.

Non-primary care profits can be preserved by more services, by fewer personnel, by more technology, by billing code creep, and by new services not yet facing cost controls. Also people desperate for very specific non-primary care services have thousands of advocacy groups clamoring for more when we have ever less available for health spending - if we hope to have a nation at all.

Even the highest income only give 14% for taxes and we passed 14% years ago. We are at 17.5% of our Gross Domestic Product spend on health care and will not stop until we reach at least 20% according to government sources. By that time we will have doubled non-primary care once again and incredible pressures will push health spending higher.

Primary care and basic health access and public health lose out in the competition - as in the past 50 years except for 1965 - 1980. But even then when we doubled primary care, we increased non-primary care slightly higher. And since 1980 we have had stagnant primary care because we have diverted more and more resources to non-primary care - which has doubled each 15 years as we have gone along with those haphazardly shaping the design over the past 100 years.

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.