Robert C. Bowman, M.D. rbowman@unmc.edu
Outline
I. Principles
II. Optimal Primary Care Practitioner
III. Optimal Primary Care Measures
IV. Different Primary Care Practitioners
V. About the Primary Care Role in Efficient and Effective Health Care
Principles of Primary Care Access
All states depend upon a variety of different practitioners to provide primary career.
Teams are important in the delivery of primary care, especially teams involving registered nurses. Integration of primary care with mental health services and social services can also improve access to health, mental health, womens health, nutrition, and social services.
States depend upon admissions of health profession students that most closely share the origins and locations of the patients throughout the state to provide the most efficient and effective access, costs, and quality. With college and health professional admissions of the students most socially and geographically different, primary care and health access can be provided, but it will be more costly in the form of incentives, inefficiencies, and sustainability.
Reimbursement must be sufficient for primary care delivery, even in the face of rapidly increasing costs of delivering health care.
Primary care in smaller locations must not be preyed upon by suppliers, insurers, labs, and larger medical entities. Larger groups and systems currently are able to cut the best deals, leaving those delivering the most needed care most vulnerable.
Location choices are about location of training, previous life experiences, and career choice. Medical school location of training is a major shaping force for location followed by early life experiences, spouse life experiences, and career choice. Family medicine choice facilitates locations outside of major medical centers and all other choices facilitate major medical center locations with 75 or more active physicians at a zip code.
Primary care access is facilitated or inhibited in different ways for different locations. In urban served or higher income or high employment locations, market forces and health care coverage are sufficient to support primary care. In underserved locations, lower income areas, high poverty locations, and locations with poor health care coverage; government support through local, state, and federal health policy is necessary. In major medical center locations, the primary determinant of health access is whether major medical centers embrace primary care and health access or whether they prioritize other areas. Since they dominate these landscapes, primary care can be left out through a number of mechanisms. In worst case scenarios major medical centers are very good at accessing government funding, but utilize the funding in areas other than primary care and health access.
The optimal primary care practitioner
stays in health care
stays in their area of training
stays in office primary care
stays in office primary care for 30 years or more with no distractions such as consideration of leaving, building significant experience and expertise in one location or similar locations
even with less than optimal health policy variations, including the insufficient policies of the current time
The optimal primary care practitioner
stays longer in a particular location expanding the ability to care for patients more effectively and efficiently with increasing contact and directed efforts to learn about the local system, personnel, needs and resources, strengths and weaknesses of the area, and patients. Less degree of effort, lack of awareness of the dimensions involved, and fewer years of experience limit primary care cost, quality, and access.
demonstrates broad scope, including the care of women, children, adults, and older adults as well as basic mental health care, also births and procedures in areas where concentrations of physicians are not around to restrict privileges and procedures and where intense training is available or pursued by the physician
stays focused on optimal direct patient primary care volume, including a continued focus on lifelong self-training relevant to primary care (no future plans to subspecialize or change careers), fewer entries and exits and transitions, and locations with less distraction from administrative, teaching, research, inpatient, urgent care, and emergent services (as in major medical centers)
stays distributed according to the geographic and socioeconomic needs of populations, this means staying outside of higher income, most urban, highest employment, greatest health care coverage, and major medical center concentrations of resources
in creation and production, does not result in the loss of critical personnel such as registered nurses (especially nursing school faculty, nurse supervisors)
Optimal measures of primary care
retention in health care
retention in area of training
lower cost of training
training that results in contributions to primary care
retention in office primary care
higher productivity to cost ratios
high rates of utilization by Community Health Centers, rural health clinics, Critical Access hospitals, and other health policy formats
rural location, especially small, isolated, and underserved locations outside of rural major medical center locations
urban underserved locations, especially outside of major medical center situations
total FTE of primary care delivered over a career (30 years for physician, more years for PA, less years for NP)
Family Medicine Residency Graduates
30 years of workforce with 0.85 FTE in primary care and greater concentrations with decreasing income, population, facilities, physicians, and employment
Family medicine match at all time lows in US MD Grads, along with all time lows in health policy, major medical center hiring of FM, and emphasis on primary care and family medicine in medical schools. Lower income, older, and rural born resistant to health policy influences, those born in major medical center locations (near medical schools especially) are the ones that changed from 70% greater choice of family medicine in 1995 1997 class years to resume lower choice levels as in 1988 1990. Osteopathic, Caribbean, and Distant International schools make up some of the losses of US MD Grads.
98% of family physicians stay in health care
98% stay in FM, negligible losses to other specialties
90% stay in office primary care
50% stay outside of major medical centers
Highest volume
Highest productivity to cost ratio in MGMA studies, would be even higher if comparisons were made using the 50% of family physicians outside of major medical centers with the most deliveries, inpatient, ER, procedures with much higher revenue generation and much lower overhead costs
Moderate cost of training
Broadest scope
Dependable 24% in rural areas, FM choice multiplies rural location by 3 times, rural underserved by 4 9 times, higher levels for family physicians with rural training
Consistent 10% or more in underserved areas, average 12% or twice national average for physicians, up to 30% for underserved origin family physicians
More likely to have rural, lower income, middle income origins, potential for greater awareness, service orientation, empathy, clear focus on direct patient care as a career
More likely to be older, aiding in distribution, maturity, life experiences, service orientation, tolerance for ambiguity (uncertainty)
Physician and Family Physician Data from the Masterfile1-8
Nurse Practitioner Graduates AANP data
10 25 years of workforce with estimated 0.5 FTE in primary care for each graduate
70 - 90% stay in health care
Recent survey of 39,000 revealed 22,000 FTE of primary care or 0.54 FTE per graduate in primary care (AANP Goolsby)9-14, losses to inactivity, gender
30 40% outside of major medical centers
Comparable productivity to cost ratio with FM, but these are major medical center physician comparisons where primary care physicians have limited scope, less inpatient, little ER, the fewest procedures and the highest overhead costs. All of primary care outside of major medical centers delivers more primary care with less distraction, but those currently in medical centers or moving there over time will face more distractions
Lower cost of training
Fewer years of primary care services with RNs entering after 5, 10, 15, or 20 years
Losses of RN services, leadership, management in hospital and clinics, nursing faculty
Scope dependent on training and practitioner environment
Variable percentage in rural areas depending upon training, origins of NPs, unknown if NP choice multiples rural location, rural underserved, isolated location, potentially limited for those trained in major medical centers and not in family nurse practice
additional cost of training to support clinics, training models not sustainable outside of state and federal support as with all primary care training
Distribution likely based on origins
NP and PA literature involves best examples rather than national (Fowkes)15, but this is also true of all workforce literature
Tremendous value in health care due to previous nursing, public health, community health experiences and training, lower and middle income origins likely to mean empathy, dedication, service orientation, maturity
Potential for selection and training to select out those more likely to serve and assist and work in teams and less likely to be independent
Distribution likely shaped by the types of RN students admitted, their training locations, and their potential careers, all likely to involve hospital directions without specific rural and underserved efforts and supportive policy
Unknown quality for health care services outside of the extensive studies of primary care quality. Primary care has been the predominant focus of NP training, but no longer
Unknown impact of lengthening of NP and PA training for higher degree with more connection to major medical center training locations
NP trends indicate decreased primary care, movement away from nearly pure focus on primary care training, movement to hospital, urgent care, emergent care, and specialist roles, following current health policy and major medical center hiring practices. Solutions involving nurses will only be satisfied by improving salaries, benefits, hours, retention efforts, and respect for nurses as RNs. Advancing RNs through local practices as in UK makes more sense for primary care because RNs maintain contact with the patients that they serve and upgrade the skills needed to care for these patients.
Physician Assistant Graduates AAPA data16
30 35 years in health care with 0.5 FTE expected in primary care
A few percent move to other careers such as 1% to medicine
70 - 90% stay in health care
Average less than 60% of each grad in primary care (may be 30 40% in some surveys and by some experts) given part time, inactivity, and losses outside of health care
40 - 50% outside of major medical centers
Lower volume through poor utilization, paperwork, administration, need for supervision
Comparable productivity to cost ratio with FM, slightly lower but these are major medical center physician comparisons where primary care physicians have limited scope, less inpatient, little ER, the fewest procedures and the highest overhead costs
Lower cost of training
Scope dependent on training and practitioner environment, fewer working with FM, rural, primary care
17% in rural areas, at least 2 times multiplier of rural location, rural underserved, isolated location, however rural location rates decline 1 percentage point a year as do national rates of primary care and working with family physicians as supervisors
Distribution based on origins, training, and market forces shaped by health policy
Literature involves best examples rather than national (Fowkes)15
Least health care training, youngest, predominantly female
Potential to serve the longest total years as the youngest to enter
Unknown quality outside of primary care focus of training
Unknown impact of lengthening of training for higher degree with more connection to major medical center training locations
PA trends indicate decreased primary care, movement away from original training, more with a second job, movement to hospital, urgent care, emergent care, and specialist roles, following current health policy and major medical center hiring practices, who see greater efficiency for these areas when using NPs, PAs, and other assistants in conjunction with physicians, impacting the entire 200,000 pool of NPs and PAs over time
Physician Assistants and Nurse Practitioners
Major medical centers continue to see greater efficiency with use of NPs, PAs, and other assistants in conjunction with physicians, impacting the entire workforce pool of 200,000 and the 12,000 a year in new entry. Primary care, rural, and underserved levels sustained only by new graduates, levels will decline with loss of growth of programs and graduates.
Major medical centers continue to seek greater efficiency with use of NPs, PAs, and other assistants in conjunction with all types of physicians, impacting the entire workforce pool of 200,000 NPs and PAs and the 12,000 new entrants each year.
Primary care, rural, and underserved levels are sustained by the continued increases of new programs and graduates, levels will decline with loss of growth of programs and graduates. NP growth has slowed, PA growth may continue longer than currently predicted, driven in part by declining primary care levels from all types of practitioners and by the increasing uses of more and more PAs in more careers outside of primary care. However more PAs with declining rates of primary care, rural, underserved, and family medicine will not address the most critical needs
Internal Medicine Residency Graduate
30 years of workforce but less than 0.4 FTE average primary care contribution and this is declining to less than 0.25 in future years
Match levels are steady with some late entry
98% stay in health care
Less than 45% stay in internal medicine, more recent declines to less than 25% remaining in office general internal medicine. (Garibaldi)17 These surveys of residents have accurately predicted the generalists remaining in Masterfile studies by class year.
70 80% stay inside of major medical centers, procedural capabilities and scope hampered by MMC environment
Lower volume, trend toward patients with multiple problems addressed at a visit
Lower productivity to cost ratio, mainly from predominant major medical center location with highest costs of delivering care
Moderate cost
Broadest scope
Lower distribution levels unless birth origins (rural to rural, lower income to lower income) or incentives (J-1 Visa). Rural distribution at less than 10% national average. Underserved distribution at national average and slightly above for those with underserved origins. No more than 1.5 factor in rural or underserved distribution.
Very few training programs with even a minimal rural experience, mission, or focus.
Internal medicine physicians more likely to be younger, higher income, urban. Some questions regarding focus on direct patient care unless remaining in office based care. Younger graduates have less tolerance for ambiguity, less focus on direct patient care, more focus on science, technology, and likely disease orientation.
Health policy makes all internal medicine physicians make a decision for retention in location, career, and office based primary care each year (or more often).
US MD foreign born have the lowest levels of retention in office primary care and the lowest rural and underserved distributions and this group is increasing the most in admissions. Subspecialization rate is highest and admitted to the higher MCAT and most urban schools, further complicating distribution and primary care levels.
Internal medicine international medical school graduates appear to have the same limited foreign born distributions to urban areas, without J-1 Visa obligations. This stems from birth in the most urban areas of the world and highest status, most professional parent factors. Other problems include limitations in years of service in rural and underserved areas (with proposals to decrease to 2 years); lower volume; difficulties related to urban, language, and culture differences; increased cost of turnover; potential impacts on rural health system market share; retention of other personnel; and losses of local economics for physicians who commute from urban locations to rural areas for work. Also recent GAO reports indicate that some IM IMG physicians do specialist work, limiting primary care emphasis and volume. Also the report notes poor monitoring and some abuses by sites and physicians. Significant abuses by some states are feared, including one proposal to allow 30 a year to be hired by medical schools to meet serious shortages of faculty.
Pediatric Residency Graduates
30 years of workforce averaging 0.65 FTE per residency graduate
98% stay in health care
A consistent 65 70% stay in office generalist pediatrics
70% stay inside of major medical centers, potentially due to multiple sources of funding in such locations (and the highest levels of reimbursement) to make up for lower reimbursement for primary care and Medicaid, fewer pediatric NP and PA likely for the same reasons
Workforce characteristics include higher levels of females and female ratio growing, current balance between graduates and needs, limitations in distribution and in training for distribution. Very few training programs with even a minimal rural experience or a rural mission or focus.
Lower productivity to cost ratio, mainly from predominant major medical center location with highest costs of delivering care
Moderate cost of training
Limited scope
Rural percentage of pediatric workforce cut in half in recent decades. Lower rural distribution levels unless birth origins (rural to rural, lower income to lower income) or incentives (J-1 Visa). Rural distribution at less than 10% national average. Underserved distribution at national average and slightly above for those with underserved origins. No multiplier factor for rural distribution.
Underserved urban pediatrics levels are higher for those with underserved origins, foreign birth, and international born IMG pediatricians.
Generalist pediatricians appear to be committed to the generalist primary care career before medical school and losses to subspecialization are low in the years after training. Generalist pediatricians are lost back to major medical center locations after obligations.
Health policy has not impacted pediatric choice or retention in decades although more females have improved pediatric workforce levels steadily.
US MD foreign born have higher subspecialization rates.
Medicine Pediatrics
Movement away from medicine pediatrics begins after the match and continues steadily with each passing class year, increasingly toward subspecialization over time. For the 2005 Masterfile less than 20% can still be found in medicine pediatrics compared to the 150 seniors a year matching into medicine pediatrics for 1987 1990 class years of US MD Grads.
The few remaining have 40% location outside of major medical centers, 16% rural distribution, and contribute to underserved above average. However those who have started in medicine pediatrics and left are 70% and above concentrated in major medical center locations, as are all others other than family physicians.
The remaining medicine pediatric physicians tend to be older at admission and attend medical schools with the highest rates of FM choice, schools with a clear focus on primary care, distribution, and FM. Choice of pediatrics or FM would result in much greater primary care contributions in more needed areas.
About the Primary Care Role in Efficient and Effective Health Care
Many advocates hold up primary care as a primary factor in greater health care quality and improved health care costs. As long as the health care quality model is dominated by the practitioner side, this concept will remain. The sad truth is that a focus on more primary care may not address real societal needs. A different model of health care quality visualizes health care as dependent upon the decisions of patients as equal to or greater than the decisions of physicians or health care systems. In this model, patients with better nurturing, child development, early education, and personal investment in their own health and education outcomes will do better as consumers of health care. The same data supports either model at all levels.
The difference is in application. A focus on improvements related to the status of women, infants, children, and families will result in health care outcome improvements as well as improvements in other areas related to efficient societies. A focus on primary care practitioners or expansion of PA, NP, or medical training may actually distract from the top priority investments needed for children. Investments in middle school, high school, and higher education can also distract from earlier investments. Societies aware of the needs of children will balance the proper investments, such as 1 2% of GDP in age 0 6 like Nordic nations and the leading nation of Denmark. The United States invests just 0.5% of GDP in age 0 6 and uses a grant process that wastes resources on writing grants rather than a focus on actually delivering child development. Estimates of health care waste in the United States run to 5% of GDP or 25% of total health care expenditures. Only a small part of this (0.5 to 1% of GDP) converted to earliest child development may accomplish more than increasing percentages of GDP involving health.
Efficient states invest in children, early education, and balanced opportunities for all across culture, social class, and geographic origins. Efficient distributions of child development, early education (before age 8), and opportunity make distributions of economics and all professionals, health and otherwise, much easier. Efficient states are also locations where teachers, nurses, public servants, and family physicians are more efficient and effective. People that have little hope represent the most difficult types to serve. People with better child development and early education make better decisions in health care and most other important areas such as employment and behavior in society. They require less social programs and health care costs less. Health care access, cost, and quality studies fail to consider the patient dimension, where half or more of the solutions to these areas reside.
Primary care may not be directly related to better cost and quality. Primary care numbers, efficiency, and effectiveness and societal efficiency and effectiveness are related to the same societal priority on the development of the full human potential of the most children from the earliest ages. This is an area where the United States ranks last among developing nations, a primary reason why it is declining in education and health outcomes, and an answer to why things work poorly in the United States.
The health problems of areas with poor distributions are irresolvable without dealing with multiple dimensions simultaneously for decades. This is similar to the process of dealing with a critically ill patient with multi-system failure. Attention must be given to all of the systems that are failing simultaneously, with a strong coordinating hand and the helm to be sure that all are aware of their roles and on task. These irresolvable situations in more and more locations and populations in American develop because we lose awareness and we ignore multiple dimensions simultaneously for decades. They are worsened by policies that penalize middle income and lower income peoples and children. These children have been and could again become the nurses, public servants, teachers, and family physicians that structure societies and that provide access to basic services to all. Current policies drive the lower and middle income peoples away from areas of greatest need and make them most ineffective in these areas. This leaves the very rich and very poor together in close proximity. The wealthy, the most urban, and the foreign born join retirees in a block of voters and voting states that see little reason for public investments because they benefit directly in very invisible ways. However societal infrastructure decline impacts all eventually, unpredictably, and substantially.
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