Primary Care Years: New Measures of Total Workforce Contribution

Robert C. Bowman, M.D.

Family medicine retains a consistent contribution over the decades, resulting in multiplier effects when compared to other types of primary care. For primary care contributions alone, the nation would need to graduate at least 2.15 NPs, 2.36 PAs, 4.51 IM physicians, or 3.42 MPD physicians to obtain the same primary care workforce effect as 1 family physician. The numbers needed for the rural and underserved contributions of family medicine would be the same in some cases but is usually much higher.

Dividing the total contribution by 60,000 graduates over 30 years yields 0.88 FTE of primary care per FM graduate, 0.41 FTE per NP, 0.374 per PA, 0.195 per IM grad, and 0.257 per MPD grad. Overall each primary care graduate for all types will only result in 0.424 FTE of primary care. 

Short on Primary Care Workforce Years with IMG calculations and updated figures

The nation retained a far greater level of primary care workforce for the 1960 graduates. Over the course of this AMA Longitudinal study, 57% remained in primary care. When setting up a survival curve from 58,000 at year 1 to 33000 or 57% remaining at 30 years, this translates to 0.71 FTE of primary care per graduate. No existing primary care type exceeds this other than family medicine at 0.88. The nation has attempted many solutions but only one effort has been effective, efficient, and consistent.

The nation has regularly turned to years of life and adjusted years of life to help measure the impact of various health care interventions. It should do much the same for measures of primary care workforce.

Primary care has regularly considered rural or underserved recruitment and retention, but primary care itself has had few. The American Medical Association Longitudinal study that detailed the activities of the 1960 class noted that 57% of primary care graduates remained in primary care with steady deteriorations were steady over time.

Do we do better or worse than this group that ended up with 57% in primary care. The 57% is and end point. Given a normal deterioration of primary care delivery over time with losses from career changes and other factors, these 1960 graduates practicing for 30 years delivered the equivalent of 71% compared to 30 years of primary care graduates staying in primary care a theoretical full time. Do we exceed this level or not, now that we have Medicare, Medicaid, family medicine, nurse practitioners, physician assistants, medicine pediatrics, and a variety of different federal and state contributions to underserved and rural support.

Surveys and databases over the last decade provide enough information to make estimates of current and future primary care workforce. The current trends are readily apparent.

Methodology

The following estimates involve a hypothetical 60,000 graduates at a single point in time. For each year after graduation for 30 years the graduates remaining in primary care were determined using current literature, changes as noted in the Masterfile by class year, and recent changes in nurse practitioner and physician assistant workforce. Family medicine remains 90% office based generalist primary care. Nurse practitioner primary care levels have decreased over time. About 21000 FTEs of primary care were generated for the 39000 surveyed or 0.54 FTE of primary care for each 1 FTE of nurse practitioner graduate. (AANP) This is not adjusted for non-responders. Also the levels continue to fall with each passing year.

Studies of the AMA Masterfile also note deteriorations of office based levels of internal medicine and of all medicine pediatrics physicians over time. Those found in internal medicine specialties can be totaled with general internal medicine levels to obtain a denominator. The office based generalist numbers provide a numerator also by class year. For measurements in 2005 the percentages remaining in office based care as well as total internal medicine residency graduates increased during the growth of Medicare and Medicaid with a peak in 1978 above 55% and then declines until the managed care/health reform era down to 44% and then increased back to 53% with steady deteriorations below 35% in recent years. The surveys of internal medicine residency graduates regarding planned careers in generalist internal medicine have been consistent with Masterfile calculations. Declines below 20% are expected. (Garibaldi, others) Given the lack of primary care policy changes and continued problems with increasing costs and no improvement in reimbursement, the declines should continue. 

Medicine pediatrics (MPD) levels are also considered, but the declines are steady and expected to worsen in the coming years. Medicine pediatrics web sites increasingly emphasize advantages regarding subspecialization. The levels of MPD graduates found with MPD as a primary specialty decline steadily over the first 15 years of practice. Significant components never practice in primary care. Others who tend to be older and from Distributional Medical Schools have sustained primary care and rural location, but overall losses of MPD dilute the impact below 20% of all who matched into MPD.

Assumptions

1. All practitioners will start with the same number of graduates, even though some take more or less than 60,000 to get the 60,000.
2. The nation will provide sufficient health policy support and distributions of health resources to middle and lower income populations to allow primary care levels to remain without collapsing and to support distribution of practitioners away from major medical centers. Five Periods of Health Policy and Physician Career Choice This is perhaps the weakest assumption. Family medicine health policy impacts are up front, facilitating choice or suppressing choice within medical school. After this impact during medical school, family medicine is the most resistant to health policy of any of the groups.
3. Continued current primary care health policy for at least 10 years, both previous major reform periods took 6 – 10 years before implementation (Medicare/Medicaid, health reform/managed care) and the last period was relatively short in duration.
4. Continued primary care losses for NPs and PAs due to health policy by years after graduation and over the next 30 years of time.
5. Losses up front for internal medicine (IM) residency graduates with less than 25% planning to remain in generalist practice. The Masterfile deteriorations in office based proportions by class year are consistent with past surveys of internal medicine residency graduates.
6. Losses over time for medicine pediatrics (MPD) with documentation of less than 20% remaining for those initially choosing MPD in the match for 1987 – 1991 graduates as of 2005 data and more declines expected during residency, in the first year after residency graduation to fellowships, and steadily over the course of the first 15 years. MPD levels of rural practice and underserved location do increase over time, a result of losses of the MPD physicians that return to major medical centers, leaving the hardy and distributional few to remain.
7. Returns to major medical center locations and deteriorations in primary care over time except for family medicine that has remained a steady 98% in family medicine, a steady 90% remaining in office based generalist practice, a steady 22 – 26% (24.4% average) in rural practice by class year and over the years, a steady 10 – 13% (average 12%) in underserved locations by class year and over the years Family Medicine Central: National Comparisons of Workforce

No adjustments were made

• for the need for supervision for NPs and PAs or for gender
• for the waste of NP and PA time as assistants instead of direct care givers
• for changes resulting from increased rates of pay overall or in certain work activities
• for the use of 36 hours as full time as noted in the NP and PA literature, instead of a much longer work week for physicians. Not including this may compensate for other duties by physicians that are done outside of primary care (ER, inpatient, facilities, administrative).
• for the greater productivity of family medicine outside of major medical centers where family medicine has a unique 50% of graduates and where office based levels are higher (85% for most urban centers, 95% in rural areas)
• for the potentially longer work careers of PAs who can enter at younger ages
• for the slightly older age of family physician graduates (1 – 2 years older than physicians)
• for the older age of nurse practitioners
• for any increased teaching contributions beyond an assumed 4% of the active workforce although sudden expansion of any group would initially require more faculty
• for losses of family medicine to emergency care as the new emergency medicine specialty has suppressed losses of all physician forms of primary care

Also the attrition and compensation rates were not considered beyond those listed. Attrition rates involve those lost during training which can be significant for NPs, PAs, and MPD. IM rates would be higher for the transitional career types, but this study only consider IM types that ended up in general or subspecialty forms of internal medicine, not match levels. Compensation levels involve those who did not “match” initially into a specialty but who enter by the back door in later years. In some medical schools, the back door does as well or better than the front door. The compensation levels of family physicians tend to compensate for losses away from office based care. All generalist physician types have 87 – 90% office based levels compared to those listing a generalist specialty. Match levels of family physicians by class year remain very consistent with levels of office based family physicians, the 90% component of family medicine. Late additions compensate completely for annual losses for academic, administrative, and hospital based careers in past studies. It is unknown if this will continue in the current environment however. Late additions were not considered in these calculations but including them would favor family medicine

Military contributions were not considered primary care and these primary care losses were included in family physician and physician assistant calculations. Military contributions are less for the other primary care types. Excluding military contributions would increase FM and PA contributions slightly through increased percentages.

Foreign born physicians were also included. If only those born in the United States were included, levels of family medicine, primary care, rural careers, and underserved locations would rise. Current and future expansions of osteopathic and Caribbean schools were also not considered as they are major sources of family physicians and primary care physicians. These schools also have greater levels of all target outcomes, along with the top distributional allopathic public schools and the Historically Black medical schools.

National averages for physicians for rural workforce are 11% and for underserved workforce are 5.4%. Family physicians have remained a steady 24.4% rural and 12% underserved. Community Health Center studies demonstrate an advantage in rural and in underserved distributions for family medicine compared to all other groups other than registered nurses. (Rosenblatt, CHC, JAMA) Nurse practitioners and physician assistants have similar underserved distributions compared to family physicians. Nurse practitioners have remained largely in urban areas, a likely result of the origins and locations of nurses, the locations of nursing schools and NP programs, and the largest employer source for nurses and nurse practitioners - major medical centers. Physician assistants did have rural distribution better than family physicians but this level declined below family medicine levels by 1998 and has declined further. (AAPA data)

Continued declines in primary care (1 – 2 percentage points), rural (0.7 – 1), and underserved distributions (0.4 – 0.6) for all physician assistants have been steady in recent years. The rural result is likely to be 12% within the next few years. This is likely to be a stable long term level as it reflects the rural workforce in all physicians, the supervisors of physician assistants. Declines in physician assistant choice of family medicine for supervision is the major reason for the declines. Before 1984 over 55% worked with FPGP physicians and this declined to 40% by 1996 to 28.5% in 2006. Even with family physician supervisors the levels may be lower since 11.5 percentage points of this 2006 group working with family physicians are involved in urgent care. Physician assistants in 2004 maintained a slight advantage in isolated rural areas compared to family physicians but family physicians had slightly greater large rural and small rural distribution.  It is unknown if there is a pattern of decline involving isolated rural locations for physician assistants as compared to other locations. 

Results

Table I is an example of the estimated changes over time in total workforce for the initial 60,000 graduates.

Table I. Summary Primary Care Contributions Over 30 Years

Family medicine retains a consistent contribution over the decades, resulting in multiplier effects when compared to other types of primary care. For primary care contributions alone, the nation would need to graduate at least 2.15 NPs, 2.36 PAs, 4.51 IM physicians, or 3.42 MPD physicians to obtain the same workforce effect as 1 family physician.

Dividing the total contribution by 60,000 graduates over 30 years yields 0.88 FTE of primary care per FM graduate, 0.41 FTE per NP, 0.374 per PA, 0.195 per IM grad, and 0.257 per MPD grad. Overall each primary care graduate for all types will only result in 0.424 FTE of primary care. 

The nation retained a far greater level for the 1960 graduates. Over the course of this AMA Longitudinal study, 57% remained in primary care. When setting up a survival curve from 58,000 at year 1 to 33000 or 57% remaining at 30 years, this translates to 0.71 FTE of primary care per graduate. No existing primary care type exceeds this other than family medicine.

The calculations were made over the entire 30 years. Representative examples of the estimates are seen below for total primary care, rural contributions, and underserved workforce. The rural and underserved percentages used in calculating the workforce are shown.

The far right columns represent the total primary care FTE by class year and the percentage contribution for family medicine, which increases over the years after graduation as the primary care, rural, and underserved contributions for the other practitioners decline.

 Discussion

No single primary care type can meet the needs of all of the various populations and locations. Primary care practitioner types should be considered complementary and not competitive; however, some realistic assessments of past, present, and future trends should be considered. Important consideration at the current time should be given to the primary care types that remain in primary care. The considerations involve cost, quality, and access.

The nation must have dependable, continuity primary care for full efficiency and effectiveness. In certain specialties it is possible to come in and see patients with less adjustment time. Primary care careers, particularly complex rural and underserved types, are not the type of patient care that can be done temporarily or intermittently.

The various health policy and other leaks in primary care, rural, and underserved workforce should be plugged rather than ramping up the production of those who will make only temporary contributions. When considering the current workforce levels, it is difficult to grasp the situation. With each passing year, lower percentages of NPs and PAs are found in target careers. What keeps the levels steady is massive expansion. NP and PA levels of primary care, rural, and underserved workforce have remained steady, but the current situation is not sustainable. Only with massive expansion that graduates 2 times as many graduates delivers the needed care. The requirement will continue to increase to 3 or 4 graduates to obtain 1 primary care of FTE if the leaks from health policy are not plugged.

Only a few of the nation’s workforce policies have appeared to be successful. Distributions specific to rural locations and underserved location have done well, Community Health Centers, National Health Service Corps, and Rural Health Clinics. The creation of family medicine was a great boost to distribution and the specific health workforce interventions were a complement to this effort. Early Medicare and Medicaid also complemented primary care and distribution although the current distributions of federal and state funds do not favor primary care and location outside of major medical centers.

The greatest disappointments for distribution of health care have involved expansions of generic physicians and the newer forms of primary care such as nurse practitioners and physician assistants. The comparisons with the 1960 AMA Longitudinal study group are telling. The 1960 primary care graduates delivered 0.71 FTE of primary care. With this as a baseline, only family medicine has represented an improvement with 0.88 per FTE. Other types of primary care, impacted by the nation’s health policies, medical center hiring practices, and market force pressures, have half of this level of contribution.

In addition family physicians supply about 120 – 200 military family physicians consistently over the first 10 class years. These are also the family physicians that are most likely to distribute (rural born, lower and middle income, underserved origin, older at graduation, osteopathic). These are all types of family physicians more likely to be married and to have children and greater levels of debt before, during, and after medical school. Family medicine contributions for primary care, rural locations, and underserved areas would increase with less military contribution, with adjustments for this loss in the calculations, or with support packages for rural and underserved areas that were level with the superior military support package. If the nation shifted family physicians away from the military, more rural and underserved peoples could be served. Again either choice is not right or wrong, but physicians choosing their most desirable options are likely to serve longer and more effectively and the nation should match up physician to location for best impact.

Another option is efforts aligned with NP, PA, and medical schools to graduate more family physicians instead of more of the temporary forms. Those forced into family medicine during the 1995 – 1997 class years remain in family medicine at 98% and deliver the same 90% primary care, 24% rural, and 12% underserved contributions as other family physicians before and after. The 1995 – 1997 class years also supplied one particular area at much higher levels. Major medical centers increased from 1200 family medicine graduates a year to 1850 a year (examined by class year as of 2005 Masterfile data) when health policy appeared to be optimal for primary care. Despite the loss of 650 a year to urban major medical centers and 200 a year to the military, family medicine increased contributions for urban underserved areas from 120 a year to 180 and from 180 a year to 240 for rural underserved locations. For sustained levels of primary care and for preserved distribution of 50% outside of major medical centers, even with the worse health policy in 40 years regarding primary care and distribution, there is a clear choice for the primary care foundation of the nation. Increased hiring of family physicians by major medical centers may well be the stimulus for increased interest in family medicine for all medical students, increased family medicine choice in US MD Grads, and major increases in physician distribution. What we see is changes in FP. What we can associate is health policy. What we should associate is decisions made by major medical centers and the attitudes and environmental effects, since they train 100% of physicians. Five Periods of Health Policy and Physician Career Choice

The limitations involving in any workforce determinations involve assumptions. Other authors are invited to submit critique, adjustments, or their own efforts. Given current health policy, the estimates may actually be conservative. If health policy does not change, these current predictions may actually be rosy compared to future realities.  

What was not included

Pediatric calculations were not included. At graduation pediatricians make a solid commitment to primary care with 70% remaining office based generalists (steady over time with few losses) and 30% doing fellowships and hospital activities. Pediatric workforce experts consider the specialty in balance with supply and demand and lament the lack of distribution. Pediatricians remain in major medical centers at 70% and do make some urban underserved contributions, but over all rural and underserved distributions remain average. Major adaptations would be needed for call coverage, specific rural training, and accreditation to allow pediatricians to increase rural contributions and the same obstacles apply to a slightly lesser degree for internal medicine. Pediatricians do make significant contributions to primary care, but in limited age and location areas. Relatively few NPs and PAs (less than 2% for PA) work with general pediatricians and the levels have been falling along with all who depend upon state and federal support.

Obstetrics-Gynecology was also not included in these primary care calculations. These physicians also make contributions to primary care through women’s health that vary from state to state and city to city. They remain 75% or above in major medical centers, limiting distribution. The levels have been steady and are not expected to change in relation to the other practitioners.

Increasing hospital, part time, shift work, hospitalist, bariatric, palliative care, chronic care, academic, administrative, major medical center, emergency room, urgent care, chain store, subspecialty, Veterans hospital, geriatric, and hospital-based women’s health duties will continue to reduce active primary care levels in all forms of primary care, with some sparing effect in pediatrics and family medicine compared to the rest. In addition, other groups outside of direct patient care and outside of health care continue to discover the value of physician assistants and nurse practitioners and to some degree all forms of primary care.

The magnitude of losses from the combined effect failing systems of health, education, public security, housing, and social services upon the primary care practitioners on the front lines is unknown, but are not likely to help the nation to the highest levels of recruitment and retention. Frustrations are also likely to increase with the “pecking order” related to health personnel at primary care clinics. The indigent and Community Health Center clinics take the least experienced personnel who move on to primary care clinics in better supported locations over time. Those acquiring skills and experience then move on to hospital, subspecialty, and other major medical center duties. This is a direct result of current local, state, and health policy support levels. For those involved in the most complex care, training new personnel and having less experienced personnel represents an additional problem.

One major concern involves a decline of support for primary care below a baseline level. Graphic at Five Periods of Health Policy and Physician Career Choice The United States has enjoyed family medicine choice in US MD Grads “above the line” or above the percentage of rural born medical students for decades. The rural born line represents a control for the distributional potential of medical students related to admissions alone. The family medicine choice level crossed above the rural born line by 1975 or within the first few years of family medicine creation. This was a period involving an extremely supportive environment created by massive growth of Medicare and Medicaid. At that time these programs were also much purer sources of primary care support, not diluted by chronic care, medications, and major medical center costs. The level of family medicine paralleled the rural born line during the Reagan years indicating adequate but not excessive health policy support and declines in family medicine choice consistent with admissions changes. The next phase involved optimal health policy for primary care and distribution involving managed care/health reform years. After 30 years “above the line,” including the massive surge for the 1994 – 1997 class years (managed care/health reform, doubling of Medicaid) the level of family medicine choice has recently fallen “below the line” of rural born medical students. Only an escape of family medicine to sources outside of allopathic US medical schools has retained 2400 family medicine graduates a year.

All of the various primary care types have models with greater levels of distribution and could use these to boost their claims. Some do a much better job of promotion than others. National workforce policies demand national data and comparisons however.

If the most distributional types of programs were compared, there would be little change. Inner city forms of family medicine have 6 times underserved distributions and rural graduate medical education programs have 4 – 8 times greater rural distribution. These levels are even beyond the levels of lower income, Black, Mexican American, and rural born medical students choosing these programs. Accelerated programs, graduates of Historically Black medical schools, graduates of Duluth and Mercer, and the most distributional osteopathic medical schools all shared top honors for desired outcomes with 40% or more found in desired rural (isolated, small rural), rural underserved, urban underserved, military, or academic locations or careers. Public medical school FPs (allopathic and osteopathic) have 30% levels. Family medicine graduates average 24% and typical allopathic medical school graduates have 12 – 18% optimal locations. Those remaining in major medical center and urban served locations are not contributing to distribution effectively and also fail to deliver the highest levels of primary care volume also. Top Workforce Outcomes Rankings

The nation has managed to make just about every choice possible involving distributions of child development, education, opportunity, medical school admissions, training, and health policy to compromise choice of primary care and distribution. Education References, Distributions, Inequities, Child Development It has distorted the most recent primary care forms after spending billions to create nurse practitioners and physician assistants. The losses in total primary care that should have been delivered are staggering. In all of the various systems in turmoil, the nation needs to find some common ground around finding those that remain, despite problem policies.

Important questions must be asked. Those who are hoping to be more than a primary care practitioners are missing the point. Primary care and health care delivery is all about having those who focus on foundational one on one direct patient care. There will never be any "more than a primary care practitioner" beyond this, and there may not be much improvement for physicians until this is the major principle for all of health care.

Eventually some of the various primary care groups may have to make a decision. With failing systems in a number of areas - Can they deliver the necessary care? Can they care for chronic pain patients without sufficient public security to reduce abuses of narcotics?  Can they address family dysfunction without sufficient social resources and mental health support?  

Primary care is a very effective health care delivery mode, but only when supported by adequate child development, adequate distributions of education and opportunity, reasonably healthy housing, and security environments for raising children. States with  Bright Futures have more family physicians and the same states have better environments for children. Should we waste family physicians and primary care on areas that clearly do not have the commitment necessary, including our wealthiest states?

Eventually leaders in primary care may be forced to decide which states and cities to support or not. Of course two things will continue to prevent this rational decision, their dedication to their patients and their previous connections from birth.

What is also disconcerting in various discussions at the state and federal level is that few have a good handle on workforce at all. Assumptions about physicians are rampant in state and federal decisions. It would be a good idea to gather some facts about differences in physicians and in primary care, especially regarding family medicine, a different specialty with different types of physicians with different origins and different distributions and clearly the strongest focus on primary care.

Robert C. Bowman, M.D.
rbowman@unmc.edu

Changes in NP and PA http://bhpr.hrsa.gov/healthworkforce/reports/nursing/changeinpractice/references.htm

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