Three Dimensions of Non-Primary Care vs Zero Growth in Primary Care

Promotors of generic expansion have commonly mentioned primary care workforce increase. At best primary care workforce remains a side effect of expansion. Training and spending and accreditation in primary care remain subservient to non-primary care interests and influences. Even primary care associations are compromised by members and leaders influenced primarily by non-primary care influences. The US should not expect an increase in primary care because this is what has been designed. Non-primary care is quite another result.

Primary care projections are actually quite easy to make. The best estimates are guided by recent decades. Recent decades of stagnation in primary care indicate no growth. Primary care spending is stagnant, permanent primary car such as family medicine is stagnant, and flexible primary care sources have been departing primary care. The US will remain at zero growth even with expansions as fewer remain in primary care during training, at graduation, and after graduation. Predictions of primary care as no growth should be easy due to stagnation in primary care spending and increases in the cost of delivering primary care - major determinants that insure declines in primary care delivery capacity. This is a design that sends primary care steadily away from primary care.

Addressing Disbelief and Assumption

For those still not convinced, the opposite approach may help. Why not calculate non-primary care workforce increase? Predictions of non-primary care workforce are most difficult with three dimensions of increase in 4 sources of health professional workforce.

• Generic expansions of nurse practitioner, physician assistant, osteopathic (DO), and allopathic (MD) annual graduates
• Increasing proportions of NP, PA, DO, and MD entering non-primary care (from 60% past 70%)
• Primary care graduates steadily converting to non-primary care over their careers

People and politicians and even academics like to think in short term solutions and cures. Short term solutions are not possible in workforce. Workforce designs result in an annual graduate number and it takes  30 - 35 years or the average career length to change the overall workforce design (25 years for NP with shortest careers).

For example it took over 30 years of graduates from 1980 to 2010 in family medicine to translate 3000 annual graduates into 100,000 for the current workforce. Steady increases from 30,000 to 100,000 were seen over this time. The Health Resources and Services Administration projected family practice to increase to 144,000. This is not possible as the family medicine annual graduates remain fixed at 3000. Even with a doubling of family medicine to 6000 in 2011, family medicine would fall short. Internal medicine primary care projections are similarly in error. Projection methods are exposed as problematic for primary care, particularly when primary care does not remain in primary care. Poor understanding of the basics goes all the way to the top experts.

Other sources not bound by primary care limitations have increased in annual graduates although the result is far more non-primary care than primary care. Sources such as NP and PA have doubled in annual graduates each 6 - 12 years since 1980 and have moved from 50% to over 65% not in primary care. Steady departures from NP and PA primary care continue with teaching hospital, emergency care, and subspecialty diversions leading the way. The last PA doubling (100% increase from 3000 to 6000 annual graduates) resulted in over a 200% increase in numbers entering non-primary care and just a 30% increase in primary care entry (AAPA). This small increase of about 3% a year will be negated due to departures in the years after graduation as Larson and Hart noted even during the 1990s - a much better primary care time period.

Osteopathic increases in annual graduates could have resulted in more primary care under a different national policy design, but the expansions have been countered with declining family practice choice from 65% (prior to 1970) to 35% in the 1990s to 17% for no gain in annual family practice - the predominant DO primary care vehicle. Family medicine entry remains fixed at about 500 - 600 per year. Only the fact that family medicine is the most permanent primary care source results in any stability of osteopathic primary care output - but there is no gain either.

And US population growth continues and the elderly that use 2 to 3 times more primary care are doubling by 2030 and we might have increased primary care demand from expansions of health care coverage (might).

MD declines in primary care involve all sources. There is a decrease in family medicine from 14% to 7% of US MD graduates, half as many internal medicine graduates (20 - 25%) enter primary care as compared to 1990s levels (over 50%), and pediatric graduates have decreased from 70% to 40% remaining in primary care. A 30% US MD expansion will not cover the losses for an overall decrease in primary care delivery per graduate from by far the major source.

What If We Stopped at Current Annual Graduate Levels and at Current Proportions Entering Primary Care?

Even if the US stopped all expansions and held at the current levels without further departures from primary care, this would be 6,500 annual physician assistant graduates times 33 years per graduate times 75% non-primary care for 161,000 in non-primary care and 56,000 in primary care (predominantly employed in family practice). About as many physician assistants will be inactive as will be found in primary care.

The nurse practitioner maximum would be 200,000 given about 8000 annual graduates. These have most recently been 70% found in the direct clinician component with 35% found in primary care (HRSA Nursing 2008). This results over 25 class years in 90,000 for a non-primary care workforce and 60,000 in nursing (especially nurse staff) positions, and 50,000 in primary care (predominantly family nurse practitioners remaining in family practice employment). Primary care comes in third in priority for nurse practitioner workforce.

The physician contribution will remain 100,000 for primary care from FM, about 42,000 from primary care IM and 48,000 for pediatrics. The non-primary care result is 192,000 for IM graduates and 58,000 for PD graduates. Family medicine and medicine pediatrics both contribute about 10,000 each to result in 270,000 for non-primary care with a total of 196,000 for physician primary care.

The total would result in 280,000 in primary care and 525,000 for non-primary care and 60,000 for nursing - and this is just the result from primary care graduates.

The total non-primary care is already set for 1.4 million as a workforce and will be higher with annual graduate expansions and stable or declining primary care proportions.

What resulted in increased primary care delivery in the 1990s with substantial NP and PA primary care efforts working together with MD and DO is quite different. The boost in workforce effort from working together will be found predominantly in non-primary care.

The 1990s design was 29% for primary care for the 2020s result. The 2010 design is set for 16% primary care result or less. The non-primary care workforce result is important to examine.

In 10 or 20 years, we will once again revisit the continual major blunder in US health care workforce reports - the lack of a SMART design steady for 30 - 50 years in the future instead of oscillating wildly.

The consequences of non-primary care excesses are substantial. Those that have promoted generic expansions and non-primary care excesses will have once again visited more problems upon our children and grandchildren as fantasy does not translate into reality.

The financial and economic repercussions of health care design are still poorly recognized. The US has clearly found a way to limit primary care workforce and primary care spending. Low priority assures little growth in this spending relative to increasing non-primary care demands.

Non-primary care workforce is quite another matter. Non-primary care workforce has always found a way to escape cost limitations (increased volume, more testing). Non-primary care expansions have been a major reason for continued health care cost increases and will be a major reason why 2020 will bring 20% of the GDP spent upon health care. This leaves less and less for all other areas other than health care. Even worse is increasing costs for people intensive endeavors such state government budgets, local and school district budgets, federal costs, and American employers. Greater deficits and lesser productivity are programmed in place by failure of health care design.

Only Specific, Measurable, Achievable, Realistic, and Timely designs work - with permanent primary care the specific focus along with sufficient primary care spending to deliver primary care to an entire nation rather than just half.

A best guess is that about 10 - 15 years from now (sooner if health care costs are reigned in more) there will be too much non-primary care workforce. Of course those claiming economic benefits from expansion will still be claiming these benefits as health care consumes an ever larger proportion.

By the time we figure out the consequences of too much, it will be too late to stop the momentum as there will be another 15 to 30 years of increase even if annual graduate levels no longer increase. Once again it is easy to forget that an annual graduate level takes 30 years for full realization. Increases in non-primary care (or any workforce) that are too rapid inevitably overshoot the mark 15 - 20 years later. There are other consequences to consider. If nurse practitioner annual graduates double as in each 6 to 12 years since 1980 the consequences will be dire for basic registered nursing workforce depleted of more and more experienced RNs.

Another decade of expansion of non-primary care workforce will result in many other national financial and economic concerns. The US rapidly forgot the lessons of economic decline as the result of rapidly rising health care costs. Few now remember $1200 of the cost of a car required for health care. The cost is now higher. Not surprisingly manufacturing has been substantially removed from the United States due to past, present, and future health care costs.

The lessons of the 1990s remain valid - costs reigned in for even a short time set the nation on course for one of the longest recent runs in economic progress in recent US history - even with a brief design change.

Spending more on health care is not going to contribute to economics in any area other than economic ruin. Designs that result in too much non-primary care must also be reigned in if there is to be hope for economic recovery.