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

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

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 and he is the author of the World of Rural Medical Education, and Physician Workforce Studies
SMART – Specific, Measurable, Achievable, Realistic, Timely


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