Still the Health Access Solution for Most Americans: Family Practice
Health access workforce solutions have always been and will always be the broadest scope generalists. Other workforce even with slightly greater specialization or limitation in age range or limitation in scope will remain limited in distribution. Other sources fail to remain in primary care and fail to distribute outside of locations where workforce is already saturated at top concentrations
Inside of Concentrations - About 3400 zip codes clustered together in 4% of the land area enjoy top health spending per capita, all lines of revenue, and the top reimbursement in each line. This is where 72% of workforce and 70% of all primary care except family practice is concentrated. These zip codes with top concentrations of physician workforce are dominated by hospital, academic, and subspecialty interests – the same interests that dominate health professional associations and health education associations and the panels that influence government designs for revenue and for workforce. Consistent steady force applied over 100 years can accomplish amazing design changes - and the consequences of the resultant design.
A design that favors basic health access is the opposite from a design favoring concentrations of workforce in concentrations of workforce. Basic health access design is a design that results in the most broad scope generalists and a design that preserves general types of specialists. This is a design that is most likely to result in practice location in 30,000 zip codes with the 65% of Americans that found outside of concentrations. This is also a design that favors economic recovery for most Americans.
One problem with emergent recovery designs is that those most consistently at the feeding trough are already in place. Those outside are left behind when new funding emerges. Not surprisingly Americans have been frustrated with the feeding trough and with those feeding - but especially by being left behind.
Designs that favor those inside of concentrations favor those that already have the top economic impact per person from health care. According the the AMA, office based physicians contribute about 2 million per physician. In zip codes with 200 or more physicians with 11% of the population this translates to $10,000 to $15,000 per person in local economic impact. Practice locations outside of concentrations receive $800 to $2000 in office based physician economic impact. The differential is much worse when considering non-office based contributions as the hospital, academic, and research economic impacts are even greater at 80% to 90% inside of concentrations due to higher proportions of such workforce inside of concentrations.
When you follow the workforce, you follow the health spending. This is the traditional design that concentrates health spending with health workforce concentrations instead of distributing health spending according to the population distribution.
Designs that result in recovery in primary care involving family practice and redistributions of primary care spending where primary care is most needed are designs that favor economic recovery for the people in these locations that are more likely to be lower income, middle income, poor, near poor, rural, underserved, disadvantaged, and complex in health care needs.
The existing design is not capable of addressing economic impact for most Americans. Economic impact from medical education is incredibly concentrated with 50% of 500 billion dollars a year concentrated in a few dozen zip codes in six states – states that already have top physician concentrations (AAMC data). Generic expansions of graduate medical education also fail to distribute health spending or health workforce. Ultimate concentrations of workforce follow top GME spending.
While health care and medical education and physicians are important to economic impact, the current designs fail to benefit most Americans. Those influencing the design are also unlikely to allow the designs to change as they control hundreds of billions of dollars each year in health care spending. Only a small portion need be diverted to influence Congress, government information, the media, insurance companies, health systems, and others important to the design. Those outside of concentrations have no effective lobby for two major reasons. First they are outside and second they are outside delivering the care needed by most Americans nearly all of their lives.
Family practice MD, DO, NP, and PA graduates are found distributed most consistently according to the population, but only when they remain in family practice employment. Family practice retention over a career is the critical component for basic health access. Family practice retention is 95% for family medicine residency graduates but only 20 – 30% of total NP or PA graduates are found in family practice employment. Physicians becoming family physicians can be tracked steadily departing top concentration locations across birth to medical school, medical school to residency, residency to practice, and to subsequent practices. The choices that lead to family practice lead to improved distribution.
A design that favors departures of primary care graduates from primary care and departures of non-physician clinicians from family practice is the same design that concentrates workforce and health spending inside of concentrations.
Permanent broadest scope generalists are the requirement for health access as such permanency forces distribution where needed. Flexibility in workforce allows a switch rather than a fight and stay or a move to a place better suited for primary care. The ability to switch away from family practice is not a good characteristic for the basic health needs of most Americans.
Family medicine residency graduates have long set the mark for retention within career. Non-physician clinicians that choose and remain in family practice have the same or better distribution as compared to family physicians although they have lesser productivity over a career (volume, years in career, activity in practice). Rural primary care also illustrates the differences as well as non-physician clinician declines in health access contributions per graduate.
Non-physician clinicians have been proposed as primary care solutions, but generic expansions have not been good primary care solutions for NP, PA, MD, or DO. The generic solution is not specific to primary care or to family practice. Permanent … broad scope… generalist.
The reason for rapid expansion of NP and PA workforce is great versatility. This versatility is also the reason for departures from primary care and from family practice. Non-physician clinicians are by far the most flexible workforce with a wide range of specialty and location choices. New specialties and subspecialties are being created and numbers continue to increase in each specialty. This all comes at the cost of lower retention in family practice over the years after graduation. The United States now has to graduate two to three times as many NPs and PAs to get the same primary care, rural primary care, or underserved primary care. This indicates a design steadily moving away from health access where needed and toward top concentrations.
Departures from family practice and from primary care insure location departures from rural or underserved or outside practice locations – a consequence of greater concentration inside. Fewer broadest scope generalists insures more concentration. More will distribute health access as long as health spending is directed to support those who do distribute. Ever lower concentrations in locations outside of concentrations, shrinking health spending outside of concentrations, increasing population growth outside of concentrations, and increasing demand from patient populations outside (elderly, lower and middle income) will also result in greater shortages. The United States unfortunately has indications of nearly all of the above for even less basic health access result in the future. Primary care itself has no indication of any increase in the face of rapidly increasing demand.
Permanent retention in broadest scope general practice is required for distribution to 60% of the urban population and 70% of the rural population – those in most need of primary care workforce in locations with primary care is 40% to 100% of the local workforce – and the economic impact of health care upon the community.
When local primary care is controlled by those outside of the community, this can lead to even less local economic impact. With primary care revenue insufficient for the cost of delivering primary care, it is likely that local primary care for the purpose of local health care will be less likely. Those supporting primary care from outside may have agendas not specific to local primary care or local health care.
Consistent changes in physicians, physician assistants, and nurse practitioners to subspecialized and hospital based careers force ever higher concentrations and lesser distribution. Graduates are less likely to be found in family practice, generalist careers, or general types of specialties that have demonstrated better distribution. A recent example of a design change was the conversion of tens of thousands of primary care nurse practitioners and physician assistants to become teaching hospital workforce to replace the gap resulting from resident work hours restrictions. Movements from generalists to teaching hospitals represents the maximal possible change toward concentration in a relatively short period of time. This is made even worse by studies that indicate that health care quality has not improved in teaching hospitals with the resident work hours restrictions.
Consequence without benefit is not a good design change. Movements of tens of thousands of internists from primary care to hospitalist careers also result in changes in practice location. Substantial responsibilities have been shifted from hospitals with greater resources to primary care with less to least resources. Primary care nurses are being pummeled with greater fragmentation, more responsibility, and no improvement in support. Hospitals have saved substantial costs and generate more revenue – with consequences for those outside. Primary care needs respect, much higher priority, and suffiicient funding to deliver primary care rather than constant marginalization.
All workforce except for that associated with family practice employment can be tracked moving toward concentrations and away from primary care steadily over time. Family medicine is the only permanent family practice source and is therefore the source most resistant to concentration. Already this has resulted in family medicine multiple times more likely to be found serving the elderly, poor, near poor, rural, disadvantaged, Community Health Center, and shortage area populations left behind (Ferrer, Mold, Rosenblatt, Bowman).
Lower and middle income and fixed income populations are most dependent upon family medicine with practice location a key determinant. The elderly that are most likely to be on fixed incomes are a prime example of a population that must move away from the highest concentrations of cost of living to more reasonable locations. In the process older and oldest Americans must depart concentrations of primary care, stroke centers, and heart attack centers to locations with less access to a wide range of services (Perotta). Over the next 20 years the elderly and all others left behind will be left even further behind.
The one source that could have addressed their needs, family medicine, has not been expanded in annual graduates for 30 years. After a generation with zero growth of annual graduates, family medicine has reached its design level of 100,000 for 3000 per year. Unfortunately the elderly and all others most dependent upon family medicine have now entered a 20 year period from 2010 to 2030 with most rapid growth in primary care demand.
Most Americans do not need 30 more years of more of the above designs that fail most Americans in one or more dimensions. What they need is more spending outside of concentrations, less spending inside of concentrations, more spending upon primary care, less spending in non-primary care, and more spending on the health care needed by nearly all Americans nearly all of the years of their lives in nearly all locations.
Whether you call broadest scope generalists MD, DO, NP, or PA does not matter. What you must make sure of is that whatever is produced, stays permanently as broadest scope generalists in primary care. This is the only design that works for most Americans and Americans most in need of health care. When people propose solutions, ask them the "P" words - permanent, primary care, and population-based distribution. Better yet, have them sign a binding contract to deliver more than promises by SMART designs.