Does Primary Care Experience Matter?


Few studies critique primary care workforce sources - especially the popular sources promoted as primary care solutions. The public receives information via the media that is even more distorted and promotional in nature.

One area to consider is experience in primary care delivery. Readers are cautioned that experience in primary care may not translate to quality for any number of reasons, but experience may be important to certain populations, workforce designers, and those in need of the most complex primary care delivery. Those most experienced in primary care contribute substantially to primary care continuity teams. It is difficult to see how continuity is aided by primary care sources with the least experience in primary care and with the least retention within specific primary care practices. 

Consistency in Primary Care Experience

Patients visiting family physicians are likely to visit sources with the most primary care experience. Family medicine is a mature stable workforce with about 3% of the family medicine workforce arising from each class year for the past 33 years. Least increase in annual graduates and maximal retention within primary care is a combination that results in most primary care experience. 

Rapid Expansion Leads to Less Experience

Primary care sources that have expanded rapidly (NP, PA) contribute to a workforce that is less experienced in primary care. A doubling of annual graduates each 6 – 12 years since 1980 results in substantially more non-physician clinicians who are new to primary care and to all other specialties as well. 

Years of Experience 

Years of Experience
Nurse Practitioner 2003 AANP
Nurse Practitioner 2007 AANP
Family Physician 2007 and Beyond
0 - 5 years
61%
45%
18%
6 - 10 years
23%
29%
15%
11 - 15 years
6%
15%
15%
16 - 20 years
3%
4%
15%
21 - 25 years
4%
3%
15%
26+ years
2%
4%
22%


The nurse practitioner data represents generic years of direct care clinician experience. The family physician proportions are 90% specific to primary care experience. Slowing of expansion has led to slightly more experience in recent NP workforce, but experience remains far less than the steady state year to year contribution of FM. Also nurse practitioners will rarely reach 26 or more years as entry into primary care averaging age 40 will result in 25 years of experience by age 65. Departures in the years after graduation will result in only the most dedicated with substantial years of primary care experience.

Departure from Primary Care in the Years After Graduation Leads to Less Experience

Certain primary care sources depart primary care steadily in the years after graduation (NP, PA, IM). Those who begin in primary care often depart primary care. Even physician assistants in primary care departed primary care from 1990 to 2000 under improving primary care policy conditions (Larson and Hart). Primary care retention woes lead to delivery by those least experienced as those more experienced depart primary care.

Lower Volume and Less Primary Care Experience

Primary care sources with lower volume (NP, PA) are likely to have less primary care experience. Fewer encounters, encounters less complex, and encounters with lesser responsibility can all contribute to lesser primary care experience.

Less Primary Care Specific Focus in a Source of Workforce

Sources of training that contribute a minority of graduates into primary care workforce can have training that is also distorted away from primary care. Graduate outcomes are powerful influences upon training. Internal medicine is over 75% not primary care in result. The consequences include dysfunctional primary care training that may drive medical students and residents away from primary care choices (Keirns, Academic Medicine).
Nurse practitioner and physician assistant graduates are found over 65% outside of primary care delivery as direct care clinicians. This could fall to 75% outside of primary care if expansions slow down and non-physician clinician workforce gets a chance to age. Steady departures over time have a number of consequences that few are willing to discuss.

It is tough for training programs or health professional associations to remain focused upon a minority of graduates, alumni, or members.

Payment Designs that Impair Continuity

AAPA studies indicate physician assistants departing for another primary care practice for a 4% increase in pay and departing primary care for a 10% pay increase. Payment designs that favor certain practices and non-primary care career choices distort flexible primary care workforce sources the most. Low pay for primary care tends to drive all primary care sources toward lower continuity and away from the practices with already least primary care workforce.

Does Less Experience Translate to Lower Quality?

Less experience in a workforce does not necessarily mean differences in quality. Research studies will continue to show no difference in the quality of care for different types of providers. The reason is that patient outcomes are more about the patient and patient environment and are less about the provider. Practices that include experienced primary care team members can benefit from the experience in ways helpful to those delivering care who are less experienced.

It is sad that we forget over and over that health care access, health care cost, health care status, and health care quality are mostly about the patient. 


Any design that hopes to result in more experience to deal with the increasing complexity of primary care and any design that hopes to result in more continuity…

Must result in greater support of the primary care personnel such that they can remain in primary care and in their current sites – by design.

Steady and consistent is not exciting, but it is Specific, Measurable, Achievable, Realistic, and Timely.


Comments

Post a Comment

Popular posts from this blog

Another Fine CMS You Have Gotten Us Into

Perhaps we are indeed back to the time of Another Fine Mess (Laurel and Hardy). In a mad rush to implement innovation and to save all possible costs, CMS is creating complications for people that it is most responsible to protect. As PBS and Ken Burns celebrate the legacy of The Roosevelts, it is tragic to see what has become of over a century of effort involving Social Security, Medicare, Medicaid, and health care equity. The United States has one of the most complex health designs and clearly the various designers often know not what they are doing to others. More cartoons and comedians would find this a ripe area for material if not for the suffering involved. Health and Human Services has a huge role across Social Security and US health care. CMS or the Centers for Medicare and Medicaid Services has a dominant role to play in the design of health care in the United States.  CMS can be progressive or regressive. Interestingly CMS has chosen to appear to be progressi...
Read more

The Essential True Reform Restores Primary Care and Much More

The list of distractions from True Reform are impressive. For decades True Reform has been specifically avoided as primary care worsens within practices and from outside. The demise is most specifically about the financial design. Unless there is a focus on True Reform, there is little hope for Basic Health Access. This may not make as much sense to those outside of family medicine. Family physicians not familiar with AAFP may also be clueless. If you think that you can fix primary care with more technology, more rearrangements, more types of health professional graduates, or more expansions of training - think again. None of these have any hope of working without financial design changes - major changes. The following are various concepts that dominate the discussions at AAFP and primary care meetings and media releases of associations and foundations and institutions. Members, staff, media releases, programs, and personnel have been reviewed.  There is little about...
Read more

Stop Killing Primary Care

Image
Primary care services have decreased in number steadily, year after year. Payments for primary care services overall have been stagnant as with other basic services taken for granted. Population, demand for care, and complexity are all increasing in ways that should have resulted in much more primary care for anyone who cares about primary care - but there is steadily less primary care. The financial design is broken by stagnant revenue and accelerating costs of delivery. The digital revolution has actually caused regression of primary care via worsening burnout, productivity, and meaningless complexity. The costs of delivering primary care have been increased across multiple dimensions by those who think that they are improving care when actually they are killing small health, primary care, generalists, general specialties, and basic access to care. This little death steadily, slowly over time is also specific to primary care physicians who appropriately describe it as trauma si...
Read more