Cost of Training per Unit of Primary Care Delivery

The cost of primary care training can be compared to primary care delivery over a career. 



The Basic Calculations of the Standard Primary Care Year


% Primary Care
Years in Career
% Remain Active
% Volume
SPCYR Per Grad
NP not FNP
15%
24
70%
70%
1.76
FNP Trained
54%
24
70%
75%
6.8
PA not FP Start
15%
33
75%
75%
2.78
PA with FP Start
60%
33
75%
80%
11.88
FM Trained MD
91%
33
84%
100%
25.23
IM Trained MD
15%
32
82%
86%
3.38
PD Trained MD
39%
33
82%
95%
10.03
MPD Trained MD
43%
32
82%
95%
10.72

The product of 4 factors is the SPCYR per Graduates specific to the time of graduation. With primary care retention declines, the overall result for all sources has declined - especially since 1998 graduates. 
The cost of training can be divided by the primary care delivery result in SPCYRs.

Cost of Training Relative to Primary Care Delivery over a Career



Cost of Training Post High School
Cost per SPCYr
NP not FNP
$380,000
$215,420
FNP Trained
$380,000
$55,850
PA not FP Start
$440,000
$158,025
PA w/FP Start
$440,000
$37,037
FM Trained
$950,000
$37,661
IM Trained
$950,000
$280,653
PD Trained
$950,000
$94,756
MPD Trained
$1,050,000
$97,957
* The cost of multiple times more graduates to result in a nursing school graduate (some schools) was not considered. Costs of attrition were not considered. The cost of physician training is less when the revenue generated from residency is considered. Some studies consider residency training to pay for itself. This would reduce the cost of training for a physician to college and medical school costs. (see below)

Only the family practice associated MD, DO, NP, and PA components had reasonable cost of training for the primary care contribution.


Substantially more graduates are required for the same primary care delivery result over a career when sources remain in primary care at low levels, have fewer years in a career, have lesser activity as a clinician (part time, inactive, managerial, other non-clinician), and less volume per FTE. 

Higher turnover is seen for NP and PA workforce with twice the annual turnover levels of primary care physicians. Higher turnover reduces productivity and experience.

Internal medicine has such low yield for primary care that the cost of training is prohibitive when the purpose is primary care workforce. 

Pediatric training and medicine pediatric training is more costly for the yield of primary care compared to family medicine. Expansions of pediatric graduates over the past decades have resulted in little change in pediatric primary care workforce. More graduates over the past 10 years have merely replaced those departing.

The nurse practitioner training cost ratios will increase substantially in 2015 with two years more required training (up $120,000) and an 8 – 10% decrease in the years in a career. This results in a 33% increase cost per primary care year for family nurse practitioners – an increase from $55,850 to about $73,486 per Standard Primary Care Year. The major NP primary care and health access delivery rests on the shoulders of family nurse practitioners as so few outside of family practice contribute to primary care and primary care where needed. Also the estimates used are generous - using 70% active. Reductions for part time, inactive, and turnover indicate about 60% active as clinicians over a career.

Family nurse practitioners are 50% of NP graduates, but only about 50% of FNP graduates remain in family practice employment. The NP family practice result is down to about 25% according to Advance for NP and PA.

There is a better decision for nursing leaders who intend primary care result from training. The appropriate move is to change the design of FNP training such that the most important outcome of family practice positions filled is made permanent. Without that move, nurse practitioner claims of primary care and workforce where needed are limited to only a small portion of NP graduates.


Only the few NP and PA graduates that get certified and enter the workforce and enter family practice employment and remain in such employment contribute at significant levels, but even these melt away over time. Such is the power of non-primary care compared to primary care in the US design.

FM with greatest retention, years, activity, and volume delivers the most primary care in a career. Nurse practitioners not training in family practice or physician assistants not starting in family practice (80% of entering PA) contribute least along with internal medicine. The reason is so few remaining in primary care. 


Only the result of family practice is efficient for the purposes of health access and primary care. Family practice is the only population based workforce or the same proportion of workforce matched up to the same proportion of US population for 1.0 result (20% of FM found in rural zip codes with 20% of the US population).

Family medicine is efficient for the purpose of primary care delivery because 90% remain in family practice over a career. The NP and PA graduates entering and remaining in family practice positions are critical for health access, but this is down to 25% of recent graduates that will contribute in family practice. Movement steadily away from family practice positions filled simultaneously reduces primary care and workforce where needed.


Distribution By Location Type


Rural %
Under-served %
Outside %
NP not FNP
10%
12%
35%
FNP Trained
28%
15%
55%
PA not FP Start
10%
12%
35%
PA with FP Start
30%
18%
55%
FM Trained
22%
15%
53%
IM Trained
10%
9%
28%
PD Trained
8%
9%
28%
MPD Trained
16%
12%
40%

Optimistic early practice estimates were given for all except FM. The actual proportions of other sources decline due to departures from family practice and from primary care over their careers. Only continued retention in family practice keeps optimal distribution. Only family medicine is retained in family practice for career long retention, documented in the FM figures from the AMA Masterfile and the Robert Graham Center. 

Cost of Training Considerations

College
Health Prof
Graduate
Cost of Living
NP not FNP
$30,000
$100,000
$70,000
$180,000
FNP Trained
$30,000
$100,000
$70,000
$180,000
PA not FP Start
$120,000
$125,000

$195,000
PA with FP Start
$120,000
$125,000

$195,000
FM Trained
$120,000
$200,000
$300,000
$330,000
IM Trained
$120,000
$200,000
$300,000
$330,000
PD Trained
$120,000
$200,000
$300,000
$330,000
MPD Trained
$120,000
$200,000
$400,000
$330,000


Additional calculations can integrate the proportions of graduates found in certain locations to generate the contributions in rural primary care, underserved primary care, and primary care delivery outside of concentrations (in 30,000 zip codes with 65% of the US population left behind). The cost of training per unit of primary care is much less for family medicine. Other sources that yield less primary care per graduate are inefficient primary care sources.


Worsening Family Medicine Contributions


The addition of a year of training to family medicine 3 year GME training would decrease career length by 4% and would add about $120,000 to training cost resulting in a $5000 increase to $43,000 per SPCYr. Even worse is that the 9000 annual training slots currently supported would need to be divided by 4 resulting in 2250 graduates per year for a 4 year GME design. This is a substantial reduction of FM workforce from 90,000 to 75,000 due to longer training.
 
More importantly millions of additional Americans would be left behind with a smaller FM workforce.

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. 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 http://www.infrastructureamerica.org/ and he is the author of the World of Rural Medical Education, and Physician Workforce Studies












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