Meeting Primary Care Needs in the Last Half of the 21st Century

Achievable primary care is one of the weakest areas in the workforce literature. Enough annual graduate expansion of any primary care source will increase primary care, but steady declines in the proportion remaining in primary care in the years after graduation make this a less efficient and less effective process for the purpose of addressing primary care workforce.

With primary care graduates departing primary care
it is not possible to recover primary care. 

Despite projections of primary care increases by government and by major associations, the US is actually losing ground in basic health access primary care. Increases in cost of training, more graduates required for less primary care result, and increases in the costs of locums, recruitment, and retention insure failure in primary care delivery with the current voluntary and flexible design that facilitates departures from primary care.

Studies and reports that project primary care workforce place too much emphasis on annual graduate numbers. The US has created 4 new primary care sources and has doubled annual primary care graduates from 14,000 in 1980 to 28,000 in 2010 but this matters less than the decline from 18 Standard Primary Care Years per graduate to 7 SPCYrs. With less than one-third remaining in primary care, the United States must find ways not to lose primary care rather than throwing more dollars at more graduates that deliver less primary care per graduate.

More important than annual graduates is what each graduate accomplishes. This is more about years in a career, activity in US health care, volume, and primary care retention. The Standard Primary Care Year uses estimates of these four factors to generate a relative measure of primary care delivery for each source specific for each class year.

The figure of 400 million people represents a good estimate for a steady state US  population in the latter half of the 21st Century as population growth slows. Health Resources and Services Administration recommendations of 95 primary care physicians per 100,000 can be adjusted to 110 primary care physicians per 100,000 as the result of aging changes effective for 2030 and beyond. This results in a need for 440,000 primary care physicians to reach a sufficient 110 per 100,000. Already it should be apparent that moving down in the last decade instead of up is not the path to sufficient primary care.

These levels can be converted to Standard Primary Care Year estimates by source to indicate how many annual graduates of each source will be required per class year for 30 class years to reach sufficient primary care.

Setting Primary Care Sufficiency: Total Workforce, Annual Graduates, and Primary Care per Graduate

Family medicine is most consistent in primary care retention and has reached a steady state. Family medicine can be used to convert total workforce to annual graduates to Standard Primary Care Years per graduate. This figure can be used to convert other sources to annual graduate requirements for sufficient primary care.

Family medicine at 3000 annual graduates for 30 years has resulted in 100,000 active family physicians for a workforce. The 100,000 for 310 million people is a workforce of 32.4 family physicians per 100,000.

In 30 years the US will have about 400 million people. For 400 million people at 110 primary care physicians per 100,000 this would require 440,000 family physicians.

For 440,000 family physicians rather than the current 100,000 this would require 4.4 times more annual graduates. The steady state 3000 annual graduates times 4.4 is 13,200 annual graduates for sufficient primary care defined as 110 per 100,000 for 400 million people.

These beginning annual graduate points and ending family physician primary care workforce numbers can be converted to Standard Primary Care Years. The SPCYr estimate of 24 SPCYrs for a family physician can be multiplied by 13,200 annual graduates for about 320,000 Standard Primary Care Years per class year. This is significantly above the recent annual yield of 200,000 SPCYrs per class year from six sources from 28,000 annual graduates (NP, PA, IM, FM, PD, MPD). Once again the SPCYr allows career years, activity, volume, and primary care retention to be considered such that all primary care training sources can be compared to each other and across the class years.  

One more adjustment is needed due to declines in family medicine of about 10% less per graduate in SPCYrs over decades of time. This results in about 350,000 Standard Primary Care Years annually required of 30 class years of graduates to result in steady state 110 primary care physician equivalents per 100,000 people.Note that this figure does not include a 10% - 20% fudge factor that should be included in all primary care estimates. This is because new workforce creations have consistently stolen primary care to result in substantally less tha predicted as noted with the creations of emergency medicine, geriatric, hospitalist, and urgent care workforce. Unanticipated losses also include tens of thousands converted from primary care to teaching hospital workforce due to resident work hours restrictions. Hospitalist changes also thrust more workload from hospital to primary care with primary care nurses most impacted. Increasing fragmentation and regulation by government and insurance also result in less efficient and effective primary care delivery.
The 350,000 SPCYr figure is not likely enough, but can be used to determine how many annual graduates are needed in each source to reach a level equivalent to 440,000 primary care physicians for 110 primary care physicians per 100,000. This can be used to estimate annual graduates for 80 and for 60 primary care physicians per 100,000 as well.

Annual Graduates Required to Reach Sufficient Primary Care for 2050 and Beyond

Higher SPCYr Estimate (requires least annual graduates)
Lower SPCYr Estimate (requires most annual graduates)

Using Highest or Best Case Estimate in Each Factor

Primary Care Retention
Active for Career
Years in Career
Volume Adjustment
Higher SPCYr Estimate

Using Lowest in Each Factor

Primary Care Retention
Active for Career
Years in Career
Volume Adjustment
Lower SPCYrEstimate
Using the Average

110 per 100,000
80 per 100,000
60 per 100,000

Incredibly high levels of annual gradutes are required to reach sufficient primary care when the sole source of primary care is not permanent.

Permanent primary care sources most active for the most years at highest volume require the fewest annual graduates to reach sufficient primary care. Flexible sources less likely to remain in primary care with fewer years, lesser activity and lower volume  require more graduates than the United States can supply or afford.

The Impossibility of Reaching Sufficient Primary Care without SMART

Currently the US only graduates about 100,000 Registered Nurses, 30,000 physicians, 9000 NPs, 7000 Internists, 6500 physician assistants, 3000 pediatricians, 3000 family physicians, and 500 medicine pediatric physicians each year.

RN workforce demand will increase substantially in the next 20 years for the same elderly and health care coverage increase reasons as primary care. Too few enter and remain as RNs already. Increasing nurse practitioners by tens of thousands of annual graduates to reach sufficient primary care would devastate RN workforce. 

The last physician assistant expansion doubling actually increased primary care numbers entering the workforce by only 30% - a level likely to be negated in future departures from primary care. Physician assistants and nurse practitioners are widely sought by a wide range of employers with new specialties created with each passing year. Win-Win-Win non-primary care benefits to the practitioner, employer, and specialist physician are innate in the US policy design and insure departures from primary care.

Low primary care yield defeats generic expansions as a primary care workforce intervention. Generic physician expansions of medical students or generic expansions of graduate medical education positions are just not specific to primary care. Even expansion limited to primary care GME positions fail as pediatric and internal medicine expansions fail to yield much primary care workforce increase. About half of family nurse practitioners deliver the predominant primary care of all nurse practitioners. Expansions without retention are mostly about non-primary care workforce result. Three dimensions insure too much non-primary care. Meanwhile primary care remains stagnant by design.

Only SMART expansion works – specific, measurable, achievable, realistic, and timely. A best approach is a primary care source that delivers more primary care than family medicine for about 12,000 annual graduates needed at a cost of 12 billion per year for sufficient primary care. This compares to the current 16 billion for 28,000 annual graduates with half enough primary care delivery capacity result (all costs of higher education and training).

Specific is the least costly because it is most specific. Primary care sources that are flexible have become 55 – 80% not primary care in yield in the United States. Sources claiming to be primary care solutions are not good solutions. Specific language is required. Advanced nurses and generic nurse practitioners are not primary care solutions.Only the nurse practitioner that remains in family practice employment (25%) is a good primary care solution. Requiring permanent family practice is the only way to reach this solution. Only the physician assistant that remains in family practice is a good solution as demonstrated by consistent primary care delivery and consistent distribution where needed but again this is only 25% of physician assistants and only 20% of new graduate PAs. Schools such as Duluth manage 50% family medicine despite the policies that drive medical students away from a permanent primary care source, but 100% entry is possible in an even better design.

What is clear is that there has been little thought and even less planning
with regard to sufficient primary care workforce.

Rapid increases in the cost of training make these even more challenging. Also primary care delivery capacity per graduate is likely to decrease with quality focus or collaborative care emphasis – models that result in lower volume per primary care graduate. Departures of primary care workforce to urgent, emergent, hospital, and subspecialty workforce will also result in fewer Standard Primary Care Years per graduate. New workforce is created each few years that steals from primary care. Historically this has included emergency medicine, geriatrics, sports medicine, and hospitalists. Resident work hours restrictions alone converted tens of thousands of NPs and PAs away from primary care.

The United States has actually avoided expanding the most permanent primary care source for over 30 years. It has chosen to expand the sources least likely to remain in primary care. These have not been SMART choices specific to primary care and indicate choices made for other reasons – including non-primary care workforce, academic interests, and teaching hospitals.

Longer training also defeats primary care workforce. Each additional year of training results in 3 - 4% less workforce yield - resulting in even more graduates required to reach sufficient workforce. Two more years required for nurse practitioner doctorates in all nurse practitioner graduates in 2015 will result in an 8 - 10% loss of NP workforce and will substantially raise the cost of training.

The consequence of increased cost of training with less workforce result
has not even been recognized
as yet another move in the opposite direction from sufficient primary care.

Family medicine and other sources remaining in family practice have demonstrated consistent distribution to the elderly, poor, near poor, CHC, rural, and underserved populations as well as 53% found in 30,000 zip codes with 65% of the US population most left behind in health access. Expansions involving IM, PD, most nurse practitioners and most physician assistants are expansions of graduate types known to fail in distribution. This is also why hybrids or combinations of primary care are a bad idea.

Better than family medicine is required for efficient and effective primary care recovery using SMART principles, but family medicine is a starting point.
HRSA Nursing Reports for 2004 and 2008 were used for NP data as well as Advance for NP and PA. AAPA data was used for PAs. HRSA 2008 Physician Projections were used for sufficient primary care. Other references came from the Standard Primary Care Year literature, Ferrer, Mold, and Rosenblatt.

Robert C. Bowman, M.D.  Basic Health Access Web   Basic Health Access Blog

SMART basic health access - Specific, Measurable, Achievable, Realistic, Timely

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


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